Approach to the patient: investigation of postmenopausal androgen excess

Androgen excess in postmenopausal women presents a challenging clinical conundrum. A crucial component in management involves identification of the underlying etiology with a focus on detection of potentially malignant pathology or underlying genetic syndromes. A basic understanding of androgen physiology in women and the associated alterations during the menopausal transition is required to accurately risk stratify this cohort and streamline investigations. Over the course of this article, we will propose an approach to investigation and management of postmenopausal androgen excess that focuses on clinical, biochemical, and radiological cues. Additionally, we will suggest an algorithmic approach to clinical and biochemical diagnostics that is underpinned by identification of red flag features of the underlying pathology.