Endogenous Hyperandrogenism in Women and Its Influence on Exercise Capacity and Athletic Performance: A Narrative Review

The increasing importance of the issue of endogenous hyperandrogenism in women (which is found in polycystic ovary syndrome (PCOS), congenital adrenal hyperplasia (CAH), and differences of sex development (DSDs)) for both sports medicine and the regulation of female competitive athletics has made it necessary to examine whether high natural levels of androgens can improve exercise ability in women. It has been clearly demonstrated that exogenously administered androgens produce a physiologic benefit for athletes; however, little information exists regarding the physiologic benefits of endogenously elevated androgen levels. Androgens, specifically testosterone, could potentially impact several systems involved in physical activity, including bone formation and muscle hypertrophy, red blood cell production, and oxygen delivery to tissues, all of which would result in a potential physiologic advantage for certain types of athletes. Therefore, this review will discuss the existing literature examining the association between endogenously elevated androgen levels in women and their exercise capabilities (specifically muscle strength, aerobic capacity, hematologic parameters), while also evaluating the methodologic quality of the available literature. A comprehensive search of the medical literature using PubMed/MEDLINE and Google Scholar, along with manual reference screening, was conducted to identify relevant literature, including peer-reviewed articles. Current evidence suggests that excessive endogenous androgen levels are associated with greater amounts of lean body mass, higher hemoglobin concentrations, and better aerobic capacity compared to nonhyperandrogenemic women. The greatest amount of consensus was observed among women with DSDs. However, the data obtained from women with PCOS and CAH have been inconsistent. Thus, based upon the currently available evidence, there may be a physiologic advantage resulting from endogenous hyperandrogenism in select groups of women. However, the extent of the effect varies by condition. Additional research using appropriately designed studies will be needed to further define these relationships and provide direction for clinical practice decisions and regulatory policies.