58 Original article

Prostate-specific antigen as a diagnostic marker in female

hyperandrogenism
Amr E. Sharafa, Naglaa N. El Mongya, Marwa M. Fawzya
and Hanan Abd El Razikb
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a
Department of Dermatology, Faculty of Medicine, Background
Cairo University, Cairo and bDepartment of
Dermatology, Faculty of Medicine, Beni Suef Prostate-specific antigen (PSA) (a known marker for prostate carcinoma) is found in a
University, Beni Suef, Egypt wide variety of female tissues and fluids. It is upregulated by androgens. Hirsutism,
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 09/27/2023

Correspondence to Naglaa N. El Mongy,
35 Dokki Street, 12311 Cairo, Egypt
Tel: + 20 101 713 196; fax: + 20 2368 7673;
e-mail: nnradw@yahoo.com
Received 11 March 2012
Accepted 24 October 2012
Journal of the Egyptian Women’s Dermatologic
Society 2013, 10:58–62
androgenetic alopecia, acne vulgaris, and seborrhea are the most common clinical
manifestations of hyperandrogenism in women. Free testosterone (FT) level represents
the most sensitive biochemical marker supporting the diagnosis of hyperandrogenism
and polycystic ovary syndrome in women.
Objective
To determine the PSA level in women with clinical manifestations of hyperandrogenism
and study the possibility of using it as a diagnostic marker compared with FT.
Patients and methods
FT and PSA serum levels were evaluated in 30 premenopausal women with different
clinical manifestations of hyperandrogenism. Thirty age-matched healthy women were
included as controls.
Results
Both serum FT and serum PSA showed a statistically significant increase in women
with clinical hyperandrogenism (P = 0.000 and 0.002, respectively). There was a
statistically significant correlation between serum FT and PSA (r = 0.342, P = 0.007)
and no significant difference was found between FT and PSA in specificity, sensitivity,
and positive and negative predictive values (P = 1, 0.152, 0.933, and 0.438,
respectively). The levels of each of FT and PSA showed no significant difference
between the grades of either androgenetic alopecia, acne, or the degrees of hirsutism.
Conclusion
The increased level of PSA could be used as a diagnostic marker of hyperandrogenism
in women.

Keywords:
acne, androgenetic alopecia, hirsutism, hyperandrogenism, prostate-specific antigen,
testosterone

J Egypt Women Dermatol Soc 10:58–62

& 2013 Egyptian Women’s Dermatologic Society
1687-1537

Hyperandrogenism is characterized by excess production

Introduction
Prostate-specific antigen (PSA) has been identified as a
33 kDa serine protease with a chymotrypsin-like enzy-
matic activity. It is a product of prostatic tissue that has
been used as a highly specific marker of normal and
cancerous prostatic tissue [1]. PSA is found in a wide
variety of female tissues and fluids such as the breast,
ovary, milk, and amniotic fluid [2]. In women, PSA
expression has been detected immunohistochemically in
some apocrine foci of female fibrocystic breast tissue as
well as in breast cancer [3].
The production of PSA in the prostate is upregulated
by androgens through the androgen receptor [4]. Non-
prostatic PSA levels are regulated by steroidal hormones
[5]. Androgens, glucocorticoids, mineralocorticoids, and
progestins upregulate PSA production through their
receptors; estrogens downregulate indirectly the PSA
production induced by androgens [6].
1687-1537 & 2013 Egyptian Women’s Dermatologic Society
of androgens by the ovaries and/or adrenal glands. The
most common clinical manifestation of hyperandrogenism
in women is hirsutism. Other clinical manifestations
include acne vulgaris, weight gain, androgenetic alopecia,
and acanthosis nigricans in some women with polycystic
ovary syndrome (PCOS) [7]. PCOS is the most frequent
endocrine derangement, affecting up to 10% of repro-
ductive-age women [8]. It is responsible for most of
the cases of hyperandrogenism and/or oligoanovulation.
Although its pathophysiology is complex and still
debated, it is now considered that hyperandrogenism is
at the heart of PCOS [9].
Free testosterone (FT) level represents the most
sensitive biochemical marker supporting the diagnosis
of hyperandrogenism [10] and PCOS in women [11].
However, the testosterone (total and free) level generally
shows an overall variability [12]; its distributions are
bimodal in families of patients with PCOS [13] and it
DOI: 10.1097/01.EWX.0000423001.67563.ee

Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.

varies not only with the menstrual cycle but also with
age [12], smoking [14], and BMI [15]. PSA level,
however, has been found to be more stable in healthy
premenopausal and postmenopausal women [16]. In
addition, poor laboratory standards are usually used for
the determination of androgen levels in women, and until
recently, there were no well-accepted reference ranges for
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serum testosterone concentrations in women [12].
The aim of this study was to detect the PSA level in
women with clinical manifestations of hyperandrogenism
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and consider the possibility of using it as a diagnostic
marker of hyperandrogenism in women compared with
FT.
Patients and methods
Patients
Thirty premenopausal female patients with hyperandro-
genism and 30 age-matched and sex-matched controls
were the participants of the current study. Patients were
selected from the Outpatient Clinic of Kasr Al Aini
Hospital, Cairo University, Egypt. This was a case–control
study, and the cases were recruited from May 2010 till
December 2010. Informed written consent was obtained
from each participant after approval by the Dermatology
Research Ethical Committee (REC) of Faculty of
Medicine, Cairo University. Inclusion criteria were the
presence of at least three of the following clinical
manifestations of hyperandrogenism, namely, andro-
genetic alopecia, hirsutism, acne vulgaris, and seborrhea.
Women who were pregnant, lactating, or on oral contra-
ceptive pills were excluded. All participants were
subjected to assessment of complete history, with a focus
on menstrual history, hair loss, hirsutism, and acne. A
complete clinical examination was performed with
assessment of the grade of androgenetic alopecia accord-
ing to the Ludwig [17] scale, the extent of hirsutism,
grading of acne according to Katsambas et al. [18], and
classification and detection of seborrhea if present.
Ultrasound evaluation was carried out for all patients
to document or exclude the presence of PCOS. The
diagnosis of PCOS was made on the basis of the
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus
Workshop Group [19]. It requires two of the following
three features for the diagnosis of PCOS: oligo-ovulation
or anovulation; clinical or biochemical evidence of
hyperandrogenism; and polycystic ovaries by ultrasound
examination as well as exclusion of other causes.
Methods
Three milliliters of blood was withdrawn from each
participant. Samples were taken in the early follicular
phase (days 3–5 of the cycle) of women with regular
menstrual cycles or any day from women with oligo-
menorrhea or amenorrhea. Serum was separated and
utilized for the measurement of FT and total PSA.
Quantitative measurement of FT was carried out accord-
ing to the method described by McCann and Kirkish [20].
Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
PSA in female hyperandrogenism Sharaf et al. 59
The FT ELISA kit (GenWay Biotech Inc., San Diego,
California, USA) is a solid-phase enzyme-linked immu-
nosorbent assay (ELISA) based on the principle of
competitive binding. The microtiter wells are coated
with an antibody directed toward an antigenic site on the
testosterone molecule. Endogenous FT of a patient
sample competes with a testosterone–horseradish perox-
idase conjugate for binding to the coated antibody. After
incubation, the unbound conjugate is washed off. The
amount of bound peroxidase conjugate is inversely
proportional to the concentration of FT in the sample.
After the addition of the substrate solution, the intensity
of color developed is inversely proportional to the
concentration of FT in the patient sample. Testosterone
in the blood is bound to serum hormone binding globulin
(60%) and at a lower quantity than other protein. Only
the measurement of FT (o1% of total testosterone)
allows estimation of biologically active hormones. The
normal range of FT in premenopausal adult women is
0–4 pg/ml.
Quantitative measurement of total PSA was carried out
according to the method described by Price et al. [21].
The PSA EIA kit (Fujeribio Diagnostics, Gothenburg,
Sweden) is a solid-phase, noncompetitive immunoassay
based on the direct sandwich technique. Calibrators,
controls, and patient samples are incubated together with
biotinylated anti-PSA monoclonal antibody and horse-
radish peroxidase-labeled anti-PSA monoclonal antibody
in streptavidin-coated microstrips. After washing, buf-
fered substrate/chromogen reagent is added to each well
and the enzyme reaction is allowed to proceed. During
the enzyme reaction, a blue color will develop if the
antigen is present. The intensity of color is proportional
to the amount of PSA present in samples. The intensity
of color is determined in a microplate spectrophotometer
at 620 nm (or optionally at 405 nm after the addition of
stop solution). Calibration curves are constructed for each
assay by plotting absorbance value versus the concentra-
tion for each calibrator. The PSA concentrations of
patient samples are then read from the calibration curve.
The normal range of total PSA in premenopausal adult
women is 0–0.02 ng/ml.
Statistical analysis
Data were statistically described in terms of range,
median, mean ± SD, frequencies, and percentages when
appropriate. Sensitivity was calculated as number of test-
positive patients/(number of test-positive + test-negative
patients). Specificity was calculated as the number of
test-negative controls/(number of test-positive + test-
negative controls). Positive predictive value (PPV) is
the number of test-positive patients/(number of test-
positive patients + number of test-positive controls).
Negative predictive value (NPV) is the number of test-
negative controls/(number of test-negative patients +
number of test-negative controls). Comparison of quan-
titative variables was carried out using the Student t-test
for independent samples to compare two groups when
normally distributed and the Mann–Whitney U-test for
 60 Journal of the Egyptian Women’s Dermatologic Society

independent samples when not normally distributed. Table 1. Number and percentage of hyperandrogenism
Comparison of quantitative variables between more than manifestations, free testosterone, and prostate-specific
antigen in patients and controls
two groups was carried out using the Kruskal–Wallis
analysis of variance test, with the Mann–Whitney U-test Group Parameters N (%)
for independent samples for post-hoc multiple two-group Patients AA
comparisons. For comparison of categorical data, the w2- + 30 (100%)
test was carried out. The Exact test was used instead – 0 (0%)
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Hirsutism
when the expected frequency was less than 5. Correlation + 25 (83.3)
between various variables was determined using the – 5 (16.7%)
Pearson moment correlation equation. A P value less than AV
+ 21 (70%)
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0.05 was considered statistically significant. All statistical – 9 (30%)

calculations were carried out using computer programs Seborrhea
Microsoft Excel 2007 (Microsoft Corporation, New York, + 19 (63.3%)
– 11 (36.7%)
USA) and SPSS, version 15 (statistical package for the Menses
social science; SPSS Inc., Chicago, Illinois, USA) for Regular 13 (34.3%)
Microsoft Windows. Irregular 17 (56.7%)
PCOS ultrasonic
+ 17 (56%)
– 13 (43%)
FT44 pg/ml
+ 24 (80%)
Results – 6 (20%)
The patient group ranged in age between 19 and 43 years, PSA40.02 ng/ml
mean age, 29.93 ± 6.389 years, and the control group + 19 (63.3%)
– 11 (36.6%)
ranged in age between 20 and 42 years, mean age Controls FT44 pg/ml
30.20 ± 6.541 years. Clinically, 25 patients (83.3%) + 4 (13.3%)
showed three of the four manifestations of hyperandro- – 26 (86.7%)
PSA40.02 ng/ml
genism studied and five patients (16.7%) showed all the + 4 (13.3%)
four manifestations. In the patient group, 11 patients – 26 (86.7%)
(36.7%) had androgenetic alopecia grade I, 14 (46.7%) AA, androgenetic alopecia; AV, acne vulgaris; FT, free testosterone;
had grade II, and five (16.7%) had grade III. In terms of – , negative; PCOS, polycystic ovary syndrome; PSA, Prostate-specific
hirsutism, five patients (16.7%) had no hirsutism, 21 antigen; + , positive.
(70%) had the localized form, and four had the general-
ized form. Nine patients (30%) had no acne vulgaris, 15
Table 2. Comparison between free testosterone and prostate-
(50%) had mild acne vulgaris (I), five (16.7%) had specific antigen in terms of sensitivity and specificity
moderate acne vulgaris (II), and one (3.3%) had severe
Marker Sensitivity Specificity PPV NPV
acne vulgaris (III). Nineteen patients (63.3%) had
seborrhea and 11 (36.7%) did not have seborrhea. FT 80.00 86.67 85.71 81.25
Thirteen patients (34.3%) had regular menses whereas PSA 63.33 86.67 82.61 70.27
P value 0.152 0.704 0.933 0.438
17 (56.7%) had irregular menses. Seventeen patients
(56.7%) had ultrasonographic evidence of PCOS and 13 FT, free testosterone; NPV, negative predictive value; PPV, positive
predictive value; PSA, prostate-specific antigen.
(43.3%) did not (Table 1). Po0.05 is significant.
In the patient group, 24 patients (80%) had elevated FT,
whereas six (20%) had a normal FT level. Nineteen Table 3. Serum level of free testosterone and prostate-specific
patients (63.3%) had elevated PSA and 11 (36.6%) had a antigen in patients and controls
normal level. Out of 30 controls, four controls (13.3%) Parameters Patients (N = 30) Controls (N = 30) P value
had elevated levels of both FT and PSA, whereas 26
(86.7%) had normal levels of FT and PSA (Table 1). This FT (pg/ml)
Median 6.025 1.305 0.000*
yielded a sensitivity of 80% for FT versus 63.3% for PSA, Range 0.66–9.39 0.00–8.48
with a nonsignificant difference (P = 0.152), and a PSA (ng/ml)
specificity of 86.7% for each of FT and PSA (P = 1). Median 0.151 0.000 0.002*
Range 0.00–0.62 0.00–0.267
Also, there was no significant difference in PPV and NPV
between FT and PSA levels (P = 0.933 and 0.438, FT, free testosterone; PSA, prostate-specific antigen.
*Po0.05 is significant.
respectively) (Table 2).
The median level of FT in patients was significantly
higher than that of the controls (P = 0.000). Also, the patients (r = 0.342, P = 0.007, correlation is significant at
median level of PSA in patients was higher than that in P = 0.01) (Fig. 1).
the controls with a significant difference (P = 0.002)
(Table 3). Of the 24 patients with elevated FT, 13 Grade III androgenetic alopecia showed a higher mean
(54.2%) had elevated PSA and 11 (45.8%) had normal value of FT compared with other grades. However, the
PSA (Table 4). There was a statistically significant difference was insignificant (P = 0.298). Also, there was
correlation between the levels of FT and PSA in all no significant difference in the PSA level between the

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Table 4. Patients with elevated levels of free testosterone and
prostate-specific antigen
PSA (ng/ml)
Parameters Normal
FT (pg/ml)
Normal 0 6
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Elevated 11
FT, free testosterone; PSA, prostate-specific antigen.
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Figure 1.
8.00
6.00
FT pg/ml
4.00
2.00
0.00
0.00 0.20 0.40
PSA ng/ml
Correlation curve between serum levels of free testosterone (FT) and
prostate-specific antigen (PSA) in all participants.
grades of androgenetic alopecia (P = 0.615). Patients with
severe acne vulgaris had a higher mean value of FT
compared with other grades; however, again, the differ-
ence was insignificant (P = 0.663). Also, there was no
significant difference between grades of acne in the PSA
level (P = 0.232). There was no significant difference
between grades of hirsutism in either FT or PSA levels
(P = 0.307 and 0.259, respectively). Again, no significant
correlation was found between the age of the patients and
the level of either FT or PSA (r = 0.167 and – 0.025;
P = 0.379 and 0.894, respectively).
Discussion
Serum PSA levels in normal women are very low, but still
detectable by ultrasensitive PSA immunoassays [21].
Only minor fluctuations in serum PSA concentrations
were observed in healthy premenopausal and postmeno-
pausal women [16]. Also, the increase in testosterone in
the mid-cycle period is relatively small compared with
the overall variability [12]. However, in this study, blood
sampling was carried out in the early follicular phase so
that higher levels of PSA or FT in our study could not be
attributed to the variations through the menstrual cycle.
Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
PSA in female hyperandrogenism Sharaf et al. 61
The results of our study indicated a significant increase in
total serum PSA in hyperandrogenic women. The same
result was found by Camacho et al. [22]. They found
statistically significant elevations in serum PSA levels in
Elevated
women with clinical signs of hyperandrogenism. Also,
they found higher levels in ovarian and adrenal subtypes,
whereas women without clinical hyperandrogenism or
13
women with clinical hyperandrogenism and normal
hormonal serum levels had lower PSA levels. The same
result was found by Wang et al. [23]. Levels of PSA greater
than 0.02 ng/ml in premenopausal women were consid-
ered a hyperandrogenism marker [22]. In our study, PSA
levels greater than 0.02 ng/ml were found in 19 women of
the hyperandrogenic group, whereas it was detected in
only four women of the control group with a sensitivity of
63.3% and a specificity of 86.7%.
The present study also found a significant increase in
serum FT levels in hyperandrogenic women. FT levels
greater than 4.00 pg/ml were observed in 24 women of the
hyperandrogenic group and in only four women in the
control group with a sensitivity of 80% and a specificity of
86.7%. The statistical comparison between FT and PSA
indicated no significant difference in sensitivity, specifi-
city, PPV, and NPV. Therefore, the PSA level may be used
as an alternative to FT in screening of hyperandrogenism
in women.
In the current study, of 24 elevated FT patients, 13
(54.2%) had elevated PSA and 11 (45.8%) had normal
0.60 PSA. There was a statistically significant correlation
between the serum levels of FT and PSA. In the study
carried out by Wang et al. [23], a weak positive correlation
was found between PSA and T (r = 0.226, Po0.05).
However, our results are not in agreement with those of
Ansam et al. [24], who found no significant correlation
between testosterone and serum total PSA whose cases
were PCOS not hyperandrogenism in general.
In this study, 17 patients had PCOS; 14 of these (82.4%)
had elevated PSA and three (17.6%) had a normal level.
This is in agreement with the result of Franks [25], who
concluded that serum PSA levels in normal women are
very low, whereas in those who have PCOS with
hyperandrogenic features, the PSA level is elevated but
not always detected using an ultrasensitive method time-
resolved fluorometric immunoassay. Also, Vural et al. [2]
and Mardanian and Heidari [26] found elevated PSA
levels in PCOS, which may be used as a useful androgen
excess marker.
In our study, there was no significant relation between
grades of hirsutism and PSA levels. Ukinc et al. [27] found
that circulating androgens and hirsutism are independently
associated with the degrees of total PSA and free PSA in
PCOS women. Also, Obiezu et al. [28] found no association
between the grades of hirsutism and the level of urinary
total PSA. However, our results are not in agreement with
those of Ansam et al. [24], who found that the higher the
score of hirsutism, the higher the total PSA level. However,
their study was restricted to PCOS with hirsutism and not
hyperandrogenism in general, which might explain this
 62 Journal of the Egyptian Women’s Dermatologic Society
disagreement. Also, there was no statistical relation
between grades of acne and PSA level, or between grades
of androgenetic alopecia and PSA level.
Conclusion
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On the basis of the results of the present study, PSA
represents a new potential marker for hyperandrogenism,
especially with the present difficulties in standardizing
normal testosterone level. More studies with larger
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 09/27/2023
sample sizes are required to document our preliminary
findings and study the possibility of using PSA in
monitoring antiandrogenic treatment.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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