Last updated: October 2, 2025
Hyperandrogenism—the condition characterized by excess androgens—relates to the hypothalamic-pituitary-gonadal axis. Women presenting with signs such as amenorrhea, hirsutism, acne, or alopecia are typically first evaluated by an endocrinologist. Most cases of hyperandrogenism are caused by polycystic ovarian syndrome (PCOS). However, less commonly, tumors of the adrenal gland or ovary may be responsible, accounting for less than 8% of women with hyperandrogenic symptoms.
Laboratory assessment should include a comprehensive evaluation of the hypothalamic-pituitary-gonadal axis, including measuring testosterone levels and performing a low-dose dexamethasone suppression test (LDDST). After the test, testosterone levels above 80 ng/dL suggest hyperandrogenism, while levels exceeding 130 ng/dL strongly indicate a tumoral source, with a sensitivity of 94% and specificity of 78%. If androgen levels are suppressed during the LDDST, a hormonally active tumor is unlikely, with nearly 100% sensitivity and 88% specificity. Conversely, if androgen levels are not suppressed after the test, an androgen-secreting tumor should be suspected.
Presentation
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Anatomy
The right gonadal vein typically courses upward through the retroperitoneum and drains into the anterior surface of the infrarenal IVC. The left gonadal vein also ascends but drains into the caudal surface of the left renal vein. Compared to adrenal veins, variant drainage patterns and additional gonadal veins are relatively common on both sides.
Indications
If imaging cannot identify the tumor, adrenal and ovarian venous sampling can be performed to assist in localization.
It is important to note that the success rate of catheterizing all four vessels (both adrenal and gonadal veins) for hyperandrogenism workup is relatively low, ranging from 27% to 45%. Anatomical variations are common and successfully catheterizing gonadal veins in nulliparous women with competent valves can be particularly challenging. There is also no consensus on how to interpret venous sampling results. A recent study by Kaltsas et al. was unable to reproduce previous findings and validate earlier guidelines. They recommended that venous sampling should not be performed routinely for hyperandrogenism, except when imaging and other workups fail to identify the cause. Furthermore, they advised that this procedure should only be conducted at centers with specialized expertise in venous sampling techniques.
Contra Indications
- None specific
Workup
Imaging evaluation for an androgen-secreting tumor should include CT or MRI scans of both the adrenal glands and pelvis to assess for ovarian tumors. Adrenal tumors typically larger than 1.5 cm are usually well visualized with CT, whereas most ovarian androgen-secreting tumors are smaller than 2 cm and may be missed during pelvic exams, diagnostic laparoscopy, or ultrasound. If imaging cannot identify the tumor, adrenal and ovarian venous sampling can be performed to assist in localization.
Material
Essentials
- Femoral vein access kit (needles, introducers, etc.)
- 4-F or 5-F catheters (e.g., Cobra 2, Simmons 1, Sidewinder 1)
- Microcatheter (if necessary for venous access)
- Contrast dye for venography
- Syringes and collection tubes for blood sampling
- Labels for sample identification
- Laboratory supplies for sample handling (e.g., transport tubes)
- Imaging equipment for digital subtraction venography
Non Essentials
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Positioning
Suppine
Steps
- Obtain femoral vein access for the procedure
- Use a 4-F or 5-F catheter (e.g., Cobra 2, Simmons 1, Sidewinder 1) to access the right gonadal vein
- Use a 4-F or 5-F Cobra 2 catheter to access the left gonadal vein
- Insert a microcatheter if necessary for adequate venous catheterization
- Confirm catheter position with a gentle digital subtraction venogram
- Obtain a blood sample from each ovarian vein
- Additionally, obtain a peripheral venous blood sample
- Perform adrenal venous sampling as previously described
- Send all specimens to the laboratory for testing of testosterone, dehydroepiandrosterone sulfate (DHEA-S), and androstenedione (A4) levels
Tips & Tricks
Complications
Aftercare
- None specific
Folder
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Literature
Halpin, Kelsee, et al. “Selective Venous Sampling Prompting Unilateral Oophorectomy in an Adolescent With PCOS and Markedly Elevated Testosterone.” Journal of Pediatric and Adolescent Gynecology, vol. 36, no. 2, 2023, pp. 103–06, https://doi.org/10.1016/j.jpag.2022.10.006.
Levens, Eric D., et al. “Selective Venous Sampling for Androgen‐producing Ovarian Pathology.” Clinical Endocrinology, vol. 70, no. 4, 2009, pp. 606–14, https://doi.org/10.1111/j.1365-2265.2008.03389.x.