Clinical Note
Women-এ androgen excess হলে আগে PCOS/NCCAH/tumor exclude করা জরুরি; আর androgen deficiency নামে healthy women-এ কোনো well-defined syndrome নেই—low testosterone alone দিয়ে diagnosis করা ঠিক নয়। Testosterone therapy women-এ মূলত postmenopausal HSDD ছাড়া routine indication নয়।
1) Definition
Androgen excess in women: female body-তে testosterone/DHT/DHEAS/androstenedione বেশি হওয়া বা androgen effect বেশি দেখা—যেমন hirsutism, acne, androgenic alopecia, irregular period, virilization। PCOS guideline অনুযায়ী adult PCOS diagnosis-এ clinical/biochemical hyperandrogenism একটি core criterion।
Androgen deficiency in women: healthy women-এ “androgen deficiency syndrome” clinically well-defined নয়। Symptoms nonspecific—low libido, fatigue, low mood—এসব শুধু testosterone কম বলে প্রমাণ হয় না। Evidence-based testosterone use: postmenopausal women with properly diagnosed HSDD।
2) Causes — Bangla point akare
A. Androgen excess causes
- PCOS — most common
Insulin resistance + ovarian theca cell androgen production বেশি → hirsutism, acne, irregular menses, infertility। PCOS diagnosis adult-এ 2/3: hyperandrogenism, ovulatory dysfunction, PCOM/AMH; irregular cycle + hyperandrogenism থাকলে ultrasound/AMH দরকার নাও হতে পারে। - Idiopathic hirsutism
Androgen normal, period regular, কিন্তু hair follicle androgen sensitive। - Non-classic congenital adrenal hyperplasia — NCCAH
Mostly 21-hydroxylase deficiency → 17-OHP precursor androgen pathway-তে যায় → hirsutism/irregular menses। - Androgen-secreting ovarian/adrenal tumor
Sudden onset, rapid progression, virilization—deep voice, clitoromegaly, male-pattern balding। Postmenopausal new severe hirsutism হলে urgent evaluation। PCOS guideline new-onset severe/worsening hyperandrogenism-এ tumor/hyperthecosis rule out করতে বলেছে। - Ovarian hyperthecosis
Usually peri/postmenopausal; severe testosterone excess, insulin resistance। - Cushing syndrome / acromegaly / hyperprolactinemia / thyroid disease
Menstrual disturbance + androgenic features তৈরি করতে পারে। - Drug-induced
Anabolic steroid, testosterone, DHEA supplement, danazol, valproate, some progestins। - Severe insulin resistance / HAIR-AN syndrome
HyperAndrogenism + Insulin Resistance + Acanthosis Nigricans।
B. Androgen deficiency causes
- Natural aging / menopause — DHEAS declines with age.
- Surgical menopause — bilateral oophorectomy after hysterectomy/ovarian surgery।
- Primary ovarian insufficiency — POI।
- Adrenal insufficiency — adrenal androgen production কমে।
- Hypopituitarism — gonadotropin/adrenal axis কম।
- Chronic glucocorticoid or opioid use।
- COCP/oral estrogen — SHBG বাড়িয়ে free testosterone কমায়; lab interpretation difficult।
নিচে women-এ androgen excess ও androgen deficiency-এর cause বাংলায় clinical mechanism সহ সাজিয়ে দিলাম।
A. Women-এ Androgen Excess-এর Cause
মূল pathophysiology
Female body-তে androgen প্রধানত ovary ও adrenal gland থেকে আসে। Skin/hair follicle-এ testosterone → DHT হয়ে androgenic effect বাড়ায়। তাই androgen excess হতে পারে ৪ভাবে:
ovary বেশি androgen বানাচ্ছে, adrenal বেশি androgen বানাচ্ছে, drug/supplement androgen effect বাড়াচ্ছে, অথবা blood androgen normal হলেও hair follicle বেশি sensitive। PCOS guideline-এ clinical/biochemical hyperandrogenism PCOS diagnosis-এর core feature হিসেবে ধরা হয়।
1) PCOS — Polycystic Ovary Syndrome
এটাই women-এ androgen excess-এর সবচেয়ে common cause।
কীভাবে androgen বাড়ে?
PCOS-এ সাধারণত insulin resistance থাকে। Insulin বেশি থাকলে ovarian theca cell বেশি testosterone/androstenedione তৈরি করে। একই সঙ্গে liver-এ SHBG কমে যায়, ফলে free testosterone বেড়ে যায়। Free testosterone বেশি থাকলে hirsutism, acne, scalp hair loss হয়।
কেন period irregular হয়?
High androgen + abnormal follicle development → ovulation ঠিকমতো হয় না → oligomenorrhea/amenorrhea হয়।
Clinical clue
Irregular period + hirsutism/acne + obesity/acanthosis nigricans থাকলে PCOS strongly suspect। 2023 PCOS guideline adult diagnosis-এ Rotterdam-based criteria ব্যবহার করে: hyperandrogenism, ovulatory dysfunction, polycystic ovarian morphology/AMH—এর মধ্যে প্রয়োজনীয় criteria অনুযায়ী diagnosis হয়।
2) Idiopathic Hirsutism
কী হয়?
এখানে blood testosterone/DHEAS অনেক সময় normal থাকে, period regular থাকে, কিন্তু hair follicle androgen-এর প্রতি বেশি sensitive হয়।
Mechanism
Skin/hair follicle-এ 5-alpha reductase activity বেশি হতে পারে। এর ফলে testosterone থেকে DHT বেশি তৈরি হয়। DHT hair follicle-কে coarse terminal hair বানাতে stimulate করে।
Clinical clue
Regular menstruation + normal androgen level + mainly facial/body hair excess = idiopathic hirsutism ভাবা যায়। তবে moderate/severe hirsutism হলে androgen level test করা উচিত। Endocrine Society guideline abnormal hirsutism score থাকলে androgen evaluation করতে বলে।
3) Non-classic Congenital Adrenal Hyperplasia — NCCAH
কী disease?
এটি usually 21-hydroxylase enzyme deficiency-এর mild form। Enzyme কম কাজ করলে cortisol synthesis pathway আটকে যায় এবং precursor hormone androgen pathway-তে চলে যায়।
কীভাবে androgen বাড়ে?
Cortisol কম/relative কম হলে ACTH বাড়ে → adrenal cortex overstimulated হয় → 17-hydroxyprogesterone ও adrenal androgen বাড়ে।
Clinical clue
Teenage/young adult female-এ hirsutism, acne, irregular period, infertility; অনেক সময় PCOS-এর মতো presentation হয়। Diagnosis-এ morning follicular 17-hydroxyprogesterone গুরুত্বপূর্ণ। Hirsutism guideline NCCAH-কে hyperandrogenism differential হিসেবে ধরে।
4) Androgen-secreting Ovarian Tumor
কীভাবে androgen বাড়ে?
Ovary-র tumor সরাসরি testosterone produce করতে পারে। Tumor হলে androgen production অনেক দ্রুত ও বেশি হতে পারে।
Important tumor examples
Sertoli–Leydig cell tumor, Leydig cell tumor, steroid cell tumor।
Clinical clue — red flag
Sudden onset hirsutism, rapid progression, virilization—যেমন deep voice, clitoromegaly, male-pattern balding, increased muscle mass। Endocrine Society guideline sudden/rapid hirsutism, clitoromegaly, menstrual dysfunction থাকলে hyperandrogenic endocrine disorder evaluate করতে বলে।
5) Androgen-secreting Adrenal Tumor
কীভাবে androgen বাড়ে?
Adrenal cortex tumor DHEA/DHEAS বা testosterone precursor excessive produce করতে পারে।
Clinical clue
Very high DHEAS, rapid virilization, abdominal mass symptom, weight loss বা Cushing features থাকতে পারে।
কেন জরুরি?
Adrenal carcinoma rare কিন্তু serious। Rapid virilization বা very high androgen হলে imaging delay করা উচিত নয়।
6) Ovarian Hyperthecosis
কী disease?
Ovary-র stromal cells luteinized হয়ে diffuseভাবে androgen produce করে। এটি tumor নয়, কিন্তু androgen level অনেক বেশি হতে পারে।
কার মধ্যে বেশি?
Perimenopausal বা postmenopausal women-এ বেশি দেখা যায়।
Clinical clue
Postmenopausal new hirsutism/virilization + insulin resistance/diabetes/obesity। PCOS-এর তুলনায় testosterone অনেক বেশি হতে পারে।
7) Cushing Syndrome
কীভাবে androgen বাড়ে?
ACTH-dependent Cushing হলে ACTH adrenal cortex-কে stimulate করে cortisol এর পাশাপাশি adrenal androgen production বাড়াতে পারে।
Clinical clue
Central obesity, moon face, buffalo hump, purple striae, proximal muscle weakness, hypertension, diabetes, easy bruising + menstrual irregularity/hirsutism।
কেন PCOS mimic করে?
Obesity, acne, irregular period, insulin resistance—সব PCOS-এর মতো দেখাতে পারে। তাই Cushing sign থাকলে আলাদা test করতে হয়।
8) Hyperprolactinemia
কীভাবে androgen problem করে?
Prolactin বেশি হলে GnRH suppression হয় → LH/FSH disturbance → ovulation problem ও menstrual irregularity। কিছু ক্ষেত্রে adrenal androgen contribution বাড়তে পারে।
Clinical clue
Amenorrhea/oligomenorrhea + galactorrhea + headache/visual symptom হলে prolactin check জরুরি। Endocrine Society hirsutism guideline galactorrhea বা menstrual dysfunction থাকলে endocrine disorder evaluate করতে বলে।
9) Thyroid Disorder
Hypothyroidism কীভাবে androgen-like presentation করে?
Hypothyroidism-এ menstrual irregularity, weight gain, infertility হতে পারে। SHBG ও reproductive axis change হওয়ার কারণে PCOS-like picture তৈরি হতে পারে।
Clinical clue
Fatigue, cold intolerance, constipation, weight gain, dry skin, bradycardia + irregular period।
10) Acromegaly
কীভাবে androgen excess-এর মতো লাগে?
Growth hormone/IGF-1 excess insulin resistance বাড়ায়। Insulin resistance ovarian androgen production বাড়াতে পারে।
Clinical clue
Large hands/feet, coarse facial features, jaw enlargement, sweating, headache, sleep apnea, diabetes + menstrual disturbance।
11) Severe Insulin Resistance / HAIR-AN Syndrome
HAIR-AN = HyperAndrogenism + Insulin Resistance + Acanthosis Nigricans
কীভাবে androgen বাড়ে?
Very high insulin ovary-কে androgen বানাতে stimulate করে এবং SHBG কমায়। ফলে free testosterone বাড়ে।
Clinical clue
Marked acanthosis nigricans, obesity/central adiposity, diabetes risk, severe hirsutism।
12) Drug-induced Androgen Excess
Common drugs/supplements
Anabolic steroid, testosterone, DHEA supplement, danazol, some progestins, valproate।
Mechanism
কিছু drug সরাসরি androgenic effect দেয়, কিছু drug ovarian/adrenal steroidogenesis বা insulin resistance influence করে।
Clinical clue
New acne/hirsutism/voice change drug শুরু করার পর হলে medication history খুব গুরুত্বপূর্ণ।
13) Pregnancy-related rare causes
Example
Pregnancy luteoma, hyperreactio luteinalis।
Mechanism
Pregnancy-এ ovarian luteinized tissue androgen produce করতে পারে। Rarely mother-এ virilization হতে পারে।
Clinical clue
Pregnancy-এর সময় new severe hirsutism/virilization।
B. Women-এ Androgen Deficiency-এর Cause
মূল কথা
Women-এ “androgen deficiency” diagnosis সহজ নয়, কারণ fatigue/low libido/low mood অনেক disease-এর symptom হতে পারে। Global consensus statement অনুযায়ী women-এ testosterone therapy-এর একমাত্র evidence-based indication হলো postmenopausal HSDD, এবং কোনো fixed testosterone cutoff দিয়ে sexual dysfunction diagnose করা যায় না।
1) Natural Aging / Menopause
কীভাবে androgen কমে?
Age বাড়ার সাথে adrenal DHEA/DHEAS কমে এবং ovarian androgen production-ও কমে। Menopause-এর পর estrogen কমার সাথে sexual symptoms, vaginal dryness, mood/sleep problem দেখা দিতে পারে।
Clinical clue
Postmenopausal low desire, fatigue, vaginal dryness—কিন্তু এগুলো শুধু testosterone deficiency নয়; estrogen deficiency, sleep, mood, relationship factors সব assess করতে হয়।
2) Surgical Menopause — Bilateral Oophorectomy
কীভাবে androgen কমে?
Ovary removal হলে ovarian testosterone/androstenedione production sudden কমে যায়। Natural menopause-এর তুলনায় sudden hormonal drop বেশি symptomatic হতে পারে।
Clinical clue
Hysterectomy with bilateral oophorectomy-এর পর sudden low libido, vasomotor symptoms, mood change, vaginal dryness।
3) Primary Ovarian Insufficiency — POI
কী disease?
৪০ বছরের আগে ovarian function কমে যায়। Estrogen কমে, ovulation বন্ধ হয়, ovarian androgen contribution-ও কমতে পারে।
Clinical clue
Age <40 + amenorrhea/irregular period + high FSH + low estradiol। Symptoms: hot flush, infertility, vaginal dryness, low sexual desire।
4) Adrenal Insufficiency
কীভাবে androgen কমে?
Female androgen-এর বড় অংশ adrenal-derived DHEA/DHEAS থেকে আসে। Primary adrenal insufficiency-এ adrenal cortex cortisol/aldosterone এর পাশাপাশি DHEA/DHEAS কম বানায়।
Clinical clue
Weakness, weight loss, hypotension, hyperpigmentation, salt craving, hyponatremia/hyperkalemia + low libido/low pubic/axillary hair।
5) Hypopituitarism / Hypothalamic Dysfunction
কীভাবে androgen কমে?
Pituitary LH/FSH কম হলে ovarian steroid production কমে। ACTH কম হলে adrenal androgen-ও কমতে পারে।
Causes
Pituitary tumor, Sheehan syndrome, pituitary surgery/radiotherapy, traumatic brain injury, functional hypothalamic amenorrhea।
Clinical clue
Amenorrhea, infertility, low libido, fatigue, headache/visual problem, lactation failure history, multiple pituitary hormone deficiency।
6) Oral Estrogen / COCP Use
কীভাবে free androgen কমে?
Oral estrogen liver-এ SHBG বাড়ায়। SHBG testosterone bind করে রাখে, ফলে free testosterone কমে। তাই COCP ব্যবহারকারীর lab interpretation সাবধানে করতে হয়। PCOS guideline biochemical androgen assessment-এ assay ও interpretation বিষয়ে সতর্কতা দিয়েছে।
Clinical clue
COCP শুরু করার পর low libido/sexual arousal issue হতে পারে, তবে cause multifactorial।
7) Chronic Glucocorticoid Use
কীভাবে androgen কমে?
Long-term steroid ACTH suppress করে। ACTH কমে গেলে adrenal DHEA/DHEAS production কমে যায়।
Clinical clue
Chronic prednisolone/dexamethasone use, Cushingoid appearance, adrenal suppression, fatigue, low libido।
8) Chronic Opioid Use
কীভাবে androgen কমে?
Opioid hypothalamic GnRH suppress করে → LH/FSH কমে → ovarian hormone production কমে। Long-term opioid-induced hypogonadism হতে পারে।
Clinical clue
Chronic pain patient on opioid + amenorrhea/low libido/fatigue।
9) Chronic Systemic Illness / Undernutrition
কীভাবে androgen কমে?
Severe illness, chronic kidney/liver disease, anorexia/low BMI, excessive exercise → hypothalamic suppression → gonadal androgen/estrogen কমে।
Clinical clue
Weight loss, low BMI, amenorrhea, fatigue, stress fracture, reduced muscle mass।
Cause মনে রাখার shortcut
Androgen excess shortcut: O-A-P-D-E
O = Ovarian: PCOS, ovarian tumor, hyperthecosis
A = Adrenal: NCCAH, adrenal tumor, Cushing
P = Peripheral: idiopathic hirsutism, increased 5-alpha reductase
D = Drug: anabolic steroid, testosterone, DHEA, danazol, valproate
E = Endocrine/metabolic: insulin resistance, thyroid, prolactin, acromegaly
Androgen deficiency shortcut: O-A-P-D-S
O = Ovarian failure: menopause, oophorectomy, POI
A = Adrenal failure: Addison/adrenal insufficiency
P = Pituitary/hypothalamic: hypopituitarism, FHA
D = Drugs: oral estrogen/COCP, glucocorticoid, opioid
S = Systemic illness: malnutrition, chronic disease
Overview / Summary
Women-এ androgen excess-এর সবচেয়ে common cause হলো PCOS, কিন্তু rapid onset/virilization/postmenopausal onset হলে ovarian/adrenal tumor rule out করা জরুরি। Androgen deficiency সাধারণত ovary/adrenal/pituitary dysfunction, menopause/oophorectomy, drug effect বা chronic illness-এর কারণে হয়; তবে low testosterone alone দিয়ে diagnosis করা যায় না।
Actionable Plan / Steps
- Symptoms আগে divide করুন: excess features আছে নাকি deficiency/HSDD features আছে।
- Excess হলে source ভাবুন: ovarian, adrenal, peripheral sensitivity, drug, metabolic endocrine।
- Rapid virilization হলে urgent testosterone, DHEAS এবং imaging consider করুন।
- Deficiency suspected হলে menopause/oophorectomy, adrenal disease, pituitary disease, drug history, chronic illness assess করুন।
- Lab interpretation-এ COCP/oral estrogen ব্যবহার history অবশ্যই নিন।
3) Symptoms — point akare
A. Androgen excess symptoms
- Hirsutism — upper lip, chin, chest, abdomen, back-এ coarse terminal hair। Modified Ferriman–Gallwey score use করা যায়; ethnicity অনুযায়ী mFG 4–6 threshold considered।
- Acne / oily skin — adult persistent acne, jawline acne।
- Female pattern hair loss — frontal/vertex thinning।
- Menstrual irregularity — oligomenorrhea, amenorrhea, anovulatory bleeding।
- Subfertility/infertility — chronic anovulation।
- Metabolic signs — central obesity, acanthosis nigricans, weight gain।
- Virilization red flags — deep voice, clitoromegaly, increased muscle mass, breast atrophy, rapid balding।
- Psychological effect — body-image distress, anxiety/depression; PCOS guideline psychological screening emphasize করেছে।
B. Androgen deficiency symptoms
- Low sexual desire with distress — HSDD
- Reduced arousal/orgasm satisfaction
- Fatigue, low energy, low mood — nonspecific
- Reduced well-being or reduced muscle strength — nonspecific
- Surgical menopause/POI হলে hot flush, vaginal dryness, dyspareunia may coexist due to estrogen deficiency
Women-এ Androgen Excess / Deficiency — Symptoms বিস্তারিত বাংলা ব্যাখ্যা
1) Androgen excess হলে মূল symptom pattern
Androgen excess মানে female body-তে androgen hormone বেশি কাজ করছে। এর effect সবচেয়ে বেশি দেখা যায় skin, hair follicle, ovary/menstrual cycle, metabolism এবং কিছু ক্ষেত্রে voice/sexual organs-এ। PCOS-এ hirsutism ও irregular menstrual cycle common clinical feature, এবং COCP guideline-এ এগুলো management target হিসেবেও উল্লেখ আছে।
A. Hair-related symptoms
1) Hirsutism — মেয়েদের male-pattern অতিরিক্ত লোম
এটাই androgen excess-এর সবচেয়ে classic symptom।
কীভাবে দেখা যায়?
চিবুক, upper lip, chest, abdomen, back, inner thigh—এই androgen-sensitive জায়গায় coarse, dark, thick terminal hair হয়।
কেন হয়?
Androgen hair follicle-কে stimulate করে। Testosterone skin-এ গিয়ে DHT হয়। DHT hair follicle-কে পাতলা vellus hair থেকে মোটা terminal hair-এ convert করে।
Clinical example
একজন ২২ বছরের female বলছে—“চিবুক ও upper lip-এ ঘন লোম হচ্ছে, বারবার threading করতে হচ্ছে”—এটা hirsutism হতে পারে।
কীভাবে severity মাপা হয়?
Modified Ferriman–Gallwey score দিয়ে ৯টি androgen-sensitive body area-তে hair growth score করা হয়। Endocrine Society hirsutism guideline-এ Ferriman–Gallwey scoring hirsutism assessment-এর standard method হিসেবে উল্লেখ আছে।
2) Scalp hair thinning / Female pattern hair loss
কীভাবে দেখা যায়?
মাথার সামনে বা vertex area-তে চুল পাতলা হয়, কিন্তু সাধারণত male-এর মতো পুরো bald patch হয় না।
কেন হয়?
Androgen scalp hair follicle-এ miniaturization করে। অর্থাৎ বড় thick hair follicle ছোট হয়ে যায়, hair shaft পাতলা হয়।
Clinical clue
Facial hair বাড়ছে + মাথার চুল পাতলা হচ্ছে = androgen excess strongly suspect।
B. Skin-related symptoms
3) Acne — বিশেষ করে adult acne
কীভাবে দেখা যায়?
Jawline, chin, lower face, chest বা back-এ recurrent acne হতে পারে।
কেন হয়?
Androgen sebaceous gland-কে stimulate করে → sebum production বাড়ে → pore blockage + inflammation → acne।
Clinical clue
Teenage পার হওয়ার পরও persistent acne, irregular period সহ থাকলে PCOS/androgen excess evaluate করা উচিত।
4) Oily skin
কীভাবে দেখা যায়?
মুখ অতিরিক্ত oily লাগে, বারবার acne হয়।
কেন হয়?
Sebaceous gland androgen-sensitive। Androgen বেশি হলে oil production বাড়ে।
5) Acanthosis nigricans
কীভাবে দেখা যায়?
ঘাড়ের পেছনে, axilla, groin-এ কালচে, মোটা, velvety skin patch হয়।
কেন হয়?
এটা সরাসরি androgen symptom না; এটা insulin resistance-এর sign। PCOS-এ insulin resistance থাকলে insulin বেশি হয়, যা ovarian androgen production বাড়াতে পারে।
Clinical meaning
Hirsutism + irregular period + acanthosis nigricans = PCOS/insulin resistance pattern।
C. Menstrual ও reproductive symptoms
6) Irregular period / Oligomenorrhea
কীভাবে দেখা যায়?
Period ৩৫ দিনের বেশি gap-এ আসে, ২–৩ মাস period বন্ধ থাকে, অথবা বছরে ৮ বারের কম period হয়।
কেন হয়?
Androgen বেশি হলে follicle maturation ঠিকভাবে হয় না। Ovulation delayed বা absent হয়। Ovulation না হলে progesterone properly rise করে না, তাই cycle irregular হয়।
Clinical clue
Irregular period + hirsutism/acne থাকলে PCOS very likely। 2023 international PCOS guideline adult diagnosis-এ ovulatory dysfunction ও hyperandrogenism-কে major diagnostic features হিসেবে বিবেচনা করে।
7) Amenorrhea
কীভাবে দেখা যায়?
৩ মাস বা তার বেশি period না হওয়া, especially আগে regular period থাকলে।
কেন হয়?
Chronic anovulation হলে endometrial cycle properly হয় না। Pregnancy, thyroid disease, prolactin disorder, POI, PCOS—সব consider করতে হয়।
8) Heavy or unpredictable bleeding
কীভাবে হয়?
Anovulation হলে progesterone কম থাকে, estrogen unopposed থাকে। Endometrium অনিয়মিতভাবে grow করে, পরে irregular heavy bleeding হতে পারে।
Clinical importance
Long-standing anovulation থাকলে endometrial hyperplasia risk বাড়তে পারে।
9) Subfertility / infertility
কেন হয়?
Ovulation irregular হলে egg release regular হয় না, তাই conception difficult হয়।
Clinical clue
১ বছর চেষ্টা করেও pregnancy না হওয়া + irregular period + hirsutism = anovulatory infertility suspect।
D. Virilization symptoms — dangerous red flag
Virilization মানে female body-তে male secondary sexual characteristics develop করা। এটা সাধারণ PCOS-এ usually mild বা absent থাকে। Rapid virilization হলে ovarian/adrenal tumor exclude করা জরুরি। Rapid onset hirsutism, late onset, progression despite treatment, বা virilization androgen-secreting tumor suggest করতে পারে।
10) Deep voice
কীভাবে দেখা যায়?
Voice permanently মোটা/গম্ভীর হয়ে যায়।
কেন serious?
Androgen vocal cord thickening করতে পারে। অনেক সময় irreversible হতে পারে।
11) Clitoromegaly
কীভাবে দেখা যায়?
Clitoris abnormal enlargement হয়।
কেন হয়?
High androgen genital tissue-তে growth effect করে।
Clinical meaning
এটা severe androgen excess marker; urgent evaluation দরকার।
12) Increased muscle mass / masculine body habitus
কীভাবে হয়?
Androgen anabolic hormone হিসেবে muscle protein synthesis বাড়ায়।
Clinical clue
Female patient suddenly muscular হয়ে যাচ্ছে, acne/hair growth/voice change হচ্ছে—tumor বা anabolic steroid use consider করতে হবে।
13) Breast size কমে যাওয়া
কেন হয়?
Severe androgen excess estrogenic balance disturb করে; virilization-এর অংশ হিসেবে breast atrophy দেখা যেতে পারে।
E. Metabolic symptoms
14) Weight gain / central obesity
কীভাবে দেখা যায়?
পেটের দিকে weight gain বেশি, waist circumference বাড়ে।
কেন হয়?
PCOS-এ insulin resistance common। Insulin resistance weight gain ও androgen excess দুটোই worsen করতে পারে।
15) Sugar craving, fatigue after meal, diabetes tendency
কেন হয়?
Insulin resistance থাকলে glucose metabolism abnormal হয়। PCOS-এর সাথে impaired glucose tolerance, type 2 diabetes, dyslipidemia risk বাড়ে—তাই metabolic screening গুরুত্বপূর্ণ।
16) High blood pressure / dyslipidemia sign
কীভাবে ধরা পড়ে?
এগুলো symptom হিসেবে সবসময় বোঝা যায় না; BP, lipid profile, HbA1c/OGTT দিয়ে detect করতে হয়।
F. Psychological symptoms
17) Anxiety, depression, low self-esteem
কেন হয়?
Hirsutism, acne, obesity, infertility concern—সব মিলিয়ে body image distress হতে পারে। PCOS guideline psychological impact ও quality-of-life issue consider করতে বলে।
18) Social avoidance
কীভাবে দেখা যায়?
Patient facial hair/acne লুকাতে social event এড়ায়, repeated grooming করে, confidence কমে যায়।
2) Androgen deficiency হলে symptoms
Important clinical note
Women-এ “androgen deficiency” symptoms অনেক nonspecific। Low libido, fatigue, mood change শুধু testosterone কম বলেই হবে—এভাবে diagnosis করা ঠিক নয়। Global consensus অনুযায়ী women-এ testosterone therapy-এর evidence-based indication মূলত postmenopausal women with HSDD; অন্য symptom treat করার জন্য testosterone routinely recommended নয়।
A. Sexual symptoms
1) Low sexual desire / HSDD
কীভাবে দেখা যায়?
Sexual desire persistently কম থাকে এবং patient নিজে distress feel করে।
Clinical meaning
শুধু libido কম হলেই HSDD নয়। Distress থাকতে হবে এবং depression, relationship conflict, pain, medication, thyroid/prolactin problem, menopause symptoms—এসব exclude করতে হবে।
2) Reduced arousal
কীভাবে দেখা যায়?
Sexual stimulation থাকা সত্ত্বেও arousal কম লাগে।
কেন হয়?
Androgen central sexual desire ও arousal pathway-তে role রাখতে পারে, তবে estrogen deficiency, vaginal dryness, mood, sleep, relationship factor একসাথে contribute করে।
3) Orgasm difficulty / reduced satisfaction
কীভাবে দেখা যায়?
Orgasm delay, intensity কম, satisfaction কম।
Clinical note
এটা androgen deficiency-specific নয়; SSRI, depression, diabetes neuropathy, relationship issue, pelvic pain—সব evaluate করতে হয়।
B. Energy ও mood symptoms
4) Fatigue / low energy
কীভাবে দেখা যায়?
সবসময় tired লাগে, কাজের আগ্রহ কমে যায়।
কেন nonspecific?
Anemia, hypothyroidism, depression, sleep apnea, diabetes, chronic illness, adrenal insufficiency—অনেক cause হতে পারে। তাই শুধু testosterone level দেখে decision নেওয়া যাবে না।
5) Low mood / irritability
কীভাবে দেখা যায়?
Mood down, irritability, motivation কম।
Clinical note
Menopause, sleep disturbance, depression/anxiety, thyroid disorder বেশি common explanation হতে পারে।
C. Body composition symptoms
6) Reduced muscle strength
কীভাবে দেখা যায়?
Exercise tolerance কমে, muscle weakness লাগে।
কেন হয়?
Severe hypogonadism, menopause, inactivity, chronic steroid use, malnutrition—সব contribute করতে পারে।
7) Reduced bone health — indirect symptom
কীভাবে বোঝা যায়?
Fracture tendency বা low BMD later detect হতে পারে।
Important
Women-এ bone health mainly estrogen, vitamin D, calcium, activity, thyroid/parathyroid, steroid exposure দ্বারা বেশি influence হয়। Testosterone alone দিয়ে bone issue explain করা ঠিক নয়।
D. Hair/body signs
8) Pubic/axillary hair কমে যাওয়া
কোথায় দেখা যায়?
Adrenal insufficiency বা hypopituitarism-এ pubic/axillary hair sparse হতে পারে।
কেন হয়?
Female pubic ও axillary hair partly adrenal androgen-dependent।
E. Underlying disease অনুযায়ী extra symptoms
9) Adrenal insufficiency থাকলে
Weakness, weight loss, hypotension, salt craving, hyperpigmentation, nausea, abdominal pain হতে পারে।
10) Pituitary disease থাকলে
Amenorrhea, infertility, headache, visual field defect, lactation failure, multiple hormone deficiency থাকতে পারে।
11) POI / menopause থাকলে
Hot flush, night sweat, vaginal dryness, dyspareunia, sleep disturbance, infertility বা irregular/absent period থাকতে পারে।
3) Symptoms দেখে quick clinical differentiation
| Symptom pattern | বেশি suggest করে |
| Irregular period + hirsutism + acne | PCOS / androgen excess |
| Rapid hirsutism + deep voice + clitoromegaly | Androgen-secreting tumor until proven otherwise |
| Regular period + only mild facial hair | Idiopathic hirsutism possible |
| Postmenopausal new severe hair growth | Ovarian/adrenal tumor or hyperthecosis |
| Low libido + distress after menopause | HSDD possible |
| Low libido + fatigue + weight loss + hypotension | Adrenal insufficiency consider |
| Low libido + amenorrhea + headache/visual symptom | Pituitary disease consider |
4) Red flag symptoms — urgent referral
- হঠাৎ করে ৬–১২ মাসের মধ্যে severe hirsutism
- Voice deepening
- Clitoromegaly
- Rapid scalp balding
- Postmenopausal new hirsutism
- Very irregular bleeding or prolonged amenorrhea
- Severe acne with virilization
- Headache + visual problem + amenorrhea/galactorrhea
- Cushing features: purple striae, proximal weakness, easy bruising
- Severe weight loss, hypotension, hyperpigmentation
Real clinical example
Case 1 — Androgen excess:
২২ বছরের female, period ৪৫–৬০ দিন পরপর, chin hair, jawline acne, weight gain, neck darkening।
Meaning: PCOS with insulin resistance likely। Symptoms explain হয় high ovarian androgen + low SHBG + insulin resistance দিয়ে।
Case 2 — Tumor red flag:
৪২ বছরের female, ৮ মাসে sudden beard growth, voice deep, scalp balding।
Meaning: PCOS ধরে বসে থাকা যাবে না; ovarian/adrenal androgen-secreting tumor urgently exclude করতে হবে।
Case 3 — Androgen deficiency/HSDD pattern:
৫২ বছরের postmenopausal female, persistent low sexual desire with distress, vaginal dryness, poor sleep।
Meaning: HSDD possible, কিন্তু estrogen deficiency, depression, medication, relationship factor, thyroid/prolactin আগে assess করতে হবে।
Overview / Summary
Androgen excess-এর প্রধান symptoms হলো hirsutism, acne, oily skin, scalp hair thinning, irregular period, infertility, weight gain/insulin resistance, এবং severe হলে virilization। Virilization symptoms—deep voice, clitoromegaly, rapid balding—danger sign। Androgen deficiency-এর symptoms mainly low sexual desire with distress, reduced arousal, fatigue, low mood, reduced muscle strength, কিন্তু এগুলো nonspecific; তাই low testosterone alone দিয়ে diagnosis করা উচিত নয়।
4) Clinical diagnosis & investigations
A. Androgen excess diagnostic approach
History: onset, speed of progression, menarche, cycle length, fertility, weight gain, drugs/supplements, galactorrhea, Cushing features, family history.
Examination: BMI, waist, BP, acne, mFG score, scalp hair loss scale, acanthosis nigricans, Cushing signs, virilization, thyroid/breast exam.
Baseline investigations:
- Pregnancy test — amenorrhea/irregular bleeding থাকলে first.
- Total testosterone by LC-MS/MS — best; direct immunoassay female range-এ inaccurate হতে পারে। PCOS guideline LC-MS/MS prefer করে।
- SHBG + calculated free testosterone / Free Androgen Index।
- DHEAS — adrenal source suspect হলে।
- 17-hydroxyprogesterone, 8 AM follicular phase — NCCAH screen।
- TSH, prolactin, FSH/LH ± estradiol — thyroid, hyperprolactinemia, POI, hypothalamic causes exclude। PCOS algorithm other causes exclude করতে TSH, prolactin, 17-OHP, FSH উল্লেখ করে।
- Metabolic assessment: fasting glucose/HbA1c or OGTT, fasting lipid profile, ALT/AST, BP।
- Cushing suspicion: 1 mg overnight dexamethasone suppression / late-night salivary cortisol / 24h urinary free cortisol।
- Pelvic US/TVS: PCOS morphology, ovarian tumor, endometrial thickness।
- Adrenal CT/MRI: very high DHEAS or adrenal tumor suspicion।
Urgent red flags: sudden severe hirsutism, virilization, postmenopausal new hyperandrogenism, rapidly rising testosterone/DHEAS.
B. Androgen deficiency diagnostic approach
- Do not diagnose only by low testosterone.
- Diagnose HSDD clinically: persistent low sexual desire + personal distress + not explained by depression, relationship issue, pain, medication, endocrine disease.
- Labs: morning total testosterone + SHBG mainly for baseline/monitoring, not for diagnosis; LC-MS/MS preferred. ISSWSH states no definitive testosterone cutoff identifies HSDD.
- Cause workup: TSH, prolactin, CBC/ferritin, HbA1c, lipids, LFT; FSH/LH/E2 for menopause/POI; cortisol/ACTH/DHEAS if adrenal/pituitary disease suspected.
5) Complications
Androgen excess complications
- Infertility: chronic anovulation → ovulation irregular।
- Endometrial hyperplasia/cancer risk: long-term anovulation → unopposed estrogen → endometrium thickening।
- Metabolic syndrome/T2DM/dyslipidemia/HTN: especially PCOS with insulin resistance। PCOS guideline metabolic and CVD risk assessment recommends।
- NAFLD, sleep apnea, pregnancy complications: GDM, hypertensive disorder risk।
- Psychological morbidity: anxiety, depression, low self-esteem।
- Tumor-related risk: ovarian/adrenal tumor delayed diagnosis হলে virilization permanent হতে পারে।
Androgen deficiency complications
- Sexual distress and relationship impairment if true HSDD।
- Quality of life reduction।
- Cause-related complications: POI/surgical menopause/adrenal insufficiency থাকলে osteoporosis, cardiovascular/metabolic risk হতে পারে—এগুলো শুধু low androgen নয়, broader hormone deficiency related।
- Overtreatment complication: testosterone misuse → acne, hirsutism, alopecia, voice deepening, clitoromegaly.
6) Treatment management
A. Non-pharmacological
- Weight management, 150 min/week moderate exercise, resistance training।
- Cosmetic hair removal: shaving, waxing, threading, laser/IPL, electrolysis।
- PCOS হলে sleep, nutrition, mental health, metabolic screening।
- Antiandrogen ব্যবহার করলে effective contraception mandatory—male fetus feminization risk। Endocrine Society antiandrogen monotherapy avoid করতে বলে যদি adequate contraception না থাকে।
B. Pharmacological treatment — Androgen excess
1) Combined oral contraceptive pill — COCP
- Generic name: Ethinyl estradiol + Drospirenone / Desogestrel / Levonorgestrel / Cyproterone acetate
- Therapeutic category: Hormonal therapy; contraception; antiandrogenic cycle control
- Pharmacological class: Combined estrogen–progestin; ovulation suppressor; SHBG increaser
- Why used: hirsutism, acne, irregular menses, endometrial protection in PCOS। COCP is first-line pharmacological therapy for menstrual irregularity and hyperandrogenism in PCOS; Endocrine Society hirsutism guideline also recommends OCP as initial therapy for most women not seeking fertility।
- Dose/duration: 1 tablet daily as pack schedule—21 active + 7 break/inert or 24 active + 4 inert. Hirsutism response assess after minimum 6 months।
- Bangladesh available brand with strength:
- Drospirenone 3 mg + Ethinyl estradiol 0.03 mg: Droscon, Novelon, Rosen, Segura, Valentino।
- Cyproterone acetate 2 mg + Ethinyl estradiol 0.035 mg: Cleo 35, Dyana, Giane। Second-line; VTE risk consider।
- Desogestrel 0.15 mg + Ethinyl estradiol 0.03 mg: Ceptiva, Desolon, Desopil 30, Marvelon।
- Levonorgestrel 0.15 mg + Ethinyl estradiol 0.03 mg + Ferrous fumarate 75 mg: Femipil, Lyta 28, Mayapill, Mini 28, Nordette 28, Noret 28, Norgest।
- Side effects: nausea, breast tenderness, headache, mood change, breakthrough bleeding, BP rise, VTE/stroke rare but serious।
- Avoid/contraindication: pregnancy, migraine with aura, VTE/PE/stroke/IHD history, breast cancer, severe liver disease, uncontrolled HTN, age ≥35 with heavy smoking; CDC U.S. MEC 2024 provides safety categories for contraceptive methods by medical condition।
- Interactions: rifampicin/rifabutin, carbamazepine, phenytoin, phenobarbital, oxcarbazepine, high-dose topiramate, St John’s wort ↓ efficacy; COCP can lower lamotrigine level.
2) Spironolactone
- Generic name: Spironolactone
- Therapeutic category: Antiandrogen for hirsutism/acne; potassium-sparing diuretic
- Pharmacological class: Aldosterone antagonist; androgen receptor antagonist; weak 5-α reductase inhibition
- Why used: COCP after 6 months inadequate হলে add-on antiandrogen; severe distress হলে COCP + antiandrogen specialist use।
- Dose/duration: 25–50 mg daily start; titrate to 50 mg BD or 100 mg BD. Trial ≥6 months; often 6–12 months or longer with monitoring.
- Bangladesh available brand with strength: Inospiron 25/100 mg, Spiretic 25 mg, Spirocard 25/50/100 mg, Spirolac 25/50/100 mg, Verospiron 25 mg।
- Side effects: hyperkalemia, dizziness, hypotension, nausea, breast tenderness, menstrual irregularity, fatigue।
- Monitoring: baseline and follow-up K+, creatinine/eGFR; pregnancy test if relevant।
- Interactions: ACEI/ARB, NSAID, trimethoprim, potassium supplement/salt substitute ↑ hyperkalemia; lithium ↑ toxicity; drospirenone COCP with caution.
3) Finasteride — off-label in women
- Generic name: Finasteride
- Therapeutic category: Antiandrogen for hirsutism/female pattern hair loss — off-label
- Pharmacological class: Type II 5-α reductase inhibitor
- Why used: testosterone → DHT conversion কমায়; hirsutism/scalp hair loss selected cases।
- Dose/duration: 2.5–5 mg once daily; assess after 6–12 months.
- Bangladesh available brand with strength: Pronor 5 mg, Prosfin 5 mg।
- Side effects: low libido, breast tenderness, mood change, headache; rare liver enzyme issue।
- Critical warning: pregnancy contraindicated—male fetus genital abnormality risk; contraception mandatory।
- Interactions: few major; avoid with pregnancy or trying to conceive.
4) Eflornithine cream
- Generic name: Eflornithine hydrochloride 13.9% cream
- Therapeutic category: Topical facial hair growth reducer
- Pharmacological class: Ornithine decarboxylase inhibitor
- Why used: facial unwanted hair কমায়; hair removal method-এর সাথে add-on।
- Dose/duration: thin layer face/chin twice daily, ≥8 hours apart; onset ~8 weeks; 4 monthsে response না হলে stop। MedEx monograph notes twice daily use and 4-month reassessment।
- Bangladesh available brand with strength: Elorim 13.9%, Vaniflo 13.9%, Wonica 13.9%।
- Side effects: burning, stinging, rash, acne, dryness।
- Interactions: irritant topical retinoid/peeling agent with caution.
5) Metformin
- Generic name: Metformin hydrochloride
- Therapeutic category: Insulin sensitizer; antidiabetic
- Pharmacological class: Biguanide; ↓ hepatic glucose production, ↑ insulin sensitivity
- Why used: PCOS-এ metabolic risk, insulin resistance, impaired glucose tolerance, cycle regulation; hirsutism alone treat করার জন্য নয়। PCOS guideline metformin metabolic outcomes-এর জন্য recommend করে; GI side effect কমাতে low dose start and 500 mg increments 1–2 weekly বলে।
- Dose/duration: 500 mg with meal daily → every 1–2 weeks increase; usual 1500–2000 mg/day; max adult 2.5 g/day if tolerated.
- Bangladesh available brand with strength examples: Glunor 500/850 mg, Meglu 500/850 mg, Meglu ER 500/750/1000 mg, Met 500/850 mg, Met XR 500 mg, Nobesit 500/850 mg, Nobesit XR 500/1000 mg, Metarin XR 500/1000 mg।
- Side effects: nausea, diarrhea, abdominal discomfort, metallic taste, B12 deficiency; lactic acidosis rare।
- Avoid/caution: eGFR <30, severe liver disease, acute hypoxia/sepsis, heavy alcohol।
- Interactions: iodinated contrast temporary hold in high-risk renal patients; alcohol ↑ lactic acidosis risk; cimetidine/dolutegravir can increase metformin level.
6) Hydrocortisone — only selected NCCAH/adrenal insufficiency
- Generic name: Hydrocortisone
- Therapeutic category: Glucocorticoid replacement
- Pharmacological class: Corticosteroid; cortisol replacement; ACTH suppression
- Why used: classic CAH/adrenal insufficiency; NCCAH-এ infertility/ovulation or refractory symptoms হলে endocrinologist decide করবে। Routine PCOS hirsutism-এ নয়। Endocrine hirsutism guideline NCCAH-এর hirsutism management PCOS-এর মতো শুরু করে; glucocorticoid only suboptimal response/intolerance situations।
- Dose/duration: replacement commonly 10–15 mg morning + 5 mg afternoon; disease-specific specialist titration.
- Bangladesh available brand with strength: Cotson 10 mg tablet; Hydrason 10/20 mg tablet; Intasone 10/20 mg tablet; Cortef/Cortinex/Cotson/G-Hidrocortisone/Glucort/Hison/Hycort 100 mg/2 ml injection।
- Side effects if excess dose: weight gain, hypertension, hyperglycemia, osteoporosis, infection risk, Cushingoid features।
- Interactions: CYP3A4 inducers rifampicin/carbamazepine ↓ effect; inhibitors ketoconazole/clarithromycin ↑ steroid effect; NSAID ↑ GI bleed risk.
C. Pharmacological treatment — Androgen deficiency / HSDD
Testosterone therapy — specialist-only, off-label in most countries
- Generic name: Testosterone transdermal gel
- Therapeutic category: Androgen therapy for postmenopausal HSDD
- Pharmacological class: Androgen receptor agonist
- Why used: only after biopsychosocial assessment when postmenopausal HSDD persists and modifiable causes are treated. Global consensus says only evidence-based indication is HSDD in postmenopausal women।
- Dose/duration: female-approved product না থাকলে guideline suggests about one-tenth of male 1% transdermal dose or ~300 mcg/day; trial 3–6 months; no response by 6 months → stop; response হলে 6–12 months পরে drug holiday consider।
- Bangladesh available brand: AndroGel topical gel 16.2 mg/gm is listed as a male product; female HSDD dosing is off-label and must be specialist-supervised।
- Oral/injectable testosterone: Andriol TestoCaps 40 mg, Androcap 40 mg are listed in Bangladesh, but ISSWSH guideline says oral formulations, IM injections, pellets, compounded products are not recommended for women due to supraphysiologic/unpredictable exposure and safety concerns।
- Monitoring: total testosterone before therapy; repeat 3–6 weeks after start/dose change; once stable every 4–6 months; keep within physiologic premenopausal female range; monitor acne, hirsutism, alopecia, voice change।
- Side effects: acne, oily skin, facial hair, scalp hair loss, mood change, voice deepening, clitoromegaly; accidental skin transfer to partner/child।
- Interactions/cautions: oral estrogen/COCP/thyroid replacement can raise SHBG and reduce response; pregnancy contraindicated; avoid in active androgen-sensitive cancer or high baseline testosterone.
7) Prevention
- Healthy weight, regular exercise, low refined carbohydrate diet—PCOS insulin resistance reduce।
- Irregular period >3 months হলে evaluation; chronic anovulation untreated রাখা যাবে না।
- Self-medication with testosterone/DHEA/anabolic steroid avoid।
- Antiandrogen চললে reliable contraception + pregnancy test।
- PCOS হলে annual BP, glucose/HbA1c/OGTT, lipid profile, weight/waist follow-up।
- Rapid virilization হলে delay না করে endocrine/gynecology referral।
- NCCAH family history থাকলে genetic counseling।
- Testosterone therapy হলে partner/child skin contact transfer prevention—application site covered, hand wash।
Real clinical example
Case: 24-year female, irregular period every 45–60 days, chin hair, acne, BMI 29, acanthosis.
Likely: PCOS with androgen excess.
Workup: pregnancy test, total testosterone LC-MS/MS, SHBG/free androgen index, DHEAS, 17-OHP, TSH, prolactin, HbA1c/OGTT, lipid, pelvic US if needed.
Treatment core: lifestyle + COCP 6 months; if hirsutism persists → add spironolactone with contraception and K+/creatinine monitoring; facial hair distress → eflornithine + laser.
Overview / Summary
Androgen excess in women is usually PCOS, but rapid onset/virilization means tumor until proven otherwise. Diagnosis is clinical + biochemical, using reliable testosterone assay and excluding thyroid, prolactin, NCCAH, Cushing, adrenal/ovarian tumor. Treatment depends on fertility goal: not seeking pregnancy হলে COCP first-line; persistent hirsutism হলে antiandrogen add; metformin mainly metabolic PCOS; eflornithine/cosmetic therapy for facial hair. Androgen deficiency is not a simple “low testosterone disease”; testosterone therapy is only evidence-supported for postmenopausal HSDD and should be transdermal, physiologic-dose, specialist-monitored.
Actionable Plan / Steps
- First classify: excess vs deficiency/HSDD.
- Red flag check: rapid onset, virilization, postmenopause, very high androgen → urgent referral.
- Order core labs: pregnancy test, total testosterone LC-MS/MS, SHBG/free androgen index, DHEAS, 17-OHP, TSH, prolactin, HbA1c/OGTT, lipid.
- Treat based on goal:
- No pregnancy desire: COCP 6 months.
- Persistent hirsutism: add spironolactone/finasteride with contraception.
- Metabolic PCOS: lifestyle ± metformin.
- HSDD postmenopause: biopsychosocial assessment → transdermal testosterone trial only if appropriate.
- Follow-up every 3–6 months: symptoms, BP, weight, side effects, K+/creatinine if spironolactone, testosterone level if testosterone therapy.
Reference List — Textbook + Guideline + DOI
Textbooks
- Harrison’s Principles of Internal Medicine, 21st ed. Chapters: Disorders of the ovary, hirsutism/virilization, adrenal insufficiency.
- Davidson’s Principles and Practice of Medicine, 24th ed. Endocrinology and reproductive endocrinology chapters.
- Guyton and Hall Textbook of Medical Physiology, 14th ed. Female physiology, adrenal cortex, reproductive hormones.
- Robbins & Cotran Pathologic Basis of Disease, 10th ed. Endocrine pathology, adrenal and ovarian tumors.
- Williams Gynecology, 4th ed. Chapters on PCOS, hirsutism, hyperandrogenic disorders.
Guidelines / Consensus
- International Evidence-based Guideline for the Assessment and Management of PCOS, 2023. DOI: 10.1210/clinem/dgad463.
- Endocrine Society Clinical Practice Guideline: Evaluation and Treatment of Hirsutism in Premenopausal Women, 2018. DOI: 10.1210/jc.2018-00241.
- Global Consensus Position Statement on Testosterone Therapy for Women, 2019. DOI: 10.1016/j.jsxm.2019.07.012.
- ISSWSH Clinical Practice Guideline for Systemic Testosterone for HSDD in Women, 2021. DOI: 10.1016/j.jsxm.2020.10.009.
- CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024
Md.Rafiqul Islam Lipu,Date:-30-05-2026 Saturday,Time:-06-42-25 Pm