Download A4Medicine Mobile App
Empower Your RCGP AKT Journey: Master the MCQs with Us! 🚀
Definition:
Exaggerated development of male secondary sexual characteristics in females or prepubertal boys.
Usually due to excess androgen production from adrenal or ovarian sources.
Can present at any age:
Infancy: ambiguous genitalia
Puberty: premature virilisation
Adulthood: rapid masculinisation
Epidemiology:
Rare condition.
More noticeable in females due to contrast with expected sexual characteristics.
May signal serious underlying pathology — e.g., androgen-secreting tumors, congenital adrenal hyperplasia (CAH).
Occurs globally, with variable prevalence depending on cause.
Key causes of virilism include
| Cause | Clinical clues / notes | Key investigations & comments |
|---|---|---|
| Polycystic ovary syndrome (PCOS) | Most common cause of mild–moderate hyperandrogenism; irregular/absent menses; polycystic ovaries on US; usually causes hirsutism > virilisation | LH/FSH ratio (>3 suggests PCOS), fasting glucose, insulin, lipid profile. Sudden virilisation → investigate other causes |
| Congenital adrenal hyperplasia (CAH) (21-hydroxylase deficiency, classic or non-classic) |
Virilisation at birth or puberty; accelerated growth, early pubarche, clitoromegaly | Early-AM 17-hydroxyprogesterone (>300 ng/dL → ACTH stimulation test). Treat with glucocorticoids; refer to endocrinology |
| Androgen-secreting ovarian tumour | Rapid virilisation; deep voice, clitoromegaly; often unilateral | ↑ Serum total testosterone (>200 ng/mL), DHEA-S normal. Pelvic US/CT; surgical removal (oophorectomy) |
| Androgen-secreting adrenal tumour | Sudden virilisation ± Cushingoid features; may cause HTN, hypokalaemia | ↑↑ DHEA-S (>700 µg/dL). CT/MRI adrenal; surgical removal (adrenalectomy) |
| Cushing syndrome | Weight gain, moon face, purple striae, easy bruising + androgenic features | 24-hr urine free cortisol and/or dex suppression test. Endocrine referral |
| Exogenous androgens / anabolic steroids | Drug use history; acne, mood changes, virilisation; often athletes | No specific biochemical test; drug history essential. Stop offending drug; psychological support |
| Rare genetic causes / DSD | Virilisation in phenotypic females (often at puberty); may have ambiguous genitalia, primary amenorrhoea | Endocrine + genetic workup; specialist referral |
Symptoms vary by age and severity but are more evident in females.
Presentation may be gradual in functional causes or sudden in androgen-secreting tumours. Key clinical features are summarised below:
| Category | Key Points |
|---|---|
| Virilising changes (females) | ↓ breast size, shrinking uterus, amenorrhoea/oligomenorrhoea, ↑ facial/body hair, acne/oily skin, male-pattern baldness, clitoromegaly, deep voice, ↑ libido |
| Onset pattern | Gradual in benign/functional causes; rapid progression → suspect androgen-producing tumour |
| Examination findings | Male-pattern alopecia, temporal hairline recession, ↑ muscle mass, deep voice, severe acne, clitoromegaly; Ferriman–Gallwey score for hirsutism; assess for obesity, insulin resistance (acanthosis nigricans), BP, abdominal/pelvic masses |
| Associated features | Psychological distress, anxiety, depression; mental-health assessment may be needed |
| Special age-related clues | Infants: ambiguous genitalia (e.g., clitoral hypertrophy in CAH) Children: accelerated growth → possible short adult stature if untreated Males: infertility from gonadal suppression |
| Red flags đźš© | Rapid onset, voice deepening, clitoromegaly, Cushingoid features (HTN, striae) |
Clinical distinction – Hirsutism vs Virilisation
Hirsutism → Excessive terminal hair growth in a male-pattern distribution (face, chest, back, abdomen).
Virilisation → Hirsutism plus additional masculinising features:
Clitoromegaly
Deepened voice
Male-pattern balding
↑ muscle mass
↓ breast size
Severity: Hirsutism usually linked to mild–moderate androgen excess (e.g., PCOS); virilisation often signals marked androgen excess.
Cleveland Clinic note: Hirsutism = milder, isolated hair growth changes; virilisation = broader endocrine and systemic signs.
Urgency: Rapid-onset virilisation → suspect androgen-producing tumour or severe endocrine disorder.
History
Onset & progression → Sudden/rapid (months) → suspect tumour; gradual (years) → PCOS/idiopathic.
Menstrual & reproductive → Cycle regularity, fertility, age at menarche, amenorrhoea, libido.
Medication/drug use → Anabolic steroids, progestins, testosterone creams, danazol.
Family & ethnicity → Relatives with hirsutism/CAH; ethnic variation in hair growth.
Associated symptoms → Cushing’s features, thyroid disease, galactorrhoea, insulin resistance, weight change, voice change, muscle strength.
Examination
General → BP, BMI, waist circumference, acne, alopecia, acanthosis nigricans, striae, breast atrophy, voice.
Genital → Clitoromegaly (index >35 mm²), labial fusion, ambiguous genitalia.
Abdominal/pelvic → Palpate for ovarian/adrenal masses.
Laboratory (initial in primary care)
Serum total testosterone → >150 ng/dL → urgent referral.
DHEA-S → >700 µg/dL → adrenal tumour suspicion.
17-hydroxyprogesterone → >300 ng/dL → non-classic CAH (ACTH test if 300–1 000 ng/dL).
LH/FSH ratio → >3 → PCOS.
Other → Prolactin, TSH, fasting glucose/insulin, lipid profile, 24-hr urinary cortisol if Cushing’s suspected.
Pregnancy test in reproductive-age women before imaging/treatment.
Imaging
Pelvic US → First-line for PCOS or ovarian mass.
Adrenal CT/MRI → High DHEA-S or testosterone without ovarian mass.
Brain MRI → If hyperprolactinaemia or pituitary signs.
Management of virilisation in primary care focuses on identifying the cause, alleviating symptoms, and coordinating specialist input. GPs are central in:
Initiating investigations to differentiate benign from serious causes.
Providing supportive and symptomatic care (e.g., hair reduction, menstrual regulation).
Addressing psychological well-being alongside physical health.
Facilitating timely referral to endocrinology, gynaecology, or oncology when indicated.
Lifestyle modification, cosmetic measures, and mental health support are often started in parallel with diagnostic work-up.
| Approach | Examples | Notes / GP Role |
|---|---|---|
| Lifestyle & Supportive |
Weight loss (5–10% in PCOS); balanced diet; regular exercise Cosmetic hair removal: shaving, waxing, depilatory creams Physical methods: laser hair removal / electrolysis |
Improves insulin sensitivity and ↓ androgens in PCOS; laser most effective for dark hair on light skin; set expectations (multiple sessions) |
| Psychological Support | Counselling; support groups; body‑image interventions | Screen for anxiety/depression; offer/refer for psychological therapies alongside medical care |
| Pharmacological (specialist‑guided) |
COCP with low‑androgenic progestin (e.g., drospirenone, cyproterone acetate) Anti‑androgens: spironolactone 50–200 mg/day; finasteride 5 mg/day Glucocorticoids for CAH (hydrocortisone/prednisolone); metformin if insulin resistance |
Ensure reliable contraception with anti‑androgens/finasteride (teratogenicity); monitor K+ (spironolactone) & LFTs (some agents); initiate with/endocrinology input |
| Condition‑Specific |
Cushing’s: treat cortisol excess (medical/surgical) CAH: glucocorticoid suppression Tumours: definitive surgical management |
GP role: recognise, stabilise if needed, and refer urgently to endocrinology/gynae/oncology |
| Surgical |
Ovarian tumour → unilateral salpingo‑oophorectomy Adrenal tumour → adrenalectomy |
Early referral improves outcomes; coordinate peri‑operative and follow‑up care |
Urgent referral (endocrinology/gynaecology ± oncology):
Rapid-onset virilising features (months), ↑ testosterone >4.8 nmol/L or markedly ↑ DHEA-S → suspect androgen-secreting tumour.
Clitoromegaly, voice deepening, or ↑ muscle mass.
Palpable adrenal or ovarian mass.
Associated systemic features:
Hypertension + Cushingoid signs
Short stature or strong FHx of CAH
Infertility of unclear cause
Paediatric cases with ambiguous genitalia or precocious puberty → urgent paediatric endocrinology.
Routine referral:
PCOS confirmation or complex management.
Laser hair removal or electrolysis in secondary care.
Metabolic risk screening and weight-management programme referral.
Lack of improvement after 6–12 months of primary care treatment.
Virilisation = significant androgen excess → not purely cosmetic; rapid progression = urgent investigation and referral.
Differentiate hirsutism (hair growth only) from virilisation (deep voice, male-pattern balding, ↑ muscle mass, clitoromegaly).
History & exam → menstrual pattern, fertility plans, drug use, family history, full physical incl. genital, metabolic, and endocrine signs.
Targeted labs → total testosterone, DHEA-S, 17-hydroxyprogesterone, LH/FSH ratio → help distinguish PCOS, CAH, tumours.
Imaging → urgent if hormones markedly ↑ or mass suspected on exam.
Psychological care → address distress; coordinate with endocrinology, gynaecology, mental health.
Williams Textbook of Endocrinology. Latest edition. Chapter on Hyperandrogenism and Virilization. Elsevier.
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19–25.
Nieman LK, et al. Endocrine Society Clinical Practice Guideline on Evaluation and Treatment of Hyperandrogenism. J Clin Endocrinol Metab. 2018;103(11):4565–4592.
Winters SJ, Troen P. Androgen excess disorders in men: Clinical features, diagnosis, and management. UpToDate. 2025.
National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summary: Hirsutism. Updated 2024.
Royal College of General Practitioners. Curriculum topic guide: Women’s Health. Updated 2024.
Teede HJ, et al. Long-term cardiometabolic health in PCOS: a review. Clin Endocrinol (Oxf). 2022;97(6):849–860.
International PCOS Network. International evidence-based guideline for the assessment and management of PCOS. Hum Reprod. 2018;33(9):1602–1618.
Speiser PW, et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(11):4043–4088.
NICE. Clinical Knowledge Summary: Hirsutism. Cosmetic and medical management options. Updated 2024.
Carmina E, et al. Relative prevalence of different androgen excess disorders in women referred for hirsutism. J Clin Endocrinol Metab. 2006;91(1):2–6.
Additional cited sources:
Cleveland Clinic. “Virilization: What It Is, Causes, Symptoms & Treatment.” Health Library. Reviewed Feb 26 2024. Available from: my.clevelandclinic.org
Mihailidis J, Dermesropian R, Taxel P, et al. Endocrine evaluation of hirsutism. Int J Women’s Dermatol. 2017;3(1):37–43.
Sachdeva S. Hirsutism: Evaluation and Treatment. Indian J Dermatol. 2010;55(1):3–7.
Santi M, Graf S, Zeino M, et al. Approach to the Virilizing Girl at Puberty. J Clin Endocrinol Metab. 2020;105(11):dgaa539.
