Virilization

Virilization, also called masculinization, is the development of male-typical secondary sexual characteristics in a person who is otherwise female or prepubertal, caused by excess androgens or exposure to androgens. Common features include clitoromegaly, deepening of the voice, increased facial and body hair, acne, redistribution of body fat and muscle mass, and cessation of menses. The onset can be gradual or rapid and may occur at any age.

Causes include endogenous androgen excess from adrenal or ovarian sources or exogenous exposure. Common etiologies include congenital adrenal hyperplasia (especially 21-hydroxylase deficiency), androgen-secreting adrenal or ovarian tumors, Cushing syndrome, polycystic ovary syndrome with hyperandrogenism, and iatrogenic administration of androgens or prohormones. In pregnancy, fetal exposure can cause virilization of a female fetus when conditions are active.

Diagnosis relies on history and examination plus laboratory evaluation and imaging. Laboratory testing typically shows elevated androgens, including total and free testosterone, DHEA-S, and androstenedione; measurement of 17-hydroxyprogesterone can screen for CAH. Prolactin and thyroid function tests may be used if menstrual changes are prominent. Imaging (ultrasound, CT, MRI) may identify adrenal or ovarian tumors. Timely assessment is important to identify potentially treatable causes.

Management targets the underlying cause. CAH is treated with glucocorticoids; androgen-secreting tumors require surgical removal; non-tumor causes such as PCOS may be managed with lifestyle modification and hormonal therapy. Antiandrogens (spironolactone, finasteride) or GnRH agonists may reduce androgen effects; appropriate counseling and support, including gender-affirming care when relevant, should be provided. Prognosis depends on the etiology and response to treatment.