Hirsutism and Virilization



Hirsutism is the medical term that refers to the presence of excessive terminal (coarse) hair in androgen-sensitive areas of the female body (upper lip, chin, chest, back, abdomen, arms, and thighs). Virilization is more extensive than hirsutism with additional evidence of masculinization. In particular, the term virilization refers to the concurrent presentation of hirsutism with a broad range of signs suggestive of androgen excess, varying with age, such as ambiguous external genitalia, increased muscle mass, acne, balding, deepening of the voice, breast atrophy, amenorrhea/oligomenorrhea, and increased libido.

Hirsutism and virilization usually have different underlying pathologic conditions, generally more severe in virilization that is frequently an expression of a life-threatening disorder such as malignancy (ovarian or adrenal tumors) (Bonfig et al., Eur J Pediatr 162:623–628, 2003) or classic congenital adrenal hyperplasia (CCAH) (White and Speiser, Endocr Rev 21:245–291, 2000; New, Mol Cell Endocrinol 211:75–83, 2003). Hirsutism commonly results from relatively benign functional disorders. Sometimes, however, it is the presentation of a more severe disorder, and it may be the first manifestation of a condition that will ultimately lead to virilization, if untreated. Therefore, both hirsutism and virilization must be seriously considered by practitioners not only for the disorder that they express but also for the considerable psychological negative impact that they exert in the individual affected, especially among young women (Barth et al., J Psychosom Res 37:615–619, 1993; Sonino et al., Postgrad Med J 69:186–189, 1993; Assante et al., International workshop “disorders of sex development: new directions and persistent doubts”, 14–15 Nov 2011, Bologna, Italy, 2011).


Androgen Receptor Hair Follicle Cyproterone Acetate Intense Pulse Light Ambiguous Genitalia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Escobar-Morreale HF. Diagnosis and management of hirsutism. Ann N Y Acad Sci. 2010;1205:166–74.PubMedCrossRefGoogle Scholar
  2. 2.
    Asuncion M, Calvo RM, San Millan JL, Sancho J, Avila S, Escobar-Morreale HF. A prospective study of the prevalence of the polycystic ovary syndrome in unselected Caucasian women from Spain. J Clin Endocrinol Metab. 2000;85:2434–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Sagsoz N, Kamaci M, Orbak Z. Body hair scores and total hair diameters in healthy women in the Kirikkale Region of Turkey. Yonsei Med J. 2004;45:483–91.PubMedGoogle Scholar
  4. 4.
    DeUgarte CM, Woods KS, Bartolucci AA, Azziz R. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab. 2006;91:1345–50.PubMedCrossRefGoogle Scholar
  5. 5.
    Sanchόn R, Gambineri A, Alpañés M, Martίnez-Garcίa MÁ, Pasquali R, Escobar-Morreale HF. Prevalence of functional disorders of androgen excess in unselected premenopausal women: a study in blood donors. Hum Reprod. 2012;27:1209–16.CrossRefGoogle Scholar
  6. 6.
    Cheewadhanaraks S, Peeyananjarassri K, Choksuchat C. Clinical diagnosis of hirsutism in Thai women. J Med Assoc Thai. 2004;87:459–63.PubMedGoogle Scholar
  7. 7.
    Noorbala MT, Kefaie P. The prevalence of hirsutism in adolescent girls in Yazd, Central Iran. Iranian Red Crescent Medical Journal. 2010;12:111–7.Google Scholar
  8. 8.
    Hickey M, Doherty DA, Atkinson H, Sloboda DM, Franks S, Norman RJ, et al. Clinical, ultrasound and biochemical features of polycystic ovary syndrome in adolescents: implications for diagnosis. Hum Reprod. 2011;26:1469–77.PubMedCrossRefGoogle Scholar
  9. 9.
    Gambineri A, Prontera O, Fanelli F, Repaci A, Di Dalmazi G, Pagotto U, et al. Epidemiological survey on the prevalence of hyperandrogenic states in adolescent and young women. In: 15th International & 14th European congress of endocrinology, 5–9 May 2012, Florence, Italy.Google Scholar
  10. 10.
    New MI. Inborn errors of adrenal steroidogenesis. Mol Cell Endocrinol. 2003;211:75–83.PubMedCrossRefGoogle Scholar
  11. 11.
    Balsamo A, Cacciari E, Piazzi S, Cassio A, Bozza D, Pirazzoli P, et al. Congenital adrenal hyperplasia: neonatal mass screening compared with clinical diagnosis only in the Emilia-Romagna region of Italy, 1980–1995. Pediatrics. 1996;98:362–7.PubMedGoogle Scholar
  12. 12.
    Stiller CA. International variations in the incidence of childhood carcinomas. Cancer Epidemiol Biom Prev. 1994;3:305–10.Google Scholar
  13. 13.
    Cagle PT, Hough AJ, Pysher TJ, Page DL, Johnson EH, Kirkland RT, et al. Comparison of adrenal cortical tumors in children and adults. Cancer. 1986;57:2235–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Federici S, Galli G, Ceccarelli PL, Ferrari M, Cicognani A, Cacciari E, et al. Adrenocortical tumors in children: a report of 12 cases. Eur J Pediatr Surg. 1994;4:21–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Balsamo A, Cacciari E. Le malattie del cortico-surrene. Edited by Prof. G. Saggese, Pacini Editore SPA, Via della Gherardesca 1, Ospedaletto, Pisa; in Monography n. 4 “Endocrinologia Pediatrica “, p. 31–56, Oct 2000.Google Scholar
  16. 16.
    Young RH, Scully RE. Ovarian Sertoli-Leydig cell tumors. A clinicopathologic analysis of 207 cases. J Surg Pathol. 1985;9:543–69.CrossRefGoogle Scholar
  17. 17.
    Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009;91:456–88.PubMedCrossRefGoogle Scholar
  18. 18.
    Carmina E. The spectrum of androgen excess disorders. Fertil Steril. 2006;85:1582–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Azziz R, Carmina E. Sawaya ME Idiopathic hirsutism Endocr Rev. 2000;21:347–62.CrossRefGoogle Scholar
  20. 20.
    Uno H. Biology of hair growth. Semin Reprod Endocrinol. 1986;4:131–41.CrossRefGoogle Scholar
  21. 21.
    Escobar-Morreale HF, Carmina E, Dewailly D, Gambineri A, Kelestimur F, Moghetti P, et al. Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome. Hum Reprod Update. 2012;18:146–70.PubMedCrossRefGoogle Scholar
  22. 22.
    Chen WC, Zouboulis CC. Hormones and the pilosebaceous unit. Dermatoendocrinol. 2009;1:81–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Thiboutot D, Jabara S, McAllister JM, Sivarajah A, Gilliland K, Cong Z, et al. Human skin is a steroidogenic tissue: steroidogenic enzymes and cofactors are expressed in epidermis, normal sebocytes, and an immortalized sebocyte cell line (SEB-1). J Invest Dermatol. 2003;120:905–14.PubMedCrossRefGoogle Scholar
  24. 24.
    Longcope C. Adrenal and gonadal androgen secretion in normal females. Clin Endocrinol Metab. 1986;15:213–28.PubMedCrossRefGoogle Scholar
  25. 25.
    Chrousos GP. Adrenal hyperandrogenism. 2012
  26. 26.
    Orentreich N, Brind JL, Rizer RL, Vogelman JH. Age changes and sex differences in serum dehydroepiandrosterone sulfate concentrations throughout adulthood. J Clin Endocrinol Metab. 1984;59:551–5.PubMedCrossRefGoogle Scholar
  27. 27.
    Balsamo A, Cicognani A, Ghirri P, Scaramuzzo RT, D’Alberton F, Bertelloni S, et al. Disorders of sexual development. In: Bonocore G, Bracci R, Weidlings M, editors. Neonatology: a practical approach to neonatal management. Milan, Italy: Springer-Verlag; 2011. Chapter 123, p. 1004–17.Google Scholar
  28. 28.
    Yamada G, Satoh Y, Baskin LS, Cunha GR. Cellular and molecular mechanisms of development of external genitalia. Differentiation. 2003;71:445–70.PubMedCrossRefGoogle Scholar
  29. 29.
    Yildiz BO, Bolour S, Woods K, Moore A, Azziz R. Visually scoring hirsutism. Hum Reprod Update. 2010;16:51–64.PubMedCrossRefGoogle Scholar
  30. 30.
    Hatch R, Rosenfield RL, Kim MH, Tredway D. Hirsutism: implications, etiology, and management. Am J Obstet Gynecol. 1981;140:815–30.PubMedGoogle Scholar
  31. 31.
    Legro RS, Schlaff WD, Diamond MP, Coutifaris C, Casson PR, Brzyski RG, et al. for the Reproductive Medicine Network. Total testosterone assays in women with polycystic ovary syndrome: precision and correlation with hirsutism. J Clin Endocrinol Metab. 2010;95:5305–13.PubMedCrossRefGoogle Scholar
  32. 32.
    Fanelli F, Belluomo I, Di Lallo VD, Cuomo G, De Iasio R, Baccini M, et al. Serum steroid profiling by isotopic dilution-liquid chromatography-mass spectrometry: comparison with current immunoassays and reference intervals in healthy adults. Steroids. 2011;76:244–53.PubMedCrossRefGoogle Scholar
  33. 33.
    Janse F, Eijkemans MJC, Goverde AJ, Lentjes EGWM, Hoek A, Lambalk CB, et al. Assessment of androgen concentration in women: liquid chromatography-tandem mass spectrometry and extraction RIA show comparable results. Eur J Endocrinol. 2011;165:925–33.PubMedCrossRefGoogle Scholar
  34. 34.
    Balsamo A, Rinaldini D, Marsigli A, Monti S, Bettocchi I, Baronio F, et al. Screening e diagnosi dell’iperplasia surrenale congenita: dalle vecchie alle nuove tecnologie. Ligand Assay. 2012;17:1–10.Google Scholar
  35. 35.
    Balsamo A, Baldazzi L, Menabò S, Cicognani A. Impact of molecular genetics on congenital adrenal hyperplasia management. Sex Dev. 2010;4:233–48.PubMedCrossRefGoogle Scholar
  36. 36.
    Koppens PF, Hoogenboezem T, Degenhart HJ. Duplication of the CYP21A2 gene complicates mutation analysis of steroid 21-hydroxylase deficiency: characteristics of three unusual haplotypes. Hum Genet. 2002;111:405–10.PubMedCrossRefGoogle Scholar
  37. 37.
    White PC, Speiser PW. Congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Endocr Rev. 2000;21:245–91.PubMedCrossRefGoogle Scholar
  38. 38.
    Speiser PW, Dupont J, Zhu D, Serrat J, Buegeleisen M, Tusie-Luna MT, et al. Disease expression and molecular genotype in congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Invest. 1992;90:584–95.PubMedCrossRefGoogle Scholar
  39. 39.
    Welzel M, Schwarz HP, Hedderich J, Dörr HG, Binder G, Brämswig JH, et al. No correlation between androgen receptor CAG and GGN repeat length and the degree of genital virilization in females with 21-hydroxylase deficiency. J Clin Endocrinol Metab. 2010;95:2443–50.PubMedCrossRefGoogle Scholar
  40. 40.
    Krone N, Arlt W. Genetics of congenital adrenal hyperplasia. Best Prac Res Clin Endocrinol Metab. 2009;23:181–92.CrossRefGoogle Scholar
  41. 41.
    Arlt W, Walker EA, Draper N, Ivison HE, Ride JP, Hammer F, et al. Congenital adrenal hyperplasia caused by mutant P450 oxidoreductase and human androgen synthesis: analytical study. Lancet. 2004;363:2128.PubMedCrossRefGoogle Scholar
  42. 42.
    Bongiovanni AM, Root AW. The adrenogenital syndrome. N Engl J Med. 1963;268:1283.PubMedCrossRefGoogle Scholar
  43. 43.
    Richards RN, Meharg GE. Electrolysis: observations from 13 years and 140,000 hours of experience. J Am Acad Dermatol. 1995;33:662–6.PubMedCrossRefGoogle Scholar
  44. 44.
    Haedersdal M, Wulf HC. Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol. 2006;20:9–20.PubMedCrossRefGoogle Scholar
  45. 45.
    Barman Balfour JA, McClellan K. Topical Eflornithine. Am J Clin Dermatol. 2001;2:197–201.CrossRefGoogle Scholar
  46. 46.
    Wolf Jr JE, Shander D, Huber F, Jackson J, Lin CS, Mathes BM, et al. Randomized, double-blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair. Int J Dermatol. 2007;46:94–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Vrbíková J, Cibula D. Combined oral contraceptives in the treatment of polycystic ovary syndrome. Hum Reprod Update. 2005;11:277–91.PubMedCrossRefGoogle Scholar
  48. 48.
    De Leo V, Morgante G, Piomboni P, Musacchio MC, Petraglia F, Cianci A. Evaluation of effects of an oral contraceptive containing ethinylestradiol combined with drospirenone on adrenal steroidogenesis in hyperandrogenic women with polycystic ovary syndrome. Fertil Steril. 2007;88:113–7.PubMedCrossRefGoogle Scholar
  49. 49.
    Lello S, Primavera G, Colonna L, Vittori G, Guardianelli F, Sorge R, et al. Effects of two estroprogestins containing ethynilestradiol 30 microg and drospirenone 3 mg and ethynilestradiol 30 microg and chlormadinone 2 mg on skin and hormonal hyperandrogenic manifestations. Gynecol Endocrinol. 2008;24:718–23.PubMedCrossRefGoogle Scholar
  50. 50.
    Batukan C, Muderris II, Ozcelik B, Ozturk A. Comparison of two oral contraceptives containing either drospirenone or cyproterone acetate in the treatment of hirsutism. Gynecol Endocrinol. 2007;23:38–44.PubMedCrossRefGoogle Scholar
  51. 51.
    Swiglo BA, Cosma M, Flynn DN, Kurtz DM, Labella ML, Mullan RJ, et al. Clinical review: Antiandrogens for the treatment of hirsutism: a systematic review and metaanalyses of randomized controlled trials. J Clin Endocrinol Metab. 2008;93:1153–60.PubMedCrossRefGoogle Scholar
  52. 52.
    Chrousos GP. Is laparoscopic adrenalectomy suitable for all adrenal masses? Nat Clin Pract Endocrinol Metab. 2007;3:210.PubMedCrossRefGoogle Scholar
  53. 53.
    Burges A, Schmalfeldt B. Ovarian Cancer: Diagnosis and Treatment. Dtsch Arztebl Int. 2011;108:635–41.PubMedGoogle Scholar
  54. 54.
    Shearer BM, Thorland EC, Gonzales PR, Ketterling RP. Evaluation of a commercially available focused aCGH platform for the detection of constitutional chromosome anomalies. Am J Med Genet. 2007;143:2357–70.CrossRefGoogle Scholar
  55. 55.
    Zimmermann B, Zhong XY, Holzgreve W, Hahn S. Real-time quantitative polymerse chain reaction measurement of male fetal DNA in maternal plasma. Methods Mol Med. 2007;132:43–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Lajic S, Nordenström A, Hirvikoski T. Long-term outcome of prenatal treatment of congenital adrenal hyperplasia. Endocr Dev. 2008;13:82–98.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Division of Endocrinology, Department of Medical and Surgical SciencesSt. Orsola-Malpighi Hospital, University of BolognaBolognaItaly
  2. 2.Pediatric Unit, Department of Medical and Surgical SciencesSt. Orsola-Malpighi Hospital, University of BolognaBolognaItaly

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