Virilization is a syndrome in which a person assigned female at birth develops traits typical of those exposed to androgen hormones. It also describes a newborn of any sex who displays signs of androgen hormone exposure at birth.
Androgens are sex hormones, such as testosterone. They are produced in higher quantities in people with testes than in people with ovaries. They control the development of the characteristics typical of people assigned male at birth.
Virilization most often occurs when the adrenal glands are dysfunctional and produce too many androgens. Certain drugs and health problems can also trigger virilization. Treatment varies based on the cause.
This article explains virilization, its symptoms, its diagnosis, and how to treat it. It also describes its role in transgender care.
A Note on Gender and Sex Terminology
Verywell Health acknowledges that sex and gender are related concepts, but they are not the same. To accurately reflect our sources, this article uses terms like “female,” “male,” “woman,” and “man” as the sources use them.
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What Is Virilization?
Virilization, or the masculinization of a person assigned female at birth, is the result of having too many androgen sex hormones. It results from an excess production of androgens, which include testosterone, that regulate your sex characteristics. It can also occur in newborns of any sex who were exposed to excessive levels of androgens in utero.
The dysfunction can occur as a result of congenital (present at birth) or acquired conditions. It is usually linked to a tumor in or enlargement of the adrenal glands. These two small organs produce the hormones that keep your body alive and healthy. Your adrenal glands also produce hormones that your body uses to make the sex hormones estrogen and testosterone.
Virilization can also occur as a result of a tumor in an ovary or imbalanced hormone production by the ovaries.
Hirsutism vs. Virilization
Virilization and hirsutism both occur as a result of excess androgen production, though their underlying causes and symptoms typically differ:
Hirsutism involves terminal (coarse) hair growth in individuals assigned female at birth. Hirsutism is often related to disorders of the pituitary gland, adrenal gland, or thyroid gland and triggers hair growth in a male pattern in the following areas:
- Chin and upper lip
- Chest
- Back
- Abdomen
- Arms
- Thighs
Virilization is a more pronounced condition that may involve ovarian or adrenal tumors. In addition to male hair patterns, virilization promotes the development of secondary sexual characteristics typical of males, or masculinization, which can include voice deepening, male pattern baldness, and increased muscle mass.
Characteristics of Virilization
Characteristics of virilization can vary based on the sex and age of the person affected. The level of excess androgens generated by adrenal glands can also affect the way the syndrome presents.
Symptoms of adrenal virilization can include:
- Thick, dark facial hair, forming a beard or mustache
- Increase in body hair
- Male-pattern baldness
- Acne
- Deepening of the voice
- Increased muscularity
- Increased libido (sex drive)
- Irregular menstrual periods
- Decreased breast size
- Anatomical changes such as an enlarged clitoris and decreased uterus size
The production of excess adrenal hormones in males can interfere with the normal function of the testes, resulting in infertility.
Virilization in newborn girls may cause genitals that are ambiguous or resemble those of boys. Ovarian cysts during childhood may also occur.
Untreated virilization in children causes the following complications:
- Accelerated growth
- Premature closure of the growth plates (growing center of the bones) resulting in short stature
- Premature sexual maturation in males
Symptom Onset
Symptom onset of virilization can occur at any age, depending on the timing of the underlying cause.
Symptom onset at birth or soon after is usually linked to congenital adrenal gland abnormalities or exposure to excessive male hormones in utero from the pregnant person.
Symptom onset at puberty in females is often the result of genetic conditions or acquired disorders affecting the adrenal glands or ovaries.
Symptom onset in adult females can occur with the development of a tumor in or enlargement of an adrenal gland. An ovarian tumor or abnormal hormone production by the ovaries can also trigger symptom onset.
Emergency Symptoms
Because virilization can occur as a symptom of an adrenal tumor, symptoms should not be ignored. Though rare, these tumors in the adrenal glands can be cancerous due to adrenocortical carcinoma (cancer of the adrenal cortex). A prompt diagnosis and treatment can reduce your risk of serious outcomes.
Contact a healthcare provider immediately if you have any of the following symptoms with signs of virilization:
- Abdominal pain or fullness
- A lump or mass within your abdomen
- Back pain or discomfort
- Menstrual abnormalities
- Hypertension (high blood pressure)
- Weight changes
- Disproportionate development of fat around your midsection
- Development of a moon-shaped or rounded face
- Depression, fatigue, and/or anxiety
- Muscle weakness
- Bruising easily
- Diabetes diagnosis
Associated Virilization Conditions and Risk Factors
Associated virilization conditions and risk factors for the overproduction of androgens can vary based on the affected person’s age.
Congenital adrenal hyperplasia is the most common genetic cause of virilization before and at puberty. This inherited disorder affects the two adrenal glands, which produce androgens, cortisol (a hormone that regulates your response to illness and injury), and aldosterone (a hormone that regulates salt and water levels).
People with congenital adrenal hyperplasia have an enzyme deficiency that interferes with the normal production of one or more of these hormones. In the most common form of the disease, nonclassical congenital adrenal hyperplasia, your body makes sufficient cortisol and aldosterone but too much of certain androgens.
In newborn females, the following causes are also linked with virilization, though they occur rarely:
- Certain medications, such as testosterone or other exogenous androgens or progestational agents (progestins used to maintain a pregnancy, treat gynecological disorders, or regulate menstrual cycles) taken by the pregnant person during pregnancy
- Certain medical conditions in the pregnant person, such as tumors of the ovaries or adrenal glands that release androgens
- Aromatase deficiency (reduced levels of estrogen and increased levels of testosterone) in the pregnant person
In addition to congenital adrenal hyperplasia, the following conditions may cause virilization in females at any age:
- Polycystic ovary syndrome (PCOS) (a condition in which multiple cysts form on the ovaries)
- Certain medications, such as androgen pills or anabolic steroid injections
- Adenomas (noncancerous tumors) or cancerous tumors of the adrenal glands that release androgens
- A cancer outside the adrenal gland, typically located in the ovaries, that produces adrenal androgens or testosterone
Diagnosing Virilization in Puberty or Young Adulthood
Diagnosing virilization in puberty or young adulthood requires finding the source of the excess androgens so treatment can be considered. Virilization that occurs at puberty can have an underlying cause of a malignant tumor, so a prompt and accurate diagnosis can help avoid ongoing virilization and other health problems. The following diagnostic tools may be used:
Medical history: This involves discussing the timing and progression of virilization symptoms. A family medical history of related conditions, such as tumors and fertility issues, is also considered.
Physical examination: This involves assessing your physical condition and the presence of physical signs of virilization, such as an enlarged clitoris.
Blood tests to determine levels of the following androgens:
Imaging tests to identify or exclude androgen-secreting ovarian or adrenal tumors based on clinical findings and blood tests:
Based on the results of first-line investigations, second-line testing may include:
- Cortisol profile, adrenocorticotropic hormone (ACTH), and /or ACTH stimulation test to evaluate adrenal gland function
- Comprehensive serum steroid profiling (LC-MS/MS) or urine profiling (GC-MS) for the evaluation of unspecific tumors
- Dexamethasone suppression test
- Repetition of imaging studies based on laboratory results
- Catheter-based procedures: These procedures use adrenal vein sampling to diagnose and locate adrenal tumors.
- Diagnostic laparoscopy and biopsy (tissue sample)
- Genetic testing based on diagnosis
When to Treat Virilization
The timing and choice of treatment of virilization depends on factors that include the cause of the syndrome as well as the age and overall health of the affected person.
In newborns and children, untreated virilization can result in accelerated growth and early closure of the bone’s growth plates, resulting in short stature. Allowing virilization to remain untreated can lead to irreversible bodily changes such as a deepening of the voice.
In puberty or young adulthood, untreated virilization that occurs due to adrenal gland dysfunction can lead to additional health complications including impaired fertility. When virilization is caused by excess androgen levels, most symptoms stop when the hormone levels normalize.
Depending on the causes of virilization, treatments can include:
- Oral glucocorticoids: Oral steroids, typically in the form of hydrocortisone, can reduce the production of androgens when a genetic condition like congenital adrenal hyperplasia causes virilization.
- Adrenalectomy (adrenal gland removal): Removal of the affected adrenal gland may be advised when virilization occurs due to benign (noncancerous) or malignant (cancerous) adrenal tumors.
- Oophorectomy (removal of ovaries): Though most ovarian tumors are noncancerous, removing one or both ovaries may be necessary when this is the source of virilization.
Virilization in Transgender Medical Care
Though a person assigned female at birth who identifies as female may seek to correct virilization, the effect can be the goal for a transgender man (a person assigned female at birth who identifies as a male).
Virilization is a key goal of gender-affirming care for transgender men during the transition process. The administration of exogenous testosterone (testosterone not produced within the body) is the primary virilizing treatment.
This involves the use of testosterone to help develop male secondary sex characteristics (male hair patterns, voice deepening, increased muscle mass) and suppress or minimize female secondary sex characteristics (voice quality, breast size, and facial hair).
Generally, the use of cross-sex hormone therapy has demonstrated positive physical and psychological effects on the transitioning individual. With proof of safety and efficacy, hormone therapy is considered a mainstay treatment for many transitioning individuals.
With testosterone therapy, transgender men can experience an improvement in their quality of life, sexual function, and mood. In transgender men, testosterone therapy can promote the following signs of virilization:
Early effects (as early as three months after starting treatment):
- Amenorrhea (cessation of menses)
- Increased facial and body hair
- Increased acne and other skin changes
- Changes in fat distribution
- Increases in muscle mass
- Increased libido
Later effects:
- Deepening of the voice
- Atrophy (wearing away) of the vaginal epithelium
- Increased size of the clitoris
However, transgender men using virilization therapy have a potentially higher risk of the following comorbidities:
- Diabetes
- Excess weight
- High hematocrit (higher red blood cell volume in relation to plasma in the blood), which can cause a stroke, heart attack, or other conditions
- Osteoporosis (a weakening of the bones)
- Acne
- Mood swings
- Worsening of anxiety, depression, or other mental health conditions in reaction to starting a “second puberty” during transition
- Migraine headaches
- Autoimmune conditions
Self-Care and Prioritizing Health During Virilization Treatment Side Effects
Self-care and lifestyle modifications that prioritize your health can help you reduce the risks and side effects common in virilization therapy. Some strategies to consider include:
- Quit smoking or greatly cut back.
- Take testosterone only in the form and dosage prescribed.
- Consult a registered dietitian to learn how to modify your diet to meet new caloric needs.
- Protect your bone health by doing weight-bearing exercises and taking calcium and vitamin D.
- Eat a heart-healthy diet high in fiber and whole foods, low in saturated fat, sodium, and processed sugars.
- Reduce stress with practices such as meditation or yoga.
- Support your mental health by consulting a behavioral health specialist.
Summary
Virilization is a process in which a female develops male sex traits. It can also occur when a newborn has signs of excess androgen exposure at birth.
This syndrome can occur if your adrenal glands produce extra androgens or you take anabolic steroids. A tumor on your adrenal gland or ovary can also trigger an excess of androgens.
Virilization is often reversible with the right treatment. Treating the cause of excess androgen can involve hydrocortisone or surgery to remove tumors and/or the involved adrenal glands or ovaries. Despite treatment, some symptoms, such as a deeper voice, often remain unchanged.
Contact your healthcare provider if you notice signs of virilization. The syndrome can be caused by underlying ailments that can include tumors and cancer. Early diagnosis can help you achieve the best results and protect your health.
