Gynecology [VIRILIZATION]

Hirsutism Hirsute Virilization

Hirsutism is the process of masculinization. It is the mild Fat Hirsutism and….
version of the process (the more severe form being virilization). Hairy Amenorrhea
It is caused by excess androgens. The classic presentation is Excessive Coarse Clitoromegaly
going to be fat and hairy – development of obesity and body hair
excessive body hair. Male distribution of ↑ Muscle Mass
body hair
There will NOT be any changes in voice, clitoris, or muscle Deepened Voice
mass.

Virilization
Virilization is a more severe form of testosterone influence. It
includes Hirsutism, but also the physiologic consequences of
testosterone in med. The clitoris will enlarge, the voice will
deepen, and she may suffer amenorrhea. Muscle mass may
increase.

Testosterone and DHEA Ovaries Adrenals

The ovaries make testosterone. Testosterone has the direct Testosterone DHEAS
effect of hirsutism and virilization. A little bit does nothing, too Ultrasound CT Scan
much causes hirsutism, and way too much causes virilization. (17-OH-Progesterone)

The adrenals make DHEA in response to ACTH. DHEA is

effectively testosterone (via androstenedione). A little bit does
nothing, too much causes hirsutism, and way too much causes
virilization.
PCOS: The not-a-tumor (Hirsute) of the ovary
In terms of DIAGNOSIS, it matters. But for her body, it doesn’t (testosterone, ultrasound)
matter from where or in which form the testosterone is in, only
how much her body sees that determines the symptoms: a little Sertoli-Leydig: the tumor (virilization) of the ovary
makes her hirsute, a lot makes her virilized. (testosterone, ultrasound)

Diagnosis Adrenal tumor: a tumor (virilization) of the adrenal gland

Pelvic Ultrasound is the test of choice to identify ovarian (DHEAS, CT scan)
tumors (granulosa-theca being the most common).
Congenital Adrenal Hyperplasia: a not-a-tumor (Hirsute)
CT scan of the abdomen is the preferred method to identify of the adrenals (DHEAS, CT Scan).
adrenal tumors or disorders.

Cancers produces way too much = virilization

Non-cancers produce too much = hirsutism.

Differential

PCOS Sertoli-Leydig Adrenal Tumor CAH Familial Hirsutism

Exam: Hirsute Virilization Virilization Hirsute Hirsute
Testosterone: ↑ ↑↑↑ Normal Normal Normal
DHEAS: Normal Normal ↑↑↑ ↑ Normal
Imaging: Bilateral Ovary Unilateral Ovary Unilateral Adrenal Bilateral Adrenal Normal
Ultrasound Ultrasound CT Scan CT Scan Normal
Dx: LH/FSH 3:1 - Adrenal vein sampling 17, OH, Progesterone Normal
Tx: OCP Resection Resection Cortisol Normal
Metformin Fludrocortisone
Spironolactone

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