What Is Virilization?
Virilization or masculinization is a condition, that leads to females developing male-pattern hair growth and other male/masculine characteristics. Virilization is caused by an excess production of testosterone or androgens which are the male sex hormones In women with virilization, there is an imbalance between the female hormone estrogen and male hormones.
Do Females Need Testosterone?
A certain amount of testosterone is absolutely necessary for proper growth, maintenance and functioning of the female body. Therefore testosterone is as important for the health of a woman as estrogen is. It’s all about the balance.
When a woman has too little testosterone in her system, she may experience lethargy, lack of muscle mass, mood changes and weight gain. So although it is a male hormone, females need it too – but in smaller amounts.
What Are Androgens?
Androgens are male sex hormones which are steroids. They increase during puberty in both boys and girls. During reproductive age the levels of androgens remain high. There are several types of androgens.
- Testosterone: The hormone mainly produced by the testicles in males and in small amounts in ovaries of females.
- Dihydrotestosterone (DHT): It is a metabolite of testosterone. DHT is more potent than testosterone as it binds well to androgen receptors. DHT causes differentiation of penis, scrotum and prostate in the male fetus while inside the uterus. In adults DHT causes the growth of prostate, sebaceous gland activity and balding in males.
- Dehydroepiandrosterone (DHEA), Androstenedione and Androstenediol: These androgens are produced by the adrenal glands of both males and females. They are also responsible for developing male sexual characteristics.
All androgens play a major role in developing male sexual characteristics in males, as well as females up to some extent. When androgens are excessive in females it leads to symptoms of virilization in affected in women.
What Are the Symptoms of Virilization?
When the female develops physical symptoms like a male, it is called virilization. That means due to excess of androgens in the body, these females start looking more and more like males and develop secondary sexual characteristics.
Excess testosterone can change your voice and make it deeper.
More Muscles Mass
If there is too much of testosterone in the system, a female can develop more muscle mass. Increasing muscle mass can be an unwanted feature for many women.
Male Pattern Baldness
Excess testosterone may lead to hair loss and thinning. Balding (mainly temples and crown of your head) may also be visible with time, which can be a huge cosmetic concern for many women.
Excessive testosterone can lead to overactivity of the sebaceous glands. Acne occurs due to excessive production of sebum or natural oils when the sebaceous glands are overly active and when pores are blocked. Acne is often associated with the face, but can also be found on neck, chest, back and upper arms.
An increase in testosterone can cause growth of the clitoris. The clitoris is the equivalent organ to the penis in males, which is why it is affected by excess male sex hormones in females.
There should be a balance between estrogen and progesterone which are the female hormones responsible for regular periods. When testosterone levels are up, this balance will be lost. As a consequence menstruation can be irregular or there will be no menstruation at all (amenorrhea). The duration between periods can also be prolonged.
Subfertility or Infertility
Hormonal imbalance can lead to dysfunction of the ovaries in females. This means, that it can become difficult for affected women to conceive. The ovaries produce ovum (egg) monthly as a reproductive cycle. When the ovaries do not function well, ova are not made, which leads to infertility.
Virilization can lead to a decrease in breast size in females.
Mood Changes and Poor Libido
When excess testosterone causes hormonal imbalance, a female can experience mood swings and poor libido. This can lead to depression and anxiety, which are serious psychological conditions. The lower sex drive can cause problems in relationships.
Obesity and Weight Gain
Excess testosterone alone doesn’t cause weight gain. However in combination with insulin resistance, it can change the metabolism and lead to cravings, which can cause weight gain and obesity.
Hirsutism (Male Pattern Hair Growth in Women)
Increased body hair is another symptom of virilization. This condition is often referred to as hirsutism. Women with hirsutism develop male pattern hair growth. Body hair is dark and coarse and grows in areas such as face, chest, back, thighs or arms. The Ferriman-Gallwey Method is often used to assess the severity of the condition.
eHirsutism is a huge issue for many affected women, as body hair will grow in excess, thicker and in areas, where women generally are not expected to be hairy. Especially excess facial hair is very noticeable and many women adopt routines, such as shaving the face in order to manage their side burns, hair on the upper lip and around chin.
What Causes Virilization in Females?
Normal level of testosterone in a female should be between 15 – 70 ng/dl. When this level is exceeded, a woman can develop symptoms of virilization.
Virilization occurs due to excessive production of testosterone, but can also be caused by certain medications, which act like testosterone. Excess testosterone in women can have many different causes, some of which are outlined below.
Women with familial hirstutism have excessive amounts of testosterone in their bodies. This is caused by their genes.
Polycystic Ovarian Syndrome (PCOS)
Polycystic ovarian syndrome is a common cause of virilization in females. Affected women show symptoms such as obesity, irregular periods, subfertility, multiple cysts (bubble-like lesions) in ovaries and acne along with hirsutism. Some also develop insulin resistance which can lead to diabetes.
PCOS is a hormonal disorder which is commonly found in females of reproductive age. While the exact cause is unknown, affected women have excessive male hormone (androgen) levels and signs of virilization.
Ultra sound scans of the abdomen and hormone tests are used in diagnosis. Management should address the symptoms, which worry the particular patients. Treatments often include laser hair removal, treatment of acne, control of diabetes, weight maintenance and treatment of subfertility
Different ovarian and adrenal tumors can be a reason for excess androgens in females and lead to virilization.
Ovarian Tumors Which Produce Excess Androgens
Only 10% of all ovarian tumors secrete androgens and can lead to virilization. Some of these ovarian tumors which secrete testosterone are gonadoblastoma, ovarian carcinoid, surface epithelial tumors (Brenner tumor) and metastatic tumors. Testosterone levels are elevated, more than 200 ng/dl. Diagnosis is usually done using ultra sound scans and testing hormone levels. Surgery will then be done to remove the tumor. If the patient is diagnosed with ovarian carcinoma (cancer), surgery is combined with chemotherapy (using strong medicines) and radiotherapy (using high energy x-rays) to destroy all cancer cells in the body.
Adrenal Tumors Which Produce Excess Androgens
Sometimes tumors can occur in the adrenal glands and produce androgens, which can lead to virilization. Adrenal tumors can produce increased levels of cortisol and aldosterone hormones in addition to elevating testosterone levels. This may cause high blood pressure, weight gain and diabetes.
The treatment for adrenal tumors includes surgery. Adrenal carcinoma is also treated with additional chemotherapy and radiotherapy. Following the removal of the adrenal glands, replacement therapy is a must and frequent follow up is needed.
Congenital Adrenal Hyperplasia
Congenital Adrenal Hyperplasia (CAH) is an inherited disorder. Adrenal glands are enlarged and hormone production will be affected. When the cortisol levels are low, the body’s response to stress and illness is poor. In addition the regulation of the body’s sodium and potassium levels is disturbed which can be life threatening.
In CAH, androgens are produced in excess which may be visible when the person develops hirsutism and virilization. CAH, when severe, can be detected in infancy already. Milder forms of CAH may start to become evident during childhood. Apart from hirsutism and virilization, girls with CAH will grow rapidly during childhood but as they reach puberty early, growth will stop and they will not get very tall.
The treatment of CAH should aim at reducing excessive androgen production and replacing deficient hormones. With proper management, hormone replacement therapy and regular follow-up women with CAH can lead normal lives.
The body is exposed to high levels of Cortisol hormone due to over production of cortisol from the adrenal gland or due to prolonged administration of prednisolone. This can lead to virilization.
Certain medications can cause virilization and hirsutism in females. Examples for this are systemic corticosteroids and fluoxetine (Prozac), which is prescribed for depression or Danazol which is used to treat endometriosis in females.
Hirsutism and Virilization
If you are looking to gain a good understanding of both hirsutism and virilization and how the two conditions are connected (hirsutism vs virilization), this comprehensive video might be interesting for you.
Treatment of Virilization in Females
Once you have been diagnosed and have a thorough understanding of what virilization actually is, you can start to work on a treatment plan with your doctor. Management depends on proper diagnosis and addressing the root cause and the symptoms. Frequent follow up is necessary, if hormonal replacement therapy is prescribed. Laser hair removal, treatment of acne, treatment of hair loss should be addressed accordingly. Maintaining a healthy weight, eating a balanced diet and regular exercise (such as yoga) should also be encouraged.