Short answer: Virilization means a woman develops male-typical physical changes because of high levels of androgens, the hormones that include testosterone. The key signs are a deepening voice, an enlarged clitoris and increasing muscle bulk, usually alongside excess hair growth.[1] It is much rarer than hirsutism on its own. When it appears quickly, it needs prompt medical attention because it can point to an androgen-producing tumor.[1], [2]
Many women with unwanted hair come across the word “virilization” and worry that it applies to them. Usually it doesn’t. Hirsutism, meaning coarse, dark hair in a male-type pattern, is common, and most of it is caused by PMOS, previously called polycystic ovary syndrome (PCOS).[1], [4] Virilization is a stronger and broader set of changes, and it has a different list of likely causes.
This article explains what virilization looks like, how it differs from hirsutism, what causes it and how doctors investigate it. If you are not sure whether your hair growth counts as hirsutism at all, start with our hirsutism self-check.
What is the difference between virilization and hirsutism?
Both are caused by androgens acting on the body. The Endocrine Society guideline on hirsutism says that androgen excess is behind at least 80% of hirsutism. It also says that signs of virilization, “such as clitoromegaly, deepening of the voice, or increasing muscularity,” make an androgen-secreting tumor more likely.[1] Clitoromegaly is the medical term for an enlarged clitoris.
| Hirsutism | Virilization | |
|---|---|---|
| What it is | Coarse, dark hair in a male-type pattern (face, chest, abdomen, back) | Wider masculinizing changes: Voice, clitoris, muscles, often scalp hair loss |
| How common | Common | Rare |
| Most common cause | PMOS (formerly PCOS) | Less often PMOS. Doctors look for tumors, classic CAH, medicines or anabolic steroids |
| Typical speed | Usually slow, often starting around puberty | Can come on over months, which is a warning sign |
Hirsutism alone is not virilization. You can have a lot of facial or body hair with normal hormone levels and no other changes at all. This is called idiopathic hirsutism.[1] Read more in what is hirsutism?
What are the signs of virilization in women?
These are the changes doctors look for. They come from guideline descriptions of androgen excess and from the known effects of anabolic steroids in women.[1], [6]
- Deepening or hoarse voice. A voice that has become noticeably lower is one of the classic signs.[1], [5]
- Enlarged clitoris (clitoromegaly). The clitoris responds to androgens and can grow when levels are high.[1]
- Increasing muscle bulk. Muscles getting noticeably bigger without a change in training.[1], [5]
- Male-pattern hair loss. Thinning at the temples and crown of the scalp.[1], [6]
- Smaller breasts. A decrease in breast size has been reported with androgen excess from anabolic steroids.[6]
- Excess facial and body hair, often coming on fast.[5]
- Irregular or missing periods.[1], [6]
- Acne or oily skin.[1]
Acne, irregular periods and excess hair are also common in PMOS. A deepening voice, an enlarged clitoris and a fast change in muscle bulk are much less typical of PMOS, and they are what make doctors think about other causes.[1]
What causes virilization in females?
Virilization happens when androgen levels rise high enough to affect more than hair follicles. These are the main causes.
Androgen-secreting tumors
Tumors of the ovary or adrenal gland that make androgens are rare. In a study of 950 women referred to Italian endocrine clinics with signs of androgen excess, only 0.2% had one.[3] Even so, they are the cause doctors most want to rule out when virilization appears. A rapid start or fast worsening of symptoms is the main clue.[1], [2] The 2023 international PCOS guideline also warns that some of these tumors raise androgen levels only mildly or moderately, so a “not very high” blood result does not rule one out on its own.[2]
Congenital adrenal hyperplasia (CAH)
CAH is a group of inherited conditions in which the adrenal glands make too many androgens. The most common type is 21-hydroxylase deficiency. Its classic forms affect about 1 in 15,000 newborns, and girls may be born with genitals that do not look clearly female. The milder non-classic form is estimated to affect about 1 in 1,000 people. It usually shows up later as hirsutism, male-pattern hair loss or irregular periods rather than marked virilization.[7] In the Italian clinic study, non-classic CAH accounted for 4.3% of women with androgen excess.[3]
Medicines, anabolic steroids and testosterone
- Anabolic steroids used for bodybuilding or sport can cause facial and body hair growth, voice deepening, male-pattern baldness, smaller breasts and period changes in women.[6]
- Danazol, an older drug for endometriosis, lists increased facial hair, baldness and a deepening or hoarse voice among its serious side effects.[8]
- Testosterone gel used by a partner. Women who touch skin where a partner has applied testosterone gel can be exposed. The drug information warns them to call a doctor if they notice new hair growth or acne.[9] The Endocrine Society guideline tells doctors to ask about this.[1]
- Testosterone therapy for women. At doses that keep levels in the normal female range, a global consensus statement found mild increases in acne and hair growth in some women. It found no evidence of clitoral enlargement, voice change or hair loss at those doses.[10]
More detail is in our article on drugs that can cause hirsutism.
Virilization after menopause
The international PCOS guideline recommends that postmenopausal women with new or worsening severe androgen excess be investigated for androgen-secreting tumors and for ovarian hyperthecosis.[2] Ovarian hyperthecosis is a non-cancerous condition in which ovarian tissue makes extra androgens. Read more in hirsutism and menopause.
Can PMOS cause virilization?
PMOS is the most common cause of androgen excess. In the Italian study, 72.1% of women had what was then called PCOS.[3] Its usual signs are hirsutism, acne and irregular periods. The Endocrine Society says that virilization makes a tumor more likely, so doctors do not simply assume PMOS when these stronger signs are present.[1] Compare the conditions in the difference between hirsutism and PCOS.
How doctors investigate virilization
If you have signs of virilization, expect your doctor to take it seriously and move faster than they would for slowly developing hirsutism. The workup usually includes:
- A careful history. When did the changes start, and how fast are they progressing? What medicines, supplements or gym products do you use? Does your partner use testosterone gel?[1], [2]
- Blood tests. Total testosterone, ideally measured with an accurate method such as mass spectrometry, in the early morning. If you still have periods, it is best measured on days 4 to 10 of your cycle.[1] Doctors may also measure DHEA sulfate (DHEAS), an adrenal androgen, and 17-hydroxyprogesterone to look for CAH.[1], [2]
- Imaging, if a tumor is suspected. The Endocrine Society suggests a transvaginal ultrasound of the ovaries, a CT scan of the adrenal glands or more specialized studies.[1]
Normal testosterone ranges vary by lab and by age, so ask your doctor how your result compares with the range your lab uses.[11] There is no single testosterone level at which virilization begins, and the Endocrine Society guideline does not set a cutoff.[1] Our guide to blood tests, ultrasound and other labs explains each test.
How is virilization treated?
Treatment targets the cause: Removing a tumor, stopping or changing a medicine, stopping anabolic steroids or treating CAH. We could not find good-quality data on how much each sign improves once androgen levels return to normal, so ask your specialist what to expect in your situation.
Evidence: Strong The excess hair itself can be treated like other hirsutism. For most women who are not trying to get pregnant, the Endocrine Society suggests combined oral contraceptive pills as the first medicine. It recommends against anti-androgen medicines such as spironolactone unless reliable contraception is used, because they can harm a developing baby. Hormonal treatments take about 6 months to show an effect.[1] See hirsutism medication and permanent hair removal.
When to see a doctor
The NHS advises an urgent appointment if new thick, dark hair suddenly starts growing on your face and body, your voice is getting lower or your muscles are getting bigger.[5] Also see a doctor promptly if you notice:
- Hair growth that is new or getting worse over weeks to months
- An enlarged clitoris
- Periods that have become irregular or stopped
- New male-pattern hair loss on your scalp
- Any of these changes after menopause
Frequently asked questions
Is virilization the same as hirsutism?
No. Hirsutism is male-pattern hair growth. Virilization includes other masculinizing changes such as a deeper voice, an enlarged clitoris and more muscle. Hirsutism is common, while virilization is rare and needs faster investigation.[1]
Is virilization dangerous?
Virilization itself is a sign, not a disease. It matters because of what may cause it. Androgen-producing tumors are rare, but doctors want to find or rule them out quickly, especially when changes come on fast.[1], [3]
What testosterone level causes virilization?
There is no fixed number. Lab ranges vary, and guidelines do not give a single cutoff. Some tumors raise testosterone only moderately, so doctors look at your symptoms and how fast they appear, not just the number.[1], [2], [11]
Can testosterone therapy cause virilization in women?
At doses that keep levels in the normal female range, the main side effects seen in studies were mild acne and extra hair growth in some women, without voice change or clitoral enlargement. Higher doses, injections, pellets and compounded products that raise levels above the female range are not recommended.[10]
Key takeaways
- Virilization is a set of male-typical changes, including a deeper voice, an enlarged clitoris and more muscle, caused by high androgen levels.
- It is far less common than hirsutism, which is usually due to PMOS (formerly PCOS).
- Fast-developing changes need prompt investigation to rule out a rare androgen-secreting tumor.
- Other causes include CAH, anabolic steroids, some medicines, exposure to a partner’s testosterone gel and, after menopause, ovarian hyperthecosis.
- Treatment targets the cause, and the excess hair can be treated with standard hirsutism options.
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Sources
- Martin KA, Anderson RR, Chang RJ, et al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(4):1233-1257. PubMed 29522147
- Teede HJ, Tay CT, Laven JJE, et al. Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023;108(10):2447-2469. PubMed 37580314
- Carmina E, Rosato F, Jannì A, Rizzo M, Longo RA. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab. 2006;91(1):2-6. PubMed 16263820
- Teede HJ, et al. Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: a multistep global consensus process. Lancet. 2026;407(10545):2329-2339. Published online May 12, 2026. PubMed 42119588
- NHS. Excessive hair growth (hirsutism). Accessed October 2026. Link
- MedlinePlus. Anabolic Steroids. Accessed October 2026. Link
- MedlinePlus Genetics. 21-hydroxylase deficiency. Accessed October 2026. Link
- MedlinePlus Drug Information. Danazol. Accessed October 2026. Link
- MedlinePlus Drug Information. Testosterone Topical. Accessed October 2026. Link
- Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660-4666. DOI 10.1210/jc.2019-01603
- MedlinePlus Medical Encyclopedia. Testosterone. Accessed October 2026. Link
This article is for education and is not medical advice. Talk to a doctor about diagnosis and treatment.