Overview & Key Clinical Distinctions

Hirsutism vs Virilization:
- Hirsutism: Excess terminal hair growth in male-pattern distribution (face, chest, lower abdomen). Caused by mild-to-moderate androgen elevation.
- Virilization: Hirsutism PLUS signs of severe androgen excess: clitoromegaly, voice deepening, male-pattern baldness (temporal balding), increased muscle mass, breast atrophy. Suggests androgen-secreting tumor.
Clinical Onset:
- Rapid onset (< 1 year) + Virilization $\to$ Neoplastic etiology (Adrenal ACC or Ovarian tumor).
- Gradual onset (pubertal) + Oligomenorrhea $\to$ Non-neoplastic etiology (PCOS or NC-CAH).

DHEA-S (Adrenal)

Source: Exclusively Adrenal Cortex.
Clinical: Rapidly progressive virilization (clitoromegaly, voice deepening), flank mass.
Causes:
- DHEA-S > 700 μg/dL: Adrenocortical Carcinoma (ACC).
- Mild ↑: NCAH, Cushing syndrome, adrenal adenoma.

Source: Ovaries (main direct source) + adipose conversion.
Clinical: Hirsutism, acne, irregular menses ± pelvic mass/virilization.
Causes:
- Total T < 150 ng/dL: PCOS (gradual, onset at puberty).
- Total T > 150–200 ng/dL: Sertoli-Leydig Cell Tumor (rapid virilization). c2
- Severe + Postmenopausal: Ovarian Hyperthecosis (bilateral, diffuse).

Source: 50% Ovaries / 50% Adrenal Cortex.
Clinical: Hirsutism + peripheral aromatization to estrogen → AUB, ↑ risk of Endometrial Hyperplasia/Cancer.
Causes: PCOS, NCAH, androgen-secreting tumors.

Source: Adrenal pathway intermediate.
Clinical: Late-onset hirsutism, acne, normal external genitalia at birth.
Cause: Nonclassic CAH (NCAH) (partial 21-hydroxylase deficiency).
- Diagnostic: Morning 17-OHP > 200 ng/dL → Confirm w/ ACTH stimulation test (> 1,000 ng/dL).

Rapid Virilization + DHEA-S > 700 μg/dL → Adrenal CT (Rule out ACC).
Rapid Virilization + Testosterone > 150 ng/dL → Pelvic US (Rule out Sertoli-Leydig).
Gradual Onset + 17-OHP > 200 ng/dL → ACTH Stimulation Test (Confirm NCAH).
Gradual Onset + LH:FSH > 2:1 + Oligomenorrhea → PCOS.

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