Virilization

Virilization is the biological process by which a female develops male secondary sex characteristics due to excessive androgen exposure, either endogenously from conditions like congenital adrenal hyperplasia or ovarian/adrenal tumors, or exogenously from medications such as anabolic steroids.^[1]^[2] This masculinization manifests prominently in traits including hirsutism, deepening voice, clitoromegaly, acne, male-pattern baldness, increased muscle mass, and menstrual irregularities or amenorrhea.^[3]^[4] Unlike milder hirsutism, virilization indicates severe hyperandrogenism requiring urgent evaluation to rule out life-threatening causes like neoplasms.^[2] Diagnosis typically involves measuring serum testosterone and dehydroepiandrosterone sulfate levels, alongside imaging for tumors, with treatment targeting the underlying etiology—such as glucocorticoid replacement for adrenal disorders or surgical excision for masses—to prevent irreversible changes and associated infertility.^[3]^[5] In neonates, prenatal virilization of female genitalia signals maternal or fetal androgen excess, often necessitating genetic testing for disorders of sex development.^[1]

Definition and Physiological Mechanisms

Virilization is the physiological process characterized by the development of male secondary sexual characteristics due to exposure to elevated levels of androgens, such as testosterone or its precursors, acting on androgen receptors in target tissues.^[2] This typically manifests in females (XX karyotype) as clitoromegaly, deepening of the voice, increased muscle mass, male-pattern baldness, and reduction in subcutaneous fat, or in genetic males with abnormally high androgen exposure leading to exaggerated traits.^[6] The process is causally driven by androgen-mediated gene expression changes in organs like the larynx, skin, and genitals, often quantified clinically by the Ferriman-Gallwey score for hirsutism severity alongside more profound changes.^[7] Virilization must be distinguished from hirsutism, a milder hyperandrogenic state limited primarily to excessive terminal hair growth in androgen-dependent areas (e.g., face, chest) without significant anatomical alterations like clitoromegaly or voice changes; hirsutism affects up to 10% of reproductive-age women but progresses to virilization in fewer than 5% of cases, signaling severe underlying pathology such as tumors.^[8] ^[9] It also differs from defeminization, which involves the loss or suppression of female secondary traits (e.g., breast atrophy, amenorrhea) due to relative or absolute androgen dominance, but without necessarily inducing full male phenotypic features; defeminization often co-occurs with virilization as part of a spectrum in conditions like congenital adrenal hyperplasia, where androgen excess disrupts ovarian function and estrogen production.^[10] Unlike normal androgen-driven masculinization in biological males during fetal development (e.g., Wolffian duct differentiation around weeks 8-12 gestation) or puberty (e.g., Tanner stages 2-5 with peak testosterone at 500-700 ng/dL), virilization implies atypical excess or ectopic androgen action, such as in XX females where baseline testosterone is 15-70 ng/dL.^[3] Masculinization and virilization are sometimes used interchangeably, but virilization more precisely denotes the pathological induction of male traits in non-male contexts, emphasizing causal androgen elevation over endogenous male patterning.^[11] This distinction underscores virilization's role in disorders of sex development, where prenatal exposure (e.g., >200 ng/dL testosterone equivalents) can fully redirect genital development toward male phenotypes.^[12]

Androgen Roles in Virilization

Androgens, chiefly testosterone and dihydrotestosterone (DHT), orchestrate virilization by binding to the androgen receptor (AR), a ligand-activated nuclear transcription factor encoded on the X chromosome, which upon activation dimerizes, translocates to the nucleus, and binds androgen response elements to modulate gene expression favoring masculinization.^[13] This process amplifies protein synthesis in target tissues, driving structural and functional changes such as genital differentiation, somatic growth, and secondary sexual traits. DHT, generated from testosterone via 5α-reductase enzymes (types 1 and 2) in peripheral tissues like skin, prostate, and genitalia, exhibits 3- to 10-fold higher AR affinity than testosterone, thereby potentiating localized androgenic effects critical for virilizing outcomes.^[13]^[14] In prenatal stages, androgens initiate virilization around weeks 8-12 of gestation in genetic males, where testosterone from fetal testes stabilizes Wolffian ducts to form epididymis, vas deferens, and seminal vesicles, while DHT induces external genital masculinization by elongating the genital tubercle into a penis and fusing urogenital folds into a scrotum.^[14] Disruptions, such as AR mutations in androgen insensitivity syndrome, prevent these effects despite elevated testosterone, resulting in female external phenotype in XY individuals, underscoring AR dependency.^[15] In female fetuses, excess androgens from maternal or fetal sources, as in congenital adrenal hyperplasia, elicit partial virilization including clitoral enlargement and labial fusion, with DHT's role amplified in genital skin fibroblasts.^[2]^[16] During puberty and adulthood, rising androgen levels—testosterone surging up to 30-fold in males—sustain virilization through AR-mediated upregulation of genes promoting laryngeal cartilage growth (voice deepening), pilosebaceous unit stimulation (hirsutism and acne), and anabolic effects on muscle (increased lean mass via enhanced protein synthesis) and bone (elevated density).^[13]^[14] In females, supraphysiological androgens induce similar traits, such as irreversible voice lowering and male-pattern baldness, with DHT disproportionately influencing scalp and beard follicles via type 2 5α-reductase predominance.^[13] These actions occur predominantly genomically, though rapid non-genomic signaling via membrane AR may modulate acute responses like vasodilation, but genomic transcription remains central to sustained virilizing morphogenesis.^[13] Dose-response relationships are linear without plateau, as evidenced by exogenous administration studies showing proportional trait intensification.^[13]

Key Virilizing Traits and Their Development

Virilizing traits encompass the androgen-driven development of male secondary sexual characteristics, which manifest through the binding of testosterone and its metabolite dihydrotestosterone (DHT) to androgen receptors, triggering gene expression changes in target tissues.^[14] These traits include deepening of the voice, androgen-dependent hair growth, increased skeletal muscle mass, genital enlargement, and skin alterations such as acne.^[14] Development occurs primarily during prenatal and pubertal periods when androgen levels surge, with DHT—produced via 5α-reductase enzyme activity—amplifying effects in tissues like skin and genitalia due to its higher receptor affinity.^[13] Deepening of the voice results from androgens stimulating hypertrophy of laryngeal cartilage, elongation and thickening of vocal cords, and increased vocal fold mass, which lowers pitch; this process begins at puberty and is largely irreversible once initiated.^[14] ^[13] In biological males, testosterone from Leydig cells drives this via the hypothalamic-pituitary-gonadal axis, with effects observable within months of elevated androgen exposure in females.^[13] Androgen-dependent hair growth, including facial, axillary, pubic, and body hair, arises from DHT activating androgen receptors in hair follicle dermal papilla cells, promoting the shift from vellus to terminal hair in sexually dimorphic areas.^[14] Conversely, in scalp follicles genetically predisposed to DHT sensitivity, miniaturization occurs, leading to male-pattern baldness characterized by frontal and vertex recession.^[13] These changes emerge postnatally and intensify at puberty, with hirsutism in females reflecting similar mechanisms under excess androgens.^[14] Increased muscle mass and strength stem from testosterone's direct anabolic action on skeletal muscle, enhancing protein synthesis, satellite cell proliferation, and myofiber hypertrophy without requiring conversion to DHT or estradiol.^[14] ^[13] Dose-dependent gains, such as those from 600 mg weekly testosterone enanthate, demonstrate peak effects during pubertal growth spurts, contributing to broader shoulders and reduced subcutaneous fat.^[13] Genital virilization, such as clitoromegaly in females or penile elongation in males, involves DHT-mediated growth of the genital tubercle and fusion of labioscrotal folds prenatally, with continued external development at puberty.^[14] Androgen excess thresholds determine severity, as seen in conditions like congenital adrenal hyperplasia where fetal exposure alters morphology.^[14] Skin changes, including acne and sebaceous gland hyperactivity, result from androgens upregulating sebum production and keratinization in pilosebaceous units, often truncal in distribution and peaking in adolescence.^[14] These traits collectively underscore androgens' role in sexual dimorphism, with tissue-specific expression modulated by receptor density and cofactor availability.^[13]

Normal Virilization in Biological Males

Prenatal Virilization

Prenatal virilization in biological males is initiated by the SRY gene on the Y chromosome, which encodes a transcription factor that directs the bipotential gonads to differentiate into testes during gestational weeks 6-7.^[17] This process begins with the proliferation and differentiation of pre-Sertoli cells around week 7, leading to the formation of testicular cords by week 8.^[18] The SRY protein's role is critical, as its absence or dysfunction results in ovarian development despite an XY karyotype.^[19] Sertoli cells in the developing testes secrete anti-Müllerian hormone (AMH), which causes regression of the Müllerian ducts between weeks 8 and 10, thereby preventing the formation of uterus, fallopian tubes, and upper vagina.^[20] Concurrently, Leydig cells begin producing testosterone around week 9, peaking during the critical masculinization window of weeks 9-12.^[14] Testosterone stabilizes the Wolffian ducts, promoting their differentiation into epididymis, vas deferens, and seminal vesicles, while its metabolite dihydrotestosterone (DHT) drives the development of the prostate and masculinizes the external genitalia, elongating the genital tubercle into the penis and fusing the urethral folds and labioscrotal swellings into the scrotum.^[21] This androgen-dependent virilization of external genitalia is largely complete by week 14 of gestation, with subsequent growth occurring primarily in the second and third trimesters.^[21] Disruptions in androgen production or action during this period, such as in androgen insensitivity syndrome, lead to undermasculinized phenotypes, underscoring the causal necessity of these hormones for normal male development.^[20] Testicular descent into the scrotum follows later, typically between weeks 25-35.^[22]

Pubertal and Adult Virilization

Pubertal virilization in biological males typically begins between ages 9 and 14 years, triggered by hypothalamic-pituitary-gonadal axis activation, leading to increased gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) secretion, which stimulate testicular Leydig cells to produce testosterone levels rising from prepubertal values below 0.3 nmol/L to adult ranges of 8.7–29 nmol/L by late adolescence.^[14]^[23] This surge, peaking around ages 15–20 with levels up to 30 nmol/L in some individuals, drives somatic and secondary sexual characteristics, distinguishing virilizing effects (e.g., genital maturation) from anabolic ones (e.g., muscle growth).^[24]^[25] Virilization progresses through Tanner stages, with stage 1 representing prepubertal status (testicular volume <1.5–4 mL). Stage 2 features testicular enlargement to 4–12 mL and scrotal skin reddening/thinning by age 11–12 on average; stage 3 involves penile length increase and further testicular growth to >12 mL around age 13, accompanied by pubic hair initiation; stage 4 sees penile width/glans development and axillary/facial hair emergence by age 14; and stage 5 achieves adult genitalia by age 15–17, with peak height velocity of 9.5 cm/year at stage 3–4.^[26]^[27] Concurrently, laryngeal growth deepens the voice, androgen-dependent hair growth expands to beard and body regions, and skeletal changes include broader shoulders and increased bone density, all androgen-mediated to promote male phenotype consolidation.^[14]^[28] In adulthood, virilization stabilizes as testosterone sustains secondary traits, including maintenance of muscle mass (via androgen receptor activation in myocytes), bone mineral density, erythropoiesis, and libido, with average levels of 10–35 nmol/L supporting these functions through ages 20–40.^[29]^[13] Post-40, levels decline approximately 1% annually due to reduced Leydig cell efficiency and hypothalamic sensitivity, potentially leading to subtle regressive changes like decreased muscle strength or libido if below 8 nmol/L, though most men retain sufficient androgens for trait preservation without hypogonadal symptoms.^[30]^[31] This gradual reduction contrasts with puberty's acute surge, reflecting physiologic aging rather than pathological defeminization reversal.^[32]

Pathological Virilization

Prenatal Virilization in Females

Prenatal virilization in genetic females manifests as masculinization of the external genitalia due to excessive androgen exposure during fetal development, typically between weeks 8 and 12 of gestation when the genital tubercle, folds, and swellings differentiate.^[33] This process overrides the default female developmental pathway, resulting in clitoromegaly (enlargement of the clitoris resembling a phallus), posterior fusion of the labia majora (forming a scrotum-like structure), and varying degrees of urethral and vaginal orifice displacement.^[34] The severity is often graded using the Prader scale, ranging from stage I (isolated clitoromegaly) to stage V (complete external resemblance to male genitalia with a blind-ending vaginal pouch).^[2] Internal female reproductive structures, including the uterus and ovaries, remain unaffected, as their development is not androgen-dependent and occurs in the absence of anti-Müllerian hormone.^[35] The predominant cause is congenital adrenal hyperplasia (CAH), particularly due to 21-hydroxylase deficiency (21-OHD), an autosomal recessive disorder resulting from mutations in the CYP21A2 gene on chromosome 6p21.3.^[33] This enzyme defect impairs cortisol and aldosterone biosynthesis, leading to adrenocorticotropic hormone (ACTH) hypersecretion, adrenal hyperplasia, and accumulation of steroid precursors shunted into the androgen synthesis pathway, producing excess androstenedione and testosterone from the fetal adrenal glands starting mid-gestation.^[34] Classic 21-OHD CAH has an incidence of approximately 1 in 15,000 live births worldwide, with nearly all affected XX fetuses exhibiting prenatal virilization; the simple virilizing form (about 25% of classic cases) specifically causes genital ambiguity without salt-wasting crisis.^[36] Non-classic or late-onset forms rarely cause prenatal effects due to milder enzyme impairment.^[37] Less common etiologies include other CAH variants such as 11β-hydroxylase deficiency (incidence ~1 in 100,000), which similarly elevates deoxycortisol and 11-deoxycorticosterone alongside androgens, or P450 oxidoreductase deficiency (PORD), involving alternative androgen biosynthesis pathways.^[38] Maternal sources of androgens, such as virilizing tumors (e.g., luteoma of pregnancy or ovarian arrhenoblastoma, occurring in <1% of virilization cases), placental aromatase deficiency, or exogenous androgen exposure from medications like progestins, can also induce fetal virilization by crossing the placenta unimpeded.^[39] These maternal factors account for fewer than 5% of cases and often resolve post-delivery without ongoing fetal adrenal involvement.^[2] Affected infants present at birth with ambiguous genitalia prompting immediate genetic sex determination via karyotyping, revealing 46,XX chromosomes.^[33]

Childhood-Onset Virilization

Childhood-onset virilization in females manifests as the progressive development of androgen-dependent male secondary sexual characteristics between infancy and the typical age of puberty onset (approximately 2 to 8 years), distinguishing it from prenatal ambiguities or adolescent hyperandrogenism. Common signs include premature pubarche with pubic or axillary hair growth, hirsutism on the face or body, acne, clitoromegaly, accelerated linear growth velocity, and advanced skeletal maturation; more severe cases may involve increased muscle mass or early voice changes, though these are less frequent pre-puberty.^[40] ^[41] Unlike benign premature adrenarche, which features mild pubic hair without clitoromegaly or rapid progression, true virilization signals pathological androgen excess requiring urgent evaluation to exclude life-threatening etiologies.^[40] The most prevalent cause is non-classical congenital adrenal hyperplasia (NCCAH) due to partial 21-hydroxylase deficiency, affecting approximately 1 in 1,000 individuals with higher rates in Ashkenazi Jewish, Mediterranean, and Middle Eastern populations; this leads to ACTH-driven adrenal androgen overproduction, often presenting as premature pubarche in 92% of affected children under 10 years, alongside hirsutism in up to 59% and clitoromegaly.^[40] Rarer genetic defects, such as 11β-hydroxylase deficiency variants, can contribute similarly through impaired cortisol synthesis and shunting toward androgens. Androgen-secreting tumors, including adrenocortical adenomas, carcinomas, or ovarian neoplasms like Sertoli-Leydig cell tumors, account for 5-10% of cases and typically cause rapid virilization with markedly elevated testosterone levels (>200 ng/dL) and possible palpable abdominal masses; adrenocortical carcinomas in children carry a malignancy risk, with virilization noted in peripheral precocious puberty alongside clitoromegaly.^[42] ^[41] Exogenous androgen exposure, such as inadvertent contact with testosterone gels or anabolic steroids, represents an acquired cause, mimicking endogenous excess through transdermal absorption and resolving upon source removal.^[43] Diagnosis begins with clinical assessment for virilizing features and exclusion of familial or ethnic predispositions, followed by laboratory confirmation of hyperandrogenemia via serum total/free testosterone, dehydroepiandrosterone sulfate (DHEAS), and androstenedione levels. For suspected NCCAH, basal 17-hydroxyprogesterone (17-OHP) exceeding 2 ng/mL prompts an ACTH stimulation test, with post-stimulation peaks >10 ng/mL diagnostic; genotyping of CYP21A2 confirms mutations like V281L in nearly all cases.^[40] Imaging modalities include pelvic/adrenal ultrasound for ovarian or adrenal masses, CT or MRI for tumor characterization, and hand X-rays for bone age advancement, which often exceeds chronological age by 1-2 years in affected children.^[41] Differential diagnosis must rule out central precocious puberty or exogenous sources via detailed history, as untreated virilization risks irreversible changes like permanent clitoromegaly or growth stunting from early epiphyseal closure.^[40] Management targets the underlying etiology: low-dose glucocorticoids (e.g., hydrocortisone 6-15 mg/m²/day) suppress ACTH excess in NCCAH, normalizing androgens, slowing bone maturation, and mitigating hirsutism, though treatment is often deferred unless growth acceleration or cosmetic concerns warrant intervention.^[40] Tumors necessitate prompt surgical resection, with adjuvant chemotherapy for malignant adrenocortical carcinoma; mitotane or ketoconazole may control hypercortisolism or androgenesis preoperatively.^[42] For exogenous causes, discontinuation suffices, with monitoring for resolution. Long-term follow-up assesses growth, pubertal progression, fertility potential, and psychosocial impacts, as NCCAH untreated can lead to oligomenorrhea or infertility in adulthood; multidisciplinary care involving endocrinologists optimizes outcomes while minimizing glucocorticoid side effects like obesity or osteoporosis.^[40]^[41]

Adolescent and Adult Female Virilization

Virilization in adolescent and adult females refers to the pathological development of male secondary sex characteristics resulting from sustained hyperandrogenism after the onset of puberty. Key manifestations include progressive hirsutism, deepening of the voice, clitoromegaly, frontal balding, increased muscle mass and strength, and acne; these differ from milder hyperandrogenism by their rapid progression and severity, often accompanied by oligo- or amenorrhea due to suppression of estrogen-dependent endometrial proliferation.^[44]^[2] Breast atrophy and reduced subcutaneous fat may also occur with prolonged exposure, reflecting androgen-mediated inhibition of female secondary traits.^[3] In contrast to prenatal or childhood forms, post-pubertal virilization typically arises from acquired androgen excess rather than congenital defects, though late-presenting genetic conditions can contribute.^[45] Among adolescents, virilization often emerges during or shortly after puberty, with signs like clitoromegaly and hirsutism accelerating alongside normal pubertal changes, potentially delaying recognition. Non-classic congenital adrenal hyperplasia (CAH) affects up to 59% of such cases with hirsutism, 54% with oligomenorrhea, and 33% with acne, though full virilization is less common without treatment non-compliance or severe enzyme deficiency.^[40] Polycystic ovary syndrome (PCOS), the most prevalent cause of hyperandrogenism in reproductive-age females (affecting 5-10% globally), rarely progresses to overt virilization, instead presenting with moderate hirsutism in 70-80% of cases; severe features like voice changes suggest alternative etiologies such as ovarian hyperthecosis or tumors.^[46] Rare disorders of sex development, including 46,XY karyotypes with androgen insensitivity variants, may unmask at puberty through virilizing progression, necessitating genetic evaluation in cases of unexplained clitoromegaly or absent breast development.^[47]^[2] In adult females, virilization signals more urgent pathology, with new-onset symptoms post-menopause occurring in fewer than 0.2% of hyperandrogenic cases and strongly indicating androgen-secreting neoplasms; adrenal carcinomas, for example, produce rapid virilization in 50-70% of affected women via excess dehydroepiandrosterone sulfate (DHEAS).^[10] Ovarian tumors, such as Sertoli-Leydig cell neoplasms, account for 0.5-1% of virilizing cases and often present with testosterone levels exceeding 200 ng/dL, leading to defeminization like uterine atrophy.^[48] Exogenous factors, including anabolic steroids or certain progestins, can induce similar traits, but idiopathic or PCOS-related progression remains milder without tumor involvement.^[49] Longitudinal studies show untreated hyperandrogenism correlates with metabolic risks, including insulin resistance in 50-70% of PCOS patients, underscoring the need to distinguish virilization from benign hirsutism via hormone profiling.^[50] Overall, while PCOS dominates mild presentations, true virilization in this demographic mandates exclusion of malignancy, as delays in diagnosis can permit irreversible changes like permanent voice deepening.^[51]^[52]

Etiology of Virilization

Congenital and Genetic Causes

Congenital adrenal hyperplasia (CAH) represents the foremost genetic etiology of virilization, comprising autosomal recessive disorders characterized by enzymatic defects in adrenal cortisol biosynthesis, which provoke adrenocorticotropic hormone (ACTH) overstimulation and consequent adrenal androgen hypersecretion. The cardinal form, 21-hydroxylase deficiency arising from mutations in the CYP21A2 gene on chromosome 6p21.3, constitutes 90-95% of CAH cases worldwide and exhibits a birth prevalence of roughly 1 in 15,000-20,000 live births, with higher rates in certain populations such as Ashkenazi Jews (1 in 6,000). In 46,XX fetuses, intrauterine androgen excess drives dose-dependent virilization of external genitalia, manifesting as clitoromegaly, posterior labial fusion, and urogenital sinus anomalies, with Prader stages ranging from I (mild) to V (severe male-like).^[36]^[53]^[36] Classic 21-hydroxylase deficiency bifurcates into salt-wasting (75% of classic cases, near-total enzyme loss leading to aldosterone deficiency and life-threatening electrolyte crises) and simple virilizing subtypes (partial activity preservation, ~25%, with isolated androgen excess but no mineralocorticoid failure); both precipitate prenatal virilization in females, while males appear unaffected at birth but risk early precocious puberty. Genotype-phenotype correlations link specific CYP21A2 alleles (e.g., deletions or intron 2 splicing mutations) to virilization severity, as milder variants permit residual 21-hydroxylase function. Newborn screening via elevated 17-hydroxyprogesterone quantifies risk, with confirmatory genotyping essential for precise prognosis.^[54]^[36]^[55] Less prevalent CAH variants further contribute to congenital virilization. 11β-hydroxylase deficiency (CYP11B1 gene mutations, 5-8% of CAH) yields deoxycorticosterone accumulation, hypertension, and hypokalemia alongside pronounced androgen-mediated genital ambiguity in 46,XX neonates. 3β-hydroxysteroid dehydrogenase type 2 deficiency (HSD3B2 mutations, <1% of cases) impairs multiple steroid conversions, resulting in milder female virilization, salt wasting, and incomplete male genital development. These disorders underscore the steroidogenic pathway's centrality, where proximal blocks shunt precursors toward Δ5-androgen pools.^[36]^[36] Extracah genetic anomalies include aromatase deficiency, an autosomal recessive condition from CYP19A1 mutations abolishing P450 aromatase activity and thus estrogen biosynthesis from androgens; this engenders fetal 46,XX virilization (ambiguous genitalia in reported cases) and transient maternal hyperandrogenism during pregnancy due to placental enzyme failure. Over 20 pathogenic variants are documented, with phenotypic severity tied to residual activity; affected females additionally face polycystic ovaries, primary amenorrhea, and tall stature from estrogen paucity. Fewer than 50 kindreds are described globally, highlighting its rarity.^[56]^[57]^[56] Cytochrome P450 oxidoreductase deficiency (PORD), stemming from biallelic POR mutations, disrupts electron transfer to adrenal and gonadal P450 enzymes, fostering alternative "backdoor" androgen synthesis pathways that virilize 46,XX external genitalia at birth despite low serum androgens; concurrent features encompass glucocorticoid insufficiency, ambiguous steroid profiles, and Antley-Bixler craniosynostosis. Maternal virilization often signals antenatal onset. Prevalence approximates 1 in 300,000, with >100 mutations identified, many impairing multiple hydroxylases.^[58]^[58]^[59] Acquired virilization in females primarily results from androgen-secreting tumors originating in the ovaries or adrenal glands, which develop after birth and cause rapid onset of symptoms such as hirsutism, deepening voice, clitoromegaly, and increased muscle mass due to excessive testosterone production.^[60] ^[61] These tumors account for a small fraction of hyperandrogenism cases but are distinguished by their aggressive progression compared to milder conditions like polycystic ovary syndrome.^[62] Androgen levels in affected individuals often exceed 200 ng/dL, prompting urgent evaluation to differentiate from non-tumorous etiologies.^[61] Ovarian tumors causing virilization include rare neoplasms such as steroid cell tumors, Sertoli-Leydig cell tumors (also known as arrhenoblastomas), and hilus cell tumors, which comprise less than 1% of all ovarian tumors and predominantly affect postmenopausal women.^[60] ^[63] These tumors autonomously produce androgens like testosterone, leading to hyperandrogenism in 56-77% of cases, often with symptoms progressing over months rather than years.^[64] Surgical removal is typically curative for benign variants, though malignant forms may require adjuvant chemotherapy.^[60] Non-tumorous ovarian hyperthecosis, characterized by nests of luteinized theca cells in the ovarian stroma, represents an acquired stromal proliferation that can mimic tumor-related virilization, particularly in postmenopausal females, with elevated testosterone levels and insulin resistance as contributing factors.^[65] Adrenal tumors, including adrenocortical adenomas and carcinomas, are another key acquired cause, secreting androgens independently of ACTH regulation and often presenting with virilization alongside Cushingoid features if cortisol is co-produced.^[66] Adrenocortical carcinomas, which are frequently malignant, arise sporadically in adults and cause virilization through high-output androgen synthesis, with tumors larger than 4 cm raising suspicion for malignancy.^[67] Diagnosis involves imaging like CT or MRI, combined with dexamethasone suppression tests showing lack of androgen suppression, as these tumors do not respond to glucocorticoid feedback.^[61] Ectopic adrenal tissue tumors, though exceedingly rare, have been documented behind the iliopsoas muscle, underscoring the need for comprehensive imaging in refractory cases.^[68] Overall, tumor-related virilization demands prompt intervention, as delays can lead to irreversible changes like voice deepening.^[69]

Pharmacological and Environmental Causes

Pharmacological causes of virilization primarily involve exposure to exogenous androgens or compounds with androgenic activity, leading to excess androgen levels that induce masculinizing effects such as hirsutism, deepening of the voice, clitoral enlargement, and menstrual irregularities in females.^[70] Anabolic-androgenic steroids (AAS), often misused for athletic performance enhancement, are a leading culprit; doses sufficient to elevate serum testosterone can produce irreversible changes like vocal cord hypertrophy and androgenic alopecia in women.^[71] ^[72] Danazol, a synthetic attenuated androgen prescribed for conditions like endometriosis and hereditary angioedema, frequently causes dose-dependent virilization, including acne, weight gain, and hirsutism, with long-term use at doses as low as 200 mg daily reported to induce mild masculinizing effects in some cases.^[73] Exposure during pregnancy heightens risks, as danazol crosses the placenta and can virilize female fetuses, resulting in clitoromegaly and labial fusion observed in multiple case reports.^[74] Testosterone formulations, including topical gels applied by male partners, pose additional risks through skin-to-skin transfer, elevating androgen levels in exposed females and causing hyperandrogenism symptoms.^[75] Certain progestins with structural similarity to testosterone, historically administered orally to prevent miscarriage, have been linked to fetal virilization in female infants, with over 70 documented cases involving masculinization of external genitalia due to androgenic metabolites.^[76] These effects occur during critical prenatal windows when androgen-sensitive genital development is underway, underscoring the need for contraindication in pregnancy.^[77] Environmental causes of virilization are less well-documented in humans compared to pharmacological exposures, with most evidence derived from animal models demonstrating androgenic activity of certain endocrine-disrupting chemicals (EDCs). Pesticides such as tebuconazole, a triazole fungicide, have induced virilization in female rat offspring following prenatal exposure, alongside feminization in males, via disruption of steroidogenesis pathways.^[78] Similarly, embryonic exposure to vinclozolin, another fungicide, caused virilization in female quail, altering progesterone receptor expression despite its primary anti-androgenic profile in mammals.^[79] In humans, such exposures remain rare and understudied, though occupational or dietary contact with persistent organochlorine pesticides has been hypothesized to contribute to hyperandrogenism, warranting further epidemiological scrutiny given the chemicals' bioaccumulative nature.^[80]

Medically Induced Virilization

Virilization in Gender Transition Therapies

Virilization in gender transition therapies refers to the deliberate induction of male secondary sex characteristics through exogenous androgen administration, primarily testosterone, in biological females seeking alignment with a male gender identity. This therapy aims to promote masculinization while suppressing ovarian function and female secondary traits. Typical regimens involve intramuscular or subcutaneous injections, transdermal gels, or subcutaneous pellets, with dosing adjusted to achieve serum testosterone levels within the mid-normal male range of 300-1000 ng/dL.^[81]^[82] Physical changes commence within months and progress over 2-5 years, varying by dose, age at initiation, and genetics. Menstruation typically ceases within 1-6 months due to ovarian suppression. Voice deepening begins at 3-12 months and becomes irreversible after 1-2 years, dropping pitch by approximately 20-30 Hz on average. Clitoral enlargement occurs within 3-6 months, reaching 2-5 cm in length and proving permanent. Facial and body hair growth accelerates after 6-12 months, with pattern baldness possible in genetically predisposed individuals. Muscle mass increases by 2-6 kg within 1-2 years, accompanied by fat redistribution from hips to abdomen, and skin coarsening with acne in up to 40% of cases during the first year. These effects stem from testosterone's androgenic actions on androgen receptors, promoting protein synthesis and hair follicle stimulation.^[83]^[81]^[84] Certain changes, such as voice alteration and clitoral hypertrophy, persist post-discontinuation due to structural remodeling of laryngeal and genital tissues, whereas menses may resume if therapy halts early, and fat distribution can partially revert. Bone density may increase in cortical regions but requires monitoring, as long-term suppression of estrogen raises fracture risk if testosterone levels fluctuate. Libido often surges within 1-3 months, linked to central nervous system androgen effects.^[85]^[86]^[87] Adverse effects necessitate regular surveillance, including hematocrit checks every 3-6 months, as erythrocytosis (hematocrit >50%) affects up to 10-20% and elevates thrombosis risk. Lipid profiles shift with decreased HDL and variable LDL changes, alongside potential hypertension and insulin resistance contributing to metabolic syndrome in 10-15% after 1-5 years. Cardiovascular outcomes remain debated, with some cohort studies showing no excess events but others noting arterial stiffness progression after 5+ years of therapy. Rare reports include pulmonary embolism (median onset 1-2 years) and low ovarian cancer incidence post-decades of use. Long-term data beyond 10 years is sparse, with systematic reviews highlighting gaps in randomized evidence and calling for caution in youth due to incomplete reversibility.^[88]^[89]^[90]^[91]^[92]

Other Iatrogenic and Therapeutic Contexts

Danazol, a synthetic androgen used therapeutically for conditions such as hereditary angioedema and endometriosis, frequently induces virilization in women through its androgenic properties. Common manifestations include hirsutism, acne, deepening of the voice, clitoromegaly, and menstrual irregularities, with studies reporting these effects in up to 76% of treated females during long-term use. ^[73] ^[93] Although lower doses mitigate severity, persistent administration often leads to irreversible changes like voice alteration, prompting discontinuation in some cases. ^[94] Anabolic-androgenic steroids (AAS), prescribed off-label or abused for performance enhancement, muscle wasting disorders, or other indications in women, cause dose-dependent virilization including hirsutism, male-pattern baldness, voice deepening, and menstrual disruptions. ^[95] ^[96] In female athletes, prolonged exposure exacerbates these effects, with acne and hirsutism appearing early, followed by potentially permanent laryngeal changes. ^[97] ^[98] Therapeutic androgen supplementation in women, such as testosterone for hypoactive sexual desire disorder in postmenopausal patients, carries virilization risks when serum levels exceed physiological norms. ^[99] ^[100] Adverse effects like clitoromegaly, increased body hair, and acne necessitate careful dosing, as excess androgens mimic pathological hyperandrogenism; however, low-dose regimens minimize these while addressing deficiency symptoms. ^[101] Attenuated androgens like stanozolol, employed for hereditary angioedema prophylaxis, similarly provoke virilization in female patients, encompassing voice changes and hirsutism alongside menstrual abnormalities. ^[102] Discontinuation often reverses milder symptoms, but androgen receptor-mediated effects can persist, highlighting the trade-off between therapeutic efficacy and masculinizing side effects in androgen-sensitive individuals. ^[103]

Diagnosis, Treatment, and Management

Diagnostic Methods and Challenges

Diagnosis of virilization begins with a detailed clinical history to assess the onset, progression, and severity of symptoms, including rapid development of male secondary sexual characteristics such as hirsutism, deepening voice, clitoromegaly, increased muscle mass, and temporal hair recession, alongside evaluation for associated features like menstrual irregularities, infertility, or acne.^[2] ^[48] Family history of endocrine disorders, medication use (e.g., androgens or progestins), and exposure to exogenous sources are critical to identify potential acquired causes.^[104] Physical examination quantifies virilization using tools like the Ferriman-Gallwey score for hirsutism (score >8 indicating excess) and evaluates for hypertension, abdominal masses, or Cushingoid features.^[48] ^[105] Laboratory evaluation is essential and focuses on confirming hyperandrogenism through measurement of total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), and androstenedione levels, preferably using liquid chromatography-tandem mass spectrometry (LC-MS/MS) for precision in the low physiological range typical of females, as immunoassays can overestimate due to cross-reactivity.^[45] Elevated total testosterone exceeding 200 ng/dL strongly suggests a virilizing tumor and warrants urgent imaging.^[106] Additional tests include 17-hydroxyprogesterone to screen for nonclassic congenital adrenal hyperplasia (CAH), with morning levels >500 ng/dL diagnostic and intermediate values (200-500 ng/dL) requiring cosyntropin stimulation; prolactin, thyroid-stimulating hormone, and cortisol assessments rule out prolactinoma or Cushing syndrome.^[45] Gonadotropins (LH/FSH ratio) and sex hormone-binding globulin help differentiate polycystic ovary syndrome (PCOS) from other etiologies.^[104] Imaging modalities localize androgen sources: transvaginal or pelvic ultrasound detects ovarian pathology like tumors or polycystic morphology in PCOS, while adrenal computed tomography (CT) or magnetic resonance imaging (MRI) evaluates for adrenal adenomas or carcinomas, particularly if DHEA-S is markedly elevated (>700 μg/dL).^[107] In postmenopausal women or when ultrasound is inconclusive, MRI offers superior soft-tissue resolution for small ovarian hyperthecosis or tumors.^[108] Selective venous sampling may be employed for ovarian vein androgen gradients in equivocal cases.^[45] Challenges in diagnosis include the overlap of mild hyperandrogenism symptoms across common conditions like PCOS and rarer virilizing tumors, where PCOS accounts for most cases but virilization signals potential malignancy requiring prompt exclusion, yet tumor incidence is low (0.5-2% of hyperandrogenic women), risking over-investigation or delays.^[109] Assay inaccuracies, such as immunoassay variability leading to false normals in early tumor stages, underscore the superiority of LC-MS/MS, though its availability limits routine use.^[45] Differentiating ovarian hyperthecosis from tumors poses difficulties due to similar biochemical profiles and imaging subtlety, often necessitating histopathology post-oophorectomy.^[110] In adolescents, pubertal variations mimic pathology, complicating thresholds, while ethnic differences in hirsutism scoring and androgen reference ranges demand adjusted norms.^[106] Rapid-onset virilization heightens urgency but can be confounded by iatrogenic or factitious sources, emphasizing comprehensive history to avoid misattribution.^[8]

Treatment Approaches by Cause

Treatment for virilization arising from congenital and genetic causes, such as 21-hydroxylase deficiency in congenital adrenal hyperplasia (CAH), centers on lifelong glucocorticoid therapy to suppress adrenocorticotropic hormone (ACTH)-driven androgen excess and prevent progression of virilizing features like clitoromegaly and hirsutism. Hydrocortisone is preferred in children to mimic physiologic cortisol rhythms, with dosing titrated to normalize 17-hydroxyprogesterone levels while avoiding iatrogenic Cushing's syndrome; adults may transition to prednisone or dexamethasone for convenience. In salt-wasting CAH variants, mineralocorticoid replacement with fludrocortisone and sodium supplementation is added to manage electrolyte imbalances. Surgical interventions, such as clitoroplasty or vaginoplasty, may address genital ambiguity but are deferred until adolescence in some protocols to preserve sensation and fertility potential. For rarer genetic etiologies like aromatase deficiency, which impairs conversion of androgens to estrogens leading to maternal and fetal virilization, estrogen replacement therapy—starting with low-dose conjugated estrogens (e.g., 0.3 mg daily, escalating to 0.625–1.25 mg)—is initiated early, often from age 2, to promote feminization, bone accrual, and metabolic health while mitigating hyperandrogenism. Acquired virilization from tumor-related causes, including androgen-secreting adrenal adenomas, carcinomas, or ovarian tumors (e.g., Sertoli-Leydig cell tumors), prioritizes surgical excision as the definitive approach to halt autonomous androgen production and reverse symptoms like deepening voice and muscle hypertrophy. Adrenal tumors necessitate unilateral or bilateral adrenalectomy, with laparoscopy preferred for benign adenomas; malignant cases may require mitotane chemotherapy postoperatively to control metastasis and residual hyperandrogenism. Ovarian sources, comprising less than 5% of virilizing neoplasms, are managed via unilateral oophorectomy in premenopausal women to preserve fertility, with bilateral salpingo-oophorectomy reserved for postmenopausal or bilateral disease; rapid symptom regression often follows if caught early. Preoperative glucocorticoid cover may be needed in adrenal cases to prevent postoperative adrenal crisis, and long-term surveillance for recurrence is essential given the 20–30% malignancy risk in virilizing adrenal lesions. Pharmacological and environmental causes of virilization, such as exogenous anabolic-androgenic steroids, progestins, or rarely endocrine-disrupting chemicals, are addressed by immediate cessation of the offending agent, which typically leads to partial reversal of reversible features like hirsutism and acne within months, though irreversible changes such as voice deepening or clitoral enlargement may persist. Supportive therapies include antiandrogens (e.g., spironolactone 100–200 mg daily) or oral contraceptives to block residual androgen effects and restore menstrual cyclicity, particularly if polycystic ovary syndrome coexists as a confounder. Environmental exposures, like certain pesticides mimicking androgens, demand source removal and monitoring, with no specific antidotes but potential benefit from androgen receptor antagonists in severe cases; however, such etiologies are uncommon and require toxicological confirmation. Multidisciplinary follow-up is advised to exclude underlying tumors mimicking iatrogenic patterns.

Prenatal Interventions and Ethical Considerations

Prenatal interventions for virilization primarily target congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, the most common cause of androgen excess in female fetuses, which can lead to ambiguous external genitalia. The standard approach involves administering dexamethasone (DEX) to the pregnant mother starting before 7-9 weeks of gestation to cross the placenta and suppress fetal pituitary-adrenal androgen production via ACTH inhibition.^[111] This treatment has demonstrated efficacy in reducing virilization of external genitalia in affected female fetuses, with studies showing decreased Prader stages of genital ambiguity and avoidance of postnatal genitoplasty in many cases when initiated early.^[112]^[113] However, efficacy is not absolute, as internal virilization and salt-wasting crises in CAH persist regardless, and treatment must be applied to all fetuses in at-risk pregnancies despite only about 25% being affected females, exposing seven out of eight unaffected siblings unnecessarily.^[114] Maternal side effects from DEX include excessive weight gain (observed in approximately 25% of cases), striae, hypertension, edema, and mood alterations, which can necessitate discontinuation in up to 20-30% of pregnancies.^[115] Fetal and childhood risks encompass reduced birth weight, intrauterine growth restriction, and potential neurodevelopmental impacts such as poorer verbal working memory, increased behavioral problems, and a possible association with orofacial clefts from first-trimester exposure.^[116]^[112] Long-term follow-up data remain limited and mixed, with some cohorts showing no significant cognitive or behavioral differences, while others report subtle deficits; ongoing randomized trials explore reduced-dose regimens (e.g., 7.5 μg/kg/day versus standard 20 μg/kg/day) to mitigate risks without sacrificing efficacy.^[117]^[118] Major endocrine societies, including the Endocrine Society in its 2018 guidelines, recommend against routine prenatal DEX use outside ethically approved research protocols due to uncertain long-term safety profiles and the ethical burden of exposing unaffected fetuses to glucocorticoids.^[119] Recent reviews as of 2024 affirm this caution, emphasizing that while DEX prevents some virilization, benefits do not clearly outweigh risks for non-affected offspring, and treatment should prioritize informed consent with comprehensive counseling on alternatives like postnatal management.^[114]^[120] Ethical concerns center on the principle of non-maleficence, as the intervention is experimental and off-label, subjecting healthy male or unaffected female fetuses to potential harm without their consent, raising questions of fetal autonomy and the moral equivalence of treating for cosmetic genital outcomes versus life-threatening aspects of CAH.^[111] Beneficence is debated, given that reduced virilization may alleviate psychological distress but does not address core disease pathology, and justice issues arise from unequal access, as monitoring requires specialized centers often unavailable globally.^[121] Critics argue it risks a slippery slope toward non-therapeutic sex-selective or enhancement uses, while proponents highlight parental rights to mitigate foreseeable suffering; multiple societies, including the American Academy of Pediatrics, have historically viewed it as not standard care pending robust evidence.^[122]^[123]^[113] Source credibility in this domain warrants scrutiny, as advocacy from CAH patient groups may overstate benefits, whereas conservative stances from bodies like the Endocrine Society prioritize empirical caution amid incomplete longitudinal data from small, non-randomized cohorts.^[124]

Demasculinization as Counterprocess

Mechanisms of Demasculinization

Demasculinization refers to the suppression or reversal of male secondary sexual characteristics and reproductive functions through interference with androgen signaling pathways, primarily during critical developmental windows or adulthood. In mammals, this process is driven by reduced bioavailability or action of androgens such as testosterone and dihydrotestosterone (DHT), which normally organize and maintain male-typical traits in the brain, genitals, and behavior. Perinatal exposure to anti-androgens, for instance, permanently alters morphology and physiology by blocking androgen receptor (AR) activation, leading to outcomes like reduced anogenital distance and impaired copulatory behavior in male rodents.^[125] At the molecular level, competitive antagonists such as flutamide bind to the AR, preventing ligand-induced conformational changes necessary for co-activator recruitment and gene transcription of androgen-responsive elements, thereby inhibiting Wolffian duct stabilization and masculinization of external genitalia. Inhibition of androgen synthesis represents another key mechanism; compounds like ketoconazole disrupt cytochrome P450 enzymes in the gonadal steroidogenic pathway, reducing testosterone production from cholesterol precursors and consequently diminishing AR signaling downstream. In developing males, insufficient androgen exposure during the organizational phase—typically gestational days 15-20 in rodents—results in demasculinization of neural circuits, evidenced by decreased vasopressin innervation in the bed nucleus of the stria terminalis and attenuated male-typical mounting behaviors.^[126] Estrogenic influences can exacerbate demasculinization by opposing androgen effects via cross-talk between estrogen receptors (ER) and AR pathways; for example, activation of ERβ with agonists like diarylpropionitrile (DPN) reduces vasotocin-like immunoreactive fibers in avian brains analogous to mammalian systems, suppressing male sexual motivation without full feminization. Environmental anti-androgens, such as vinclozolin, induce epigenetic changes including altered DNA methylation at spermatogenic genes, perpetuating transgenerational demasculinization with reduced sperm counts and fertility in exposed male offspring. These mechanisms highlight the sensitivity of androgen-dependent processes to disruption, with outcomes varying by timing, dose, and species, as seen in fish where AR blockers like cyproterone acetate cause ovotestis formation.^[127]^[128]

Clinical Relevance and Examples

Androgen deprivation therapy (ADT), commonly used in prostate cancer treatment, induces demasculinization by suppressing testosterone levels, leading to reduced muscle mass, increased adiposity, gynecomastia, erectile dysfunction, diminished libido, and osteoporosis.^[129] These effects emerge within months of initiation; for instance, studies report hot flashes in up to 80% of patients and sexual dysfunction in over 70% after one year.^[130] Long-term ADT, often combined with GnRH agonists or antagonists, exacerbates bone density loss at rates of 2-4% annually in the first year, increasing fracture risk by 20-30%.^[131] While partially reversible upon discontinuation, persistent changes like gynecomastia may require surgical intervention in 10-20% of cases.^[132] In hormone therapy for phenotypic feminization in biological males, anti-androgens such as spironolactone or cyproterone acetate, combined with estrogen, promote demasculinization by blocking androgen receptors and reducing testosterone to female-typical levels (below 50 ng/dL).^[133] Clinical outcomes include decreased facial and body hair (observable in 60-90% of cases after 12-24 months), reduced penile volume by 20-25%, and testicular atrophy, alongside feminizing effects like breast growth.^[134] Systematic reviews indicate these changes are dose-dependent and partially irreversible, with fertility impairment approaching 100% after prolonged exposure.^[133] Risks include thromboembolism (1-5% annually) and mood alterations, though efficacy varies by age and baseline androgen levels, with older individuals showing slower secondary sex characteristic suppression.^[135] Chemical castration with anti-androgens for paraphilic disorders represents another context, where depot medroxyprogesterone or GnRH analogs demasculinize by lowering testosterone, reducing sexual drive and associated behaviors; recidivism drops by 50-80% in monitored cohorts, but side effects mirror ADT, including fatigue and cognitive fog in up to 40% of users.^[136] These applications highlight demasculinization's therapeutic utility in androgen-driven pathologies, balanced against metabolic and psychological burdens documented in longitudinal trials.^[137]

Controversies and Empirical Debates

Debates in Prenatal Treatment

Prenatal dexamethasone (DEX) treatment is administered to pregnant women carrying fetuses at risk for classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, aiming to suppress fetal adrenal androgen production and thereby reduce virilization of external genitalia in affected females.^[138] The regimen typically involves high-dose oral DEX starting as early as the 6th-7th week of gestation, continued until prenatal diagnosis confirms an unaffected male or non-affected female fetus, with only about 1 in 4 fetuses being affected females requiring full-term exposure.^[139] Efficacy in preventing or mitigating virilization—measured by lower Prader stages of genital ambiguity—is supported by observational studies showing substantial reduction in affected girls, though complete normalization occurs in fewer than 30% of cases, and evidence quality remains low due to small sample sizes, lack of randomization, and confounding factors like variable dosing.^[140]^[141] Debates intensify over the risk-benefit balance, as DEX exposes seven unaffected fetuses for every treated affected female, raising concerns about unnecessary glucocorticoid effects on organ development.^[138] Short-term risks include maternal side effects such as excessive weight gain, hypertension, and edema, alongside fetal reductions in birth weight (by 5-10% on average) and potential increases in orofacial clefts with first-trimester exposure.^[139]^[119] Long-term human outcomes are inconsistent: some cohort studies report subtle deficits in verbal working memory and self-perception in exposed children, particularly those treated throughout gestation, while others find no significant cognitive or behavioral impairments into adulthood.^[115]^[142] Animal models, however, demonstrate glucocorticoid-induced alterations in brain structure, HPA axis programming, and metabolic function, fueling caution despite human data limitations from retrospective designs and small cohorts.^[143] Major endocrine societies, including the Endocrine Society, recommend against routine prenatal DEX use outside ethically approved research protocols, citing incomplete understanding of benefits versus risks and the experimental status of the intervention.^[119]^[144] Ethical debates highlight issues of equipoise, informed consent for off-label use, and equity, as treatment access varies globally with some European centers continuing it under strict monitoring while U.S. practice has largely halted non-trial use.^[145] Ongoing prospective studies like PREDICT aim to clarify optimal dosing and outcomes, but critics argue that the causal chain from androgen suppression to improved psychosexual adjustment lacks robust empirical support, given persistent CAH management challenges postnatally.^[120]^[124]

Outcomes and Risks in Hormone-Induced Virilization

Hormone-induced virilization in females, typically from exogenous androgens such as testosterone, leads to dose- and duration-dependent masculinizing changes, including hirsutism, acne, deepening of the voice, clitoral enlargement, increased muscle mass, and male-pattern baldness.^[3]^[146] These outcomes are intentional in masculinizing hormone therapy for transgender men, where testosterone administration induces progressive virilization over 1-2 years, with voice deepening often irreversible after 6-12 months and clitoral growth persisting post-cessation.^[83] In therapeutic contexts like low-dose testosterone for hypoactive sexual desire disorder (HSDD) in postmenopausal women, outcomes include improved libido and sexual function without severe virilization when serum levels remain within physiological female ranges (e.g., 0.3-0.8 nmol/L).^[147]^[148] Reversible effects predominate in short-term or low-dose exposure, such as hirsutism and acne, which regress upon discontinuation, whereas irreversible changes like vocal cord thickening and permanent hair loss occur with prolonged high-dose therapy.^[1]^[149] Unintended iatrogenic virilization, as from topical testosterone transfer (e.g., from a partner's gel application), manifests as hyperandrogenism with hirsutism, menstrual irregularities, and elevated serum testosterone levels exceeding 10 nmol/L, often resolving after exposure cessation but requiring monitoring for persistent effects.^[150]^[151] Risks encompass metabolic and cardiovascular adverse events, with testosterone therapy in cisgender women associated with heightened incidence of coronary artery disease, stroke, and dyslipidemia, particularly at supraphysiological doses.^[152] Potential fertility impairment arises from ovulatory dysfunction and amenorrhea, alongside uterine atrophy and reduced breast tissue, with long-term safety data limited beyond 2-3 years.^[3]^[153] In prenatal exposure scenarios, such as maternal androgen use, fetal virilization risks include ambiguous genitalia in female offspring, with case reports documenting clitoromegaly at birth following paternal gel transfer during gestation.^[154] Behavioral changes, including increased aggression, and rare hepatic effects have been noted, though non-oral routes minimize liver risks compared to oral androgens.^[155]^[156] Monitoring serum levels and clinical markers is essential to mitigate these risks, as adverse effects like erythrocytosis and lipid alterations can exacerbate cardiovascular vulnerability.^[83]