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1. The images demonstrate hirsutism with frontal balding and layngeal hypertrophy, breast atrophy and clitoromegaly. The clinical diagnosis is virilisation.
2. In contrast to the 'common' phenomenon of hirsutism, virilisation is rare. Virilisation also has more serious implications. It is associated with androgen-producing tumours of the ovary and adrenals, congenital adrenal hyperplasia (adult variety), and, occasionally severe hyperthecosis of the ovary. Virilisation is a severe form of hyperandrogenism and is usually rapidly progressing, developing in months rather than years.
3. The tests required to confirm the diagnosis are serum testosterone, dehydroepiandrosterone sulphate, and 17 a-OH progesterone; the cut-off values are > 200 ng/dL, 700 mg/dL, and 800 ng/dL respectively. In addition, ultrasound examination of the adrenals and ovaries is useful to determine any enlargement.
4. The clitoral index is defined as the product of the largest sagittal and transverse diameters of the glans clitoris; an index of more than 35 mm2 suggests clitoromegaly. Clitoromegaly is considered by some to exist if the transverse shaft diameter of the clitoris is more than 1 cm at the base.
5. Treatment is dependent on the underlying aetiology. Surgery is undertaken in the case of tumours. A low-dose corticosteroid such as 0.5 mg dexamethasone or 5-7 mg prednisolone at night is sufficient to suppress adrenocorticotrophic hormone (ACTH) secretion and to achieve lower androgen levels in patients with congenital adrenal hyperplasia.
Dr Rajaram adds ...
Virilisation in pregnancy is an exceptional, but interesting phenomenon and is associated with a luteoma in which the ovarian stroma shows an exaggerated response to human chorionic gonadotrophin (hCG). This regresses spontaneously postpartum. Fortunately, the female foetus is spared of masculinisation because of high levels of sex hormone-binding globulin (SHBG) in the mother and metabolism of androgens in the placenta.
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