# Hirsutism and Virilisation > NEET-PG Obstetrics and Gynaecology notes on hirsutism and virilisation covering Ferriman-Gallwey scoring, ovarian versus adrenal androgen source and treatment. - Canonical URL: https://prepelephant.com/topics/neet-pg/obstetrics-and-gynaecology/hirsutism-and-virilisation - Exam / course: NEET-PG · Subject: Obstetrics and Gynaecology - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-08 - Last updated: 2026-10-08 - Reference basis: Williams Gynecology; Dutta's Textbook of Gynecology - How to cite: "Hirsutism and Virilisation", PrepElephant, https://prepelephant.com/topics/neet-pg/obstetrics-and-gynaecology/hirsutism-and-virilisation ## Direct answer Hirsutism is excessive terminal hair growth in a male pattern in women, while virilisation is hirsutism together with signs of stronger androgen excess such as deepening voice, clitoromegaly and temporal balding. Polycystic ovary syndrome is the commonest cause, but a rapid onset with markedly raised testosterone points to an ovarian or adrenal androgen-secreting tumour and needs urgent localisation. ## What you must remember - **Hirsutism:** coarse terminal hair in androgen-dependent areas such as the upper lip, chin, chest, abdomen and back, which is distinct from hypertrichosis, a generalised and androgen-independent growth of fine hair. - **Ferriman-Gallwey score:** nine body areas, each scored 0 to 4; the classic cut-off for hirsutism is 8 or more, but it is population-specific, so local norms may differ. - **Virilisation:** hirsutism with clitoromegaly, deepening voice, temporal balding, muscle bulk and acne, which signals a serious androgen source and warrants prompt investigation. - **Ovarian source:** testosterone is disproportionately raised, and levels above about 200 ng/dL suggest a Sertoli-Leydig or hilus cell tumour, especially with rapid progression. - **Adrenal source:** DHEA-S is the key marker, and levels above about 700 µg/dL suggest an adrenal tumour, with adrenal carcinoma more likely when virilisation is marked. - **Drug treatment:** a combined oral contraceptive is first line, with an antiandrogen such as cyproterone acetate or spironolactone added if needed; finasteride and spironolactone must not be used in pregnancy, so effective contraception is essential. ## A stepwise work-up from score to source A 24-year-old woman with irregular cycles, acne and a Ferriman-Gallwey score of 12 asks for treatment. Her plan should separate a common, treatable pattern from a rare tumour. The steps below follow the usual order of assessment. 1. **Quantify the hair:** Score the nine androgen-sensitive areas with the modified Ferriman-Gallwey method and record the total before treatment starts. 2. **Look for virilisation:** Examine for clitoromegaly, voice change, temporal balding and muscle bulk, because any of these changes the urgency of the work-up. 3. **Measure androgens:** Draw total testosterone and DHEA-S in the early follicular phase, along with SHBG, 17-hydroxyprogesterone, prolactin and TSH. 4. **Localise the source:** Disproportionate testosterone points to the ovary and high DHEA-S to the adrenal gland, and ultrasound is followed by MRI or CT when a tumour is suspected. 5. **Exclude mimics:** Late-onset congenital adrenal hyperplasia is checked with 17-hydroxyprogesterone, and a dexamethasone suppression test is used when Cushing syndrome is a concern. 6. **Start treatment:** A combined oral contraceptive is used for most women, an antiandrogen is added for an inadequate response, and eflornithine cream or laser treatment addresses cosmetic concerns. ## Where the exam tries to catch you Examiners test whether you can separate a benign androgen pattern from a dangerous source before choosing treatment. - **Trap:** Start an antiandrogen at once for every hirsute woman. **Correct:** Establish the androgen profile first, because an antiandrogen does not treat an ovarian or adrenal tumour and may delay diagnosis. - **Trap:** Treat a high Ferriman-Gallwey score as proof of hyperandrogenism. **Correct:** Idiopathic hirsutism has a normal androgen profile with increased follicular sensitivity, so normal testosterone with a high score is not hyperandrogenism. - **Trap:** Order only testosterone when the picture is moderate. **Correct:** An adrenal tumour can raise DHEA-S with only modest testosterone, so draw both markers together. - **Trap:** Prescribe spironolactone or finasteride without contraception. **Correct:** Both are unsafe in pregnancy, so effective contraception must be confirmed before starting. ## Frequently asked questions ### Which testosterone level suggests an ovarian androgen-secreting tumour? Testosterone markedly above the usual polycystic range, commonly cited above about 200 ng/dL, suggests an ovarian androgen-secreting tumour in hirsute women. This is especially likely when virilisation appears rapidly. Pelvic ultrasound and MRI then localise the mass. ### What is the modified Ferriman-Gallwey score used for? The modified Ferriman-Gallwey score quantifies hair growth in nine androgen-sensitive body areas, each scored from 0 to 4. It measures hirsutism objectively before and after treatment, and the cut-off used to define hirsutism varies by population. ### Why is 17-hydroxyprogesterone checked before diagnosing PCOS-related hirsutism? Late-onset congenital adrenal hyperplasia can mimic polycystic ovary syndrome with hirsutism and irregular cycles. A raised 17-hydroxyprogesterone in the early follicular phase identifies this treatable mimic before a diagnosis of PCOS is accepted. ### Which drugs for hirsutism must be avoided in pregnancy? Finasteride and spironolactone must be avoided in pregnancy because of their antiandrogen effects on a male fetus. Effective contraception should be confirmed before either drug is started in a woman who may conceive. ### Is hirsutism always a sign of polycystic ovary syndrome? Hirsutism is not always due to polycystic ovary syndrome, because idiopathic hirsutism and late-onset congenital adrenal hyperplasia also cause it. Hormonal profiling and ovarian imaging are needed to confirm the cause before long-term treatment.