[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Systemic syndromes](https://durgical.com/en/clinical-exam/areas/systemic/) › Hirsutism and virilization: the Ferriman-Gallwey score and the causes # Hirsutism and virilization: the Ferriman-Gallwey score and the causes - Sign Extra coarse hair in a male pattern in a woman, how it is scored, and the signs that point to a serious cause. Updated Nov 13, 2026 **See it in 3D:** [Skin](https://durgical.com/en/anatomy/skin/) · [Ovaries](https://durgical.com/en/anatomy/ovary/) · [Left adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland/) · [Right adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland-abdomen/) · [Pituitary gland](https://durgical.com/en/anatomy/pituitary-gland/) ## Key points - Hirsutism = androgen-dependent male-pattern terminal hair; hypertrichosis = generalized, not androgen-dependent. - Modified Ferriman-Gallwey: nine areas, each scored 0 to 4; about 8 or more is hirsutism in most populations. - Polycystic ovary syndrome causes most cases. - Virilization or rapid onset: look for an androgen-secreting tumor. - Always ask about hair removal before scoring. ## What it is Hirsutism is excess terminal (thick, pigmented) hair in women in areas where hair growth depends on androgens, such as the upper lip, chin, chest and lower abdomen. It differs from hypertrichosis, a generalized increase of fine hair that does not depend on androgens. Virilization means stronger androgen effects, such as a deeper voice, clitoral enlargement and male-pattern balding, and suggests an androgen-secreting tumor or severe adrenal disease. ## The anatomy it tests - The pilosebaceous unit in androgen-sensitive skin turns fine vellus hair into terminal hair under androgen stimulation. - The ovaries (theca cells) and the adrenal glands (zona reticularis) are the main sources of androgens in women. - The pituitary drives both glands through LH (ovary) and ACTH (adrenal). - Skin sensitivity to androgens varies, so the degree of hirsutism does not always match blood androgen levels. ## How to elicit it - Ask when the hair appeared, how fast it is progressing, about menstrual cycles, medicines and family history. - Ask about hair removal, because shaving, waxing or laser can hide the real degree of hair growth. - Inspect nine areas: upper lip, chin, chest, upper abdomen, lower abdomen, upper arms, thighs, upper back and lower back. - Score each area from 0 (no terminal hair) to 4 (frank male pattern) and add the scores (modified Ferriman-Gallwey). - Look for other signs of androgen excess: acne, oily skin and thinning hair at the crown. - Look for virilization: deep voice, increased muscle mass, breast atrophy, temporal balding and an enlarged clitoris. - Look for clues to the cause: acanthosis nigricans, central obesity, purple striae, a moon face, and an abdominal or pelvic mass. ## What a positive result means - A score of about 8 or more is the usual threshold for hirsutism; lower cut-offs are used in some populations, including about 6 in South American women. - Gradual onset around puberty with irregular cycles: polycystic ovary syndrome, by far the most common cause. - Hirsutism with regular cycles and normal androgens: idiopathic hirsutism, a diagnosis of exclusion. - Nonclassic congenital adrenal hyperplasia (21-hydroxylase deficiency) can look like polycystic ovary syndrome. - Rapid onset over months, late onset, virilization or a palpable mass suggest an ovarian or adrenal androgen-secreting tumor; Cushing syndrome and some medicines are other causes. ## Usefulness and limits - The score is subjective and varies by ethnicity; it does not capture localized heavy growth. - Total or free testosterone first; DHEA sulfate if an adrenal source is suspected; early-morning 17-hydroxyprogesterone for nonclassic congenital adrenal hyperplasia. - Prolactin and TSH when cycles are irregular; tests for Cushing syndrome when its features are present. - Pelvic ultrasound or adrenal imaging when a tumor is suspected. ## Memory aid 'Nine areas, four points, ask about the razor': score each of nine zones 0 to 4 and remember that hair removal hides the score. ## Test yourself Think of the answer, then tap the question to see it. ## What is the difference between hirsutism and hypertrichosis? Hirsutism is androgen-dependent terminal hair in a male pattern; hypertrichosis is a generalized increase in hair that does not depend on androgens. ## How is the modified Ferriman-Gallwey score calculated? Nine androgen-sensitive areas are each scored from 0 to 4 and added; about 8 or more usually defines hirsutism. ## Which features suggest an androgen-secreting tumor? Rapid onset over months, onset later in life, virilization (deep voice, clitoral enlargement, balding) or a palpable abdominal or pelvic mass. ## What is the most common cause of hirsutism? Polycystic ovary syndrome. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/hirsutism-and-virilization-the-ferriman-gallwey-score-and-the-causes/) ## Connections ## See it in 3D 5 The structures of Durgical's 3D anatomy where it is found. - [Skin](https://durgical.com/en/anatomy/skin/) - [Ovaries](https://durgical.com/en/anatomy/ovary/) - [Left adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland/) - [Right adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland-abdomen/) - [Pituitary gland](https://durgical.com/en/anatomy/pituitary-gland/) ## Related 6 - [Amenorrhea and galactorrhea: primary, secondary and four compartments](https://durgical.com/en/clinical-exam/amenorrhea-and-galactorrhea-primary-secondary-and-four-compartments/) - [Cushing syndrome and adrenal insufficiency: the signs](https://durgical.com/en/clinical-exam/cushing-syndrome-and-adrenal-insufficiency-the-signs/) - [Skin examination: primary and secondary lesions](https://durgical.com/en/clinical-exam/skin-examination-primary-and-secondary-lesions/) - [Diagnostic facies](https://durgical.com/en/clinical-exam/diagnostic-facies/) - [Gynecologic and obstetric history](https://durgical.com/en/clinical-exam/gynecologic-and-obstetric-history/) - [Gynecologic examination: speculum and bimanual exam](https://durgical.com/en/clinical-exam/gynecologic-examination-speculum-and-bimanual-exam/) ## Related conditions 5 - [Polycystic ovary syndrome](https://durgical.com/en/conditions/polycystic-ovary-syndrome/) - [Congenital adrenal hyperplasia due to 21-hydroxylase deficiency](https://durgical.com/en/conditions/congenital-adrenal-hyperplasia-due-to-21-hydroxylase-deficiency/) - [Cushing syndrome](https://durgical.com/en/conditions/cushing-syndrome/) - [Adrenocortical carcinoma](https://durgical.com/en/conditions/adrenocortical-carcinoma/) - [Ovarian germ-cell and sex cord–stromal tumours](https://durgical.com/en/conditions/ovarian-germ-cell-and-sex-cord-stromal-tumours/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [Hirsutism in Women](https://www.aafp.org/pubs/afp/issues/2019/0801/p168.html) (American Family Physician (AAFP), 2019); [Polyendocrine Metabolic Ovarian Syndrome (PMOS)](https://www.msdmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/polycystic-ovary-syndrome-pcos) (MSD Manual Professional Edition, 2024). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/hirsutism-and-virilization-the-ferriman-gallwey-score-and-the-causes/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/hirsutism-and-virilization-the-ferriman-gallwey-score-and-the-causes/