An objective clinical assessment of hair distribution and quantity is central to the evaluation. A commonly used method to grade hair growth is the Ferriman-Gallwey score (see Fig. 68-1, p. 333, in HPIM-19). Associated manifestations of androgen excess include acne and male-pattern balding (androgenic alopecia). Virilization, on the other hand, refers to the state in which androgen levels are sufficiently high to cause deepening of the voice, breast atrophy, increased muscle bulk, clitoromegaly, and increased libido. Historic elements include menstrual history and the age of onset, rate of progression, and distribution of hair growth. Sudden development of hirsutism, rapid progression, and virilization suggests an ovarian or adrenal neoplasm.