Virilization refers to the development of male secondary sexual characteristics in females due to excessive androgen exposure. It may manifest as hirsutism, acne, androgenic alopecia, deepening of voice, increased muscle mass, menstrual disturbances, and clitoromegaly. The presence of progressive virilization, particularly with primary amenorrhea in an adolescent, is clinically significant because it may indicate an underlying androgen-secreting tumor requiring urgent evaluation and management.1 The commonest cause of hyperandrogenism in young women is polycystic ovary syndrome, but severe virilization, rapidly progressive symptoms, very high androgen levels, and a palpable adnexal mass should raise suspicion of an ovarian or adrenal tumor.8,9 Ovarian sex cord–stromal tumors constitute a rare group of neoplasms arising from sex cord derivatives and ovarian stromal cells.2 Depending on the cellular composition and differentiation, these tumors may produce estrogen or androgens. Early surgical removal can lead to symptomatic improvement and restoration of menstrual function.5 Granulosa cell tumors are traditionally considered estrogen-producing tumors and commonly present with abnormal uterine bleeding or endometrial hyperplasia.2,4 Virilizing presentations are uncommon, which may result in diagnostic confusion and delayed treatment. We report a rare case of an adolescent girl presenting with primary amenorrhea and progressive virilization due to a sex cord–stromal ovarian tumor confirmed as granulosa cell tumor on histopathology and immunohistochemistry.

A 17-year-old girl presented with absence of menarche (primary amenorrhea) and progressively increasing virilization for the past two years. Her symptoms included increased terminal hair growth over the face and body, acne, and mild frontal hair thinning. She also reported intermittent lower abdominal pain and a gradually increasing lower abdominal mass for one year. There was no history of exogenous androgen exposure or long-term medication use. On examination, her general condition was stable. She weighed 45 kg and measured 150 cm in height (body mass index 20 kg/m²). Vital parameters were within normal limits. Clinical examination showed hirsutism and acne. Abdominal examination revealed an irregular firm mass arising from the pelvis, corresponding to approximately 16 weeks’ gestation size; the uterus could not be clearly palpated separately. There was no clinical evidence of ascites. Local examination revealed clitoromegaly. Endocrine evaluation revealed markedly elevated serum testosterone (284 ng/dL; normal 40–50 ng/dL). Thyroid-stimulating hormone was normal (2.13 µIU/mL). Gonadotropins were within normal range (LH 5.78mIU/mL; FSH 5.2 mIU/mL). Dehydroepiandrosterone sulfate was 6 ng/mL. Pelvic ultrasonography demonstrated a left adnexal hypoechoic lesion. MRI abdomen and pelvis revealed a left ovarian neoplasm measuring approximately 8.5 × 6.5 × 8.5 cm with no evidence of ascites or metastasis. Following counseling and informed consent, exploratory laparotomy was performed. A bosselated yellowish solid mobile tumor arising from the left ovary measuring approximately 8.3× 9.5 cm was excised. The uterus and right ovary appeared grossly normal with no peritoneal deposits. Histopathology confirmed granulosa cell tumor. Immunohistochemistry was positive for CD99, inhibin, and calretinin, supporting sex cord–stromal origin. The postoperative period was uneventful. Menstruation resumed four months after surgery and virilizing features gradually improved; clitoromegaly persisted on long-term follow-up.

Virilization in females is a clinical red flag due to the possibility of androgen-secreting tumors. In adolescents, primary amenorrhea with virilization requires careful evaluation as delayed diagnosis can lead to irreversible changes and psychosocial distress.9 Clinical clues favoring a tumor include rapid progression, severe virilization such as clitoromegaly, and very high serum testosterone.9 Biochemical testing assists in localization: markedly elevated testosterone generally suggests ovarian origin, whereas highly elevated dehydroepiandrosterone sulfate suggests adrenal pathology.9 In this patient, testosterone was markedly raised and imaging demonstrated a unilateral ovarian mass. Ovarian sex cord–stromal tumors are uncommon. Granulosa cell tumors are classically estrogen-secreting, commonly presenting with abnormal uterine bleeding.2 However, they may rarely present with androgen excess, potentially due to stromal luteinization or mixed tumor components.2,4 MRI helps characterize the lesion and assess spread; in this case no metastatic disease was identified. Surgery remains the definitive management, and fertility-sparing excision is appropriate in adolescents when disease is confined to one ovary.5 Following tumor removal, hormonal normalization usually leads to gradual improvement of symptoms. Menstrual resumption within four months supported recovery of endocrine function. Persistence of clitoromegaly emphasizes that some virilizing changes may not fully reverse after prolonged androgen exposure. Granulosa cell tumors can recur late; therefore, long-term follow-up is advised. Monitoring may include clinical examination, imaging when indicated, and serum markers such as inhibin or anti-Müllerian hormone where available.

Primary amenorrhea with progressive virilization in an adolescent warrants evaluation for androgen-secreting tumors. Ovarian sex cord–stromal tumors are rare but clinically important. This case demonstrates that granulosa cell tumor may rarely present with virilization. Prompt imaging, endocrine evaluation, and early surgical management can restore menstruation and improve virilizing features with good prognosis and preserved fertility.   AUTHORS’ CONTRIBUTIONS STATEMENT Shilpi Kushwah: Conceptualization, patient evaluation, data collection, manuscript drafting, and final approval. Surbhi Porwal: Supervision, critical revision of manuscript, and final approval. Hemlata Jharbade: Mentorship, clinical guidance, manuscript review, and final approval.   TABLES AND FIGURES Table 1. Key clinical, hormonal and imaging findings Parameter Findings Age 17 years Presenting complaints Primary amenorrhea; progressive virilization; abdominal pain; abdominal mass Clinical examination Hirsutism; acne; clitoromegaly; abdominopelvic mass (~16 weeks size) Serum testosterone 284 ng/dL DHEAS 6 ng/mL MRI abdomen/pelvis Left ovarian neoplasm ~8.5 × 6.5 × 8.5 cm; no metastasis/ascites Surgery Exploratory laparotomy; excision of left ovarian tumor Histopathology/IHC Granulosa cell tumor; CD99/inhibin/calretinin positive Outcome Menstruation resumed at 4 months; virilizing features improved; clitoromegaly persisted

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