Clitoral Hypertrophy From Maternal Medication

A female infant was born vaginally to a gravida 4, para 1, 24-year-old woman at term. The child's birth weight was 2,800 g; her length was 51 cm. The mother had a history of three spontaneous abortions. The present pregnancy was complicated by threatened abortion at 15 weeks. The mother was given hydroxyprogesterone hexanoate, 500 mg IM weekly for 6 weeks.

Physical examination showed an infant in no apparent distress. The clitoris was enlarged, and the labia majora and labia minora were hyperpigmented. The child's blood pressure and pulse were normal, as were abdominal ultrasound and chromosomal analysis. Levels of serum electrolytes and serum 17a-hydroxyprogesterone were also normal.

Clitoral hypertrophy suggests fetal exposure to excessive androgens, most commonly from congenital adrenal hyperplasia or other disorders of sexual differentiation, maternal use of progesterone, or maternal arrhenoblastoma.

Exposure to excessive androgen before 13 weeks of gestational age usually results in labioscrotal fusion with clitoral hypertrophy, whereas exposure to excessive androgens after this age usually results in isolated clitoral hypertrophy. In premature infants, the clitoris may appear inappropriately large, but it tends to regress with time. Other causes of clitoral hypertrophy include chronic severe vulvovaginitis, neurofibromatosis, and hemangiopericytoma.

The infant had clitoral hypertrophy secondary to maternal use of hydroxyprogesterone hexanoate. Although progesterone therapy has been used for the treatment of recurrent and threatened abortion, there is no evidence that its use improves fetal salvage.