Purpose <p>To characterize the clinical, biochemical, radiological, and histological features of benign androgen-producing adrenal tumors in adults.</p> Methods <p>Systematic review of published case reports and case series. A systematic search of PubMed, Web of Science, and Scopus was conducted for studies published between 1980 and 2024. Eligible cases included adults (≥ 19 years) with histologically confirmed benign adrenal tumors, biochemical evidence of androgen excess with postoperative normalization, and available individual patient data. Extracted variables included demographics, clinical signs, hormonal values, imaging, and histopathology.</p> Results <p>Ninety-seven cases from 81 publications fulfilled inclusion criteria. Most were women (96/97), with a mean age of 42.1 years. Hirsutism (87.5%) and clitoromegaly (55.2%) were the most common features, though a minority of tumors were discovered incidentally, often in postmenopausal women. While most tumors were unilateral adenomas, 18% showed alternative histologies, including oncocytomas and ganglioneuromas. Total testosterone was elevated in 93.4% of women, DHEAS in 69.4%; combined assessment achieved 100% sensitivity. However, 25.9% of cases did not exceed thresholds commonly used to suggest tumoral hyperandrogenism (7 nmol/L for testosterone, 18.5 µmol/L for DHEAS), highlighting a risk of underdiagnosis. A paradoxical androgen rise after dexamethasone was observed in ~ 30% of tested cases. Cortisol co-secretion was present in 28% of cases.</p> Conclusion <p>Benign androgen-producing adrenal tumors are rare but clinically significant. They predominantly affect women and may present with subtle or atypical findings, or be discovered incidentally. Reliance on strict hormonal cut-offs may overlook some cases. Broader biochemical assessment and clinical suspicion are crucial to ensure accurate diagnosis.</p>