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Stancampiano MR, Meroni SLC, Bucolo C, Russo G. 46,XX Differences of Sex Development outside congenital adrenal hyperplasia: pathogenesis, clinical aspects, puberty, sex hormone replacement therapy and fertility outcomes. Front Endocrinol (Lausanne) 2024; 15:1402579. [PMID: 38841305 PMCID: PMC11150773 DOI: 10.3389/fendo.2024.1402579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024] Open
Abstract
The term 'differences of sex development' (DSD) refers to a group of congenital conditions that are associated with atypical development of chromosomal, gonadal, and/or anatomical sex. DSD in individuals with a 46,XX karyotype can occur due to fetal or postnatal exposure to elevated amount of androgens or maldevelopment of internal genitalia. Clinical phenotype could be quite variable and for this reason these conditions could be diagnosed at birth, in newborns with atypical genitalia, but also even later in life, due to progressive virilization during adolescence, or pubertal delay. Understand the physiological development and the molecular bases of gonadal and adrenal structures is crucial to determine the diagnosis and best management and treatment for these patients. The most common cause of DSD in 46,XX newborns is congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, determining primary adrenal insufficiency and androgen excess. In this review we will focus on the other rare causes of 46,XX DSD, outside CAH, summarizing the most relevant data on genetic, clinical aspects, puberty and fertility outcomes of these rare diseases.
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Yavas Abalı Z, Guran T. Diagnosis and management of non-CAH 46,XX disorders/differences in sex development. Front Endocrinol (Lausanne) 2024; 15:1354759. [PMID: 38812815 PMCID: PMC11134272 DOI: 10.3389/fendo.2024.1354759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/01/2024] [Indexed: 05/31/2024] Open
Abstract
Prenatal-onset androgen excess leads to abnormal sexual development in 46,XX individuals. This androgen excess can be caused endogenously by the adrenals or gonads or by exposure to exogenous androgens. The most common cause of 46,XX disorders/differences in sex development (DSD) is congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, comprising >90% of 46,XX DSD cases. Deficiencies of 11β-hydroxylase, 3β-hydroxysteroid dehydrogenase, and P450-oxidoreductase (POR) are rare types of CAH, resulting in 46,XX DSD. In all CAH forms, patients have normal ovarian development. The molecular genetic causes of 46,XX DSD, besides CAH, are uncommon. These etiologies include primary glucocorticoid resistance (PGCR) and aromatase deficiency with normal ovarian development. Additionally, 46,XX gonads can differentiate into testes, causing 46,XX testicular (T) DSD or a coexistence of ovarian and testicular tissue, defined as 46,XX ovotesticular (OT)-DSD. PGCR is caused by inactivating variants in NR3C1, resulting in glucocorticoid insensitivity and the signs of mineralocorticoid and androgen excess. Pathogenic variants in the CYP19A1 gene lead to aromatase deficiency, causing androgen excess. Many genes are involved in the mechanisms of gonadal development, and genes associated with 46,XX T/OT-DSD include translocations of the SRY; copy number variants in NR2F2, NR0B1, SOX3, SOX9, SOX10, and FGF9, and sequence variants in NR5A1, NR2F2, RSPO1, SOX9, WNT2B, WNT4, and WT1. Progress in cytogenetic and molecular genetic techniques has significantly improved our understanding of the etiology of non-CAH 46,XX DSD. Nonetheless, uncertainties about gonadal function and gender outcomes may make the management of these conditions challenging. This review explores the intricate landscape of diagnosing and managing these conditions, shedding light on the unique aspects that distinguish them from other types of DSD.
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Affiliation(s)
| | - Tulay Guran
- Department of Pediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Türkiye
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Zhao J, Zhu J, Ding S, Li H. Ovotesticular Disorder of Sex Development Presenting as a Scrotal Emergency. Pediatrics 2023; 152:e2023061810. [PMID: 37990579 DOI: 10.1542/peds.2023-061810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 11/23/2023] Open
Abstract
Ovotesticular (OT) disorder of sex development (DSD) is a rare condition that affects the development of reproductive organs and manifests in a wide range of phenotypic presentations. The clinical diagnosis of this condition is challenging because of its atypical nature, and the variability of presentation in 46,XX OT-DSD cases makes it a complex issue in medical practice. We report a case of a 13-year-old boy who presented with left scrotal pain. Further exploration revealed a tunica rupture without testicular torsion of the left testis, whereas the histopathological analysis of a nodule excised from the right testis indicated the presence of ovotestis tissues. A second nonemergent surgery preserved the testicular tissues as the ovarian tissue in both gonads was excised. After 22 months of follow-up, the patient's testes produced normal testosterone levels sustained over time without any exogenous supplementation. This case reveals that, in male children who present with an acute scrotal disease as adolescents, the gonads should be retained until the etiology is confirmed, and the possibility of OT-DSD should be considered.
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Affiliation(s)
| | | | | | - Haibo Li
- Molecular Genetics Laboratory, Ningbo Women and Children's Hospital, Ningbo, China
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Reyes AP, León NY, Frost ER, Harley VR. Genetic control of typical and atypical sex development. Nat Rev Urol 2023:10.1038/s41585-023-00754-x. [PMID: 37020056 DOI: 10.1038/s41585-023-00754-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 04/07/2023]
Abstract
Sex development relies on the sex-specific action of gene networks to differentiate the bipotential gonads of the growing fetus into testis or ovaries, followed by the differentiation of internal and external genitalia depending on the presence or absence of hormones. Differences in sex development (DSD) arise from congenital alterations during any of these processes, and are classified depending on sex chromosomal constitution as sex chromosome DSD, 46,XY DSD or 46,XX DSD. Understanding the genetics and embryology of typical and atypical sex development is essential for diagnosing, treating and managing DSD. Advances have been made in understanding the genetic causes of DSD over the past 10 years, especially for 46,XY DSD. Additional information is required to better understand ovarian and female development and to identify further genetic causes of 46,XX DSD, besides congenital adrenal hyperplasia. Ongoing research is focused on the discovery of further genes related to typical and atypical sex development and, therefore, on improving diagnosis of DSD.
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Affiliation(s)
- Alejandra P Reyes
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Genetics Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Nayla Y León
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Emily R Frost
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Vincent R Harley
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.
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Gonen N, Eozenou C, Mitter R, Elzaiat M, Stévant I, Aviram R, Bernardo AS, Chervova A, Wankanit S, Frachon E, Commère PH, Brailly-Tabard S, Valon L, Barrio Cano L, Levayer R, Mazen I, Gobaa S, Smith JC, McElreavey K, Lovell-Badge R, Bashamboo A. In vitro cellular reprogramming to model gonad development and its disorders. SCIENCE ADVANCES 2023; 9:eabn9793. [PMID: 36598988 PMCID: PMC9812383 DOI: 10.1126/sciadv.abn9793] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 12/02/2022] [Indexed: 05/28/2023]
Abstract
During embryonic development, mutually antagonistic signaling cascades determine gonadal fate toward a testicular or ovarian identity. Errors in this process result in disorders of sex development (DSDs), characterized by discordance between chromosomal, gonadal, and anatomical sex. The absence of an appropriate, accessible in vitro system is a major obstacle in understanding mechanisms of sex-determination/DSDs. Here, we describe protocols for differentiation of mouse and human pluripotent cells toward gonadal progenitors. Transcriptomic analysis reveals that the in vitro-derived murine gonadal cells are equivalent to embryonic day 11.5 in vivo progenitors. Using similar conditions, Sertoli-like cells derived from 46,XY human induced pluripotent stem cells (hiPSCs) exhibit sustained expression of testis-specific genes, secrete anti-Müllerian hormone, migrate, and form tubular structures. Cells derived from 46,XY DSD female hiPSCs, carrying an NR5A1 variant, show aberrant gene expression and absence of tubule formation. CRISPR-Cas9-mediated variant correction rescued the phenotype. This is a robust tool to understand mechanisms of sex determination and model DSDs.
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Affiliation(s)
- Nitzan Gonen
- The Mina and Everard Goodman Faculty of Life Sciences and the Institute of Nanotechnology and Advanced Materials, Bar-Ilan University, Ramat Gan 5290002, Israel
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Caroline Eozenou
- Institut Pasteur, Université de Paris, CNRS UMR3738, Human Developmental Genetics, F-75015 Paris, France
| | - Richard Mitter
- Bioinformatics Core, The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Maëva Elzaiat
- Institut Pasteur, Université de Paris, CNRS UMR3738, Human Developmental Genetics, F-75015 Paris, France
| | - Isabelle Stévant
- The Mina and Everard Goodman Faculty of Life Sciences and the Institute of Nanotechnology and Advanced Materials, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Rona Aviram
- The Mina and Everard Goodman Faculty of Life Sciences and the Institute of Nanotechnology and Advanced Materials, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Andreia Sofia Bernardo
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Almira Chervova
- Department of Stem Cell and Developmental Biology, Institut Pasteur, Paris 75724, France
| | - Somboon Wankanit
- Institut Pasteur, Université de Paris, CNRS UMR3738, Human Developmental Genetics, F-75015 Paris, France
| | - Emmanuel Frachon
- Biomaterials and Microfluidics Core Facility, Institut Pasteur, F-75015 Paris, France
| | - Pierre-Henri Commère
- Cytometry and Biomarkers, Centre de Ressources et Recherches Technologiques (C2RT), Institut Pasteur, F-75015 Paris, France
| | - Sylvie Brailly-Tabard
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Molecular Genetics, Pharmacogenetics, and Hormonology, Le Kremlin-Bicêtre, France
| | - Léo Valon
- Institut Pasteur, Université de Paris, CNRS UMR3738, Cell Death and Epithelial Homeostasis, F-75015 Paris, France
| | - Laura Barrio Cano
- Cytometry and Biomarkers, Centre de Ressources et Recherches Technologiques (C2RT), Institut Pasteur, F-75015 Paris, France
| | - Romain Levayer
- Institut Pasteur, Université de Paris, CNRS UMR3738, Cell Death and Epithelial Homeostasis, F-75015 Paris, France
| | - Inas Mazen
- Genetics Department, National Research Center, Cairo, Egypt
| | - Samy Gobaa
- Biomaterials and Microfluidics Core Facility, Institut Pasteur, F-75015 Paris, France
| | - James C. Smith
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Kenneth McElreavey
- Institut Pasteur, Université de Paris, CNRS UMR3738, Human Developmental Genetics, F-75015 Paris, France
| | | | - Anu Bashamboo
- Institut Pasteur, Université de Paris, CNRS UMR3738, Human Developmental Genetics, F-75015 Paris, France
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