Gynecological challenges in the diagnosis and care of patients with DSD: The role of the obstetrician gynecologist in the multidisciplinary approach to the patient

Steroid signaling controls sex-specific development in an invertebrate

In vertebrate sexual development, two important steroid hormones - testosterone and estrogen - regulate the sex-specific development of many tissues. In contrast, invertebrates utilize a single steroid hormone, ecdysone, to regulate developmental timing in both sexes. Here, we show that in the fruit fly Drosophila melanogaster, sex-specific ecdysone activity controls important aspects of gonad sexual dimorphism. Rather than being regulated at the level of hormone production, hormone activity is regulated cell-autonomously through sex-specific hormone reception. We found that Ecdysone receptor (EcR) is regulated downstream of the sex determination factor Doublesex (Dsx), the founding member of the Dsx/Mab3 Related Transcription Factor (DMRT) family that regulates gonad development in all animals. EcR is restricted to the developing ovary and repressed in the testis at a time when ecdysone initiates ovary morphogenesis. EcR activity drives ovary development and antagonizes development of the testis stem cell niche. Interestingly, de-repression of the ecdysone response in the testis led to rapid feminization, which is known to cause infertility. This work demonstrates that invertebrates can also use steroid hormone signaling to control sex-specific development. Further, it may help explain recent work showing that vertebrate sexual development is surprisingly cell-autonomous. For example, in birds that have a mixture of cells with male and female genotypes, the male cells develop as male and the female cells develop as female despite exposure to the same circulating hormones. Sex-specific regulation of steroid hormone response in vertebrates may well underly such cellular sexual fate choices.

Delivery of multidisciplinary care in the field of differences and disorders of sex development (DSD)

INTRODUCTION

Differences and disorders of sex development (DSD) are a diverse group of conditions, which often present in early childhood and may require input from a group of experts in a wide range of clinical fields. Clinical guidance in this field recommends that these experts function as a multidisciplinary team (MDT) within which each expert has a defined role, which ensures an integrated and streamlined approach to the care of affected individuals.

AREAS COVERED

This review will focus on the benefits of multidisciplinary care for people with DSD, as well as the challenges that may be faced.

EXPERT OPINION

Core members of the MDT for people with DSD include endocrinologists, surgeons, psychologists, geneticists, specialist nurses, radiologists, and gynecologists, although many other health-care professionals may also be pertinent, at different stages of the patient's life. With greater acceptance of remote and digital health-care technology, there is a need to review the traditional concepts of the clinical MDT so that new care models can be explored for effective and efficient delivery of complex care.

Reproductive health counseling and contraceptive use in adolescents with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a progressive, genetic disease posing reproductive health concerns to affected women, such as high-risk pregnancies and medication interactions leading to contraceptive failure. Reproductive health counseling in this population is of the utmost importance, but barriers to providing it include lack of time, knowledge, and provider discomfort. We sought to evaluate reproductive health counseling and contraceptive use in female adolescent CF patients.

METHODS

An Institutional Review Board approved retrospective chart review was performed between March 2008 and March 2018. Females 10-21 years old with the diagnosis of CF were reviewed. Descriptive statistics were used.

RESULTS

Thirty-three patients met inclusion criteria: 16 non-sexually active and 17 sexually active. Thirteen patients were counseled about pregnancy risks. All sexually active patients used contraception, with the most common being condoms and combined oral contraceptive pills. Six pregnancies occurred, resulting in five live births and one termination.

CONCLUSIONS

Less than half of patients were counseled about pregnancy and contraception, and most patients chose high failure methods. Female adolescents with CF should be routinely screened for sexual activity, offered long-acting reversible contraception, and counseled on the effects of CF on pregnancy.