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Mediå LM, Fauske L, Sigurdardottir S, Billaud Feragen KJ, Waehre A. Differences of sex development and surgical decisions: focus group interviews with health care professionals in Norway. Health Psychol Behav Med 2024; 12:2371134. [PMID: 38979393 PMCID: PMC11229732 DOI: 10.1080/21642850.2024.2371134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/12/2024] [Indexed: 07/10/2024] Open
Abstract
Background Differences of Sex Development (DSD) are congenital conditions where the chromosomal, gonadal and anatomical sex characteristics do not strictly belong to male or female categories, or that belong to both at the same time. Surgical interventions for individuals with DSD remain controversial, among affected individuals, caregivers, and health-care providers. A lack of evidence in support of, for deferring, or for avoiding surgery complicates the decision-making process. This study explores Norwegian health-care professionals' (HCPs) perspectives on decision-making in DSD-related surgeries and the dilemmas they are facing in this process. Methods Focus group interviews with 14 HCPs integrated into or collaborating with multidisciplinary DSD teams were analyzed using reflexive thematic analysis. Results Two overarching dilemmas shed light on the intricate considerations and challenges that HCPs encounter when guiding affected individuals and caregivers through surgical decision-making processes in the context of DSD. The first theme describes how shared decision-making was found to be influenced by fear of stigma and balancing the interplay between concepts of normality, personal experiences and external expectations when navigating the child's and caregivers' needs. The second theme illuminated dilemmas due to a lack of evidence-based practice. The core concepts within each theme were the dilemmas health-care professionals face during consultations with caregivers and affected individuals. Conclusion HCPs were aware of the controversies with DSD-related surgeries. However, they struggled to reconcile knowledge with parents' wishes for surgery and faced dilemmas making decisions in the best interests of the child. This study draws attention to the benefits of increased knowledge on the consequences of performing or withholding surgery as well as incorporating tools enabling shared decision-making between HCPs and affected individuals/caregivers.
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Affiliation(s)
- Line Merete Mediå
- Women’s and Children’s Division, Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lena Fauske
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Solrun Sigurdardottir
- Women’s and Children’s Division, Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
| | | | - Anne Waehre
- Department of Child and Adolescent Psychiatry, Oslo University Hospital and Institute of Clinical Medicine, Oslo, Norway
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2
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Yu T, Liu L. Pure 46, XY gonadal dysgenesis and 46, XY complete androgen insensitivity syndrome: A case report. Medicine (Baltimore) 2024; 103:e38297. [PMID: 38905377 PMCID: PMC11191977 DOI: 10.1097/md.0000000000038297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/29/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Disorders of sex development (DSD) are congenital conditions characterized by atypical development of chromosomal, gonadal, and phenotypic sex. 46, XY DSD can result from disorders of testicular development or androgen synthesis. METHODS We present 2 rare cases of 46, XY DSD, specifically XY pure gonadal dysgenesis and complete androgen insensitivity syndrome. RESULTS Both cases underwent prophylactic gonadectomy due to the elevated risk of gonadal malignancy. Bilateral gonadoblastoma and dysgerminoma were diagnosed on one side, while Leydig cell hyperplasia and only Sertoli cells were diagnosed in the seminiferous tubules on both sides. The normal menstruation for the pure gonadal dysgenesis patient only as CAIS patients never menstruate. Estrogen replacement therapy was administered periodically to promote the development of secondary sexual characteristics and menstruation in pure gonadal dysgenesis case, as well as to prevent osteoporosis. Follow-up examinations revealed no tumor recurrence, and the patient with Swyer syndrome had regular menstrual cycles. CONCLUSION Laparoscopic bilateral prophylactic gonadectomy and long-term hormone therapy with patient counseling and support are recommended.
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Affiliation(s)
- Tengge Yu
- Department of Gynecology and Obstetrics, West China Xiamen Hospital of Sichuan University, Xiamen, China
| | - Li Liu
- Department of Emergency, The First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China
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3
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Rudnicka E, Jaroń A, Kruszewska J, Smolarczyk R, Jażdżewski K, Derlatka P, Kucharska AM. A Risk of Gonadoblastoma in Familial Swyer Syndrome-A Case Report and Literature Review. J Clin Med 2024; 13:785. [PMID: 38337479 PMCID: PMC10856735 DOI: 10.3390/jcm13030785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
A complete gonadal dysgenesis (CGD) with 46,XY karyotype is known as the Swyer syndrome and belongs to the group of 46,XY differences of sex development (DSD). The main problem in patients with Swyer syndrome is the delayed puberty and primary amenorrhea. Moreover, intrabdominal dysgenetic gonads in the patient with genetic material of a Y chromosome may conduce to the development of gonadal tumors, such as gonadoblastoma or germinoma. The management of such patients is based on preventive excision of dysgenetic gonads and long-term hormonal replacement therapy. Sporadic cases are considered more common than familial cases. This paper presents two siblings with Swyer syndrome in whom gonadoblastoma was found. A thorough review of familial CGD with 46,XY DSD in the literature from the last 15 years suggests that the risk of gonadal tumors could be increased in familial compared to sporadic cases (66.6% vs. 15-45%, respectively).
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Affiliation(s)
- Ewa Rudnicka
- Department of Gynecological Endocrinology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksandra Jaroń
- Students Scientific Group of Department of Pediatrics and Endocrinology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Jagoda Kruszewska
- Students Scientific Group of Department of Gynecological Endocrinology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Roman Smolarczyk
- Department of Gynecological Endocrinology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Krystian Jażdżewski
- Human Cancer Genetics, Biological and Chemical Research Center University of Warsaw, 02-089 Warszawa, Poland
| | - Paweł Derlatka
- Second Department Obstetrics and Gynaecology, Medical University of Warsaw, 02-091 Warszawa, Poland;
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Mediå LM, Sigurdardottir S, Fauske L, Waehre A. Understanding sexual health concerns among adolescents and young adults with differences of sex development: a qualitative study. Int J Qual Stud Health Well-being 2023; 18:2204635. [PMID: 37092307 PMCID: PMC10128427 DOI: 10.1080/17482631.2023.2204635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/14/2023] [Indexed: 04/25/2023] Open
Abstract
PURPOSE Differences of sex development (DSD) are congenital conditions that involve variations in individuals' sex chromosomes, genes, external and/or internal genitalia, hormones, and/or secondary sex characteristics. This study sought to elucidate the experiences of adolescents and young adults living with DSD by focusing on their experiences of intimacy and sexual health. METHODS An interpretative phenomenological research design was adopted. Semi-structured qualitative interviews were conducted with 11 Norwegian adolescents and young adults aged 16-26 years who had five different DSD conditions. The interview findings were analysed by means of a reflexive thematic analysis. RESULTS The participants reported feeling different, both in terms of how their body functioned and how their body looked. Lack of knowledge increased this feeling of differentness. Moreover, lack of everyday language with which to talk about intimacy and sexual concerns resulted in the participants feeling stigma. Anticipating stigmatization and lacking everyday language complicated the participants' communication regarding their DSD and sexual health. CONCLUSIONS The sexual experiences of adolescents and young adults with DSD are diverse. Fear of stigmatization and lack of everyday language complicate communication with healthcare professionals and others. Understanding their unique needs is crucial to helping individuals achieve good sexual health.
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Affiliation(s)
- Line Merete Mediå
- Women and Children’s Division, Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Solrun Sigurdardottir
- Women and Children’s Division, Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
| | - Lena Fauske
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Anne Waehre
- Department of Child and Adolescent Psychiatry, Oslo University Hospital and Institute of Clinical Medicine, Oslo, Norway
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Challenges in the Diagnosis of XY Differences of Sexual Development. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121736. [PMID: 36556938 PMCID: PMC9787768 DOI: 10.3390/medicina58121736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/31/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022]
Abstract
Background: We report the clinical case of female patient with 46,XY difference of sexual development (DSD) and discuss the challenges in the differential diagnosis between complete gonadal dysgenesis (also called Swyer syndrome) and complete androgen insensitivity syndrome. Case Presentation: The patient's with primary amenorrhea gynaecological examination and magnetic resonance imaging (MRI) revealed the absence of the uterus and a very short vagina. Two sclerotic structures, similar to ovaries, were recognised bilaterally in the iliac regions. Hormonal assay tests revealed hypergonadotropic hypogonadism and the testosterone level was above normal. The karyotype was 46,XY and a diagnosis of Swyer syndrome was made. At the age of 41, the patient underwent a gynaecological review and after evaluating her tests and medical history, the previous diagnosis was questioned. Therefore, a molecular analysis of sex-determining region Y (SRY) and androgen receptor (AR) genes was made and the results instead led to a definite diagnosis of complete androgen insensitivity syndrome. Conclusions: The presented case illustrates that differentiating between complete gonadal dysgenesis and complete androgen insensitivity can be challenging. A well-established diagnosis is crucial because the risk of malignancy is different in those two syndromes, as well as the timing and importance of gonadectomy.
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Li H, Li J, Li X, Yi H, Ren Q, Chen X. Case Report: Is It Premature Ovarian Insufficiency or Swyer Syndrome After Bone Marrow Transplantation? Front Pediatr 2021; 9:808277. [PMID: 35096717 PMCID: PMC8794742 DOI: 10.3389/fped.2021.808277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Iatrogenic factor is one of the recognized causes for premature ovarian insufficiency. The aim of this case report was to present a rare case with premature ovarian insufficiency and 46, XY karyotype after bone marrow transplant (BMT) for thalassaemia major at childhood. We also reviewed some relevant literature in this report. Case Presentation: A 17-year-old girl was presented with primary amenorrhea and premature ovarian insufficiency after receiving chemotherapy and BMT from her brother due to thalassaemia major at childhood. She had poor secondary sex characteristics, assessed as stage I for the development of breasts and external genitalia based on the Tanner scale. Transabdominal ultrasound showed small uterus with visible endometrial lining and small ovaries. Laboratory data showed hypergonadotropic hypogonadism profile with low level of estrogen and high level of follicular-stimulating hormone (FSH). Patient's peripheral lymphocytes karyotype was 46, XY. Conclusions: This case was diagnosed as a chemotherapy induced premature ovarian insufficiency. Patient's peripheral lymphocytes karyotype (46, XY) after she received BMT from a male donor was a misleading finding, and the case could be easily misdiagnosed as Swyer syndrome. A correct diagnosis in such cases should depend not only on the recent clinical findings, but also on the detailed medical history. To prevent premature ovarian insufficiency in similar cases, fertility preservation should be offered to girls before they receive chemotherapy, total body irradiation and BMT.
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Affiliation(s)
- Hui Li
- Department of Reproductive Health, Shenzhen Baoan Women's and Children's Hospital, Shenzhen University, Shenzhen, China
| | - Jin Li
- Department of Reproductive Health, Shenzhen Baoan Women's and Children's Hospital, Shenzhen University, Shenzhen, China
| | - Xiaohong Li
- Department of Reproductive Health, Shenzhen Baoan Women's and Children's Hospital, Shenzhen University, Shenzhen, China
| | - Hong Yi
- Department of Reproductive Health, Shenzhen Baoan Women's and Children's Hospital, Shenzhen University, Shenzhen, China
| | - Qixiu Ren
- Department of Reproductive Health, Shenzhen Baoan Women's and Children's Hospital, Shenzhen University, Shenzhen, China
| | - Xiaoyan Chen
- Department of Obstetrics and Gynaecology, Shenzhen Baoan Women's and Children's Hospital, Shenzhen University, Shenzhen, China.,Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Kruszewska J, Krzywdzińska S, Grymowicz M, Smolarczyk R, Meczekalski B. POI after chemotherapy and bone marrow transplant may mimic disorders of sexual differentiation - a case report of a patient with primary amenorrhea and 46, XY karyotype. Gynecol Endocrinol 2020; 36:564-566. [PMID: 31858843 DOI: 10.1080/09513590.2019.1703941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cytogenetic examination may be useful in determining the reason for primary amenorrhea in phenotypically female patients. The result 46, XY usually indicates two syndromes: complete androgen insensitivity or pure gonadal dysgenesis. We report a case of a patient, who due to acute lymphoblastic leukemia in childhood was treated with total body irradiation and bone marrow transplantation. Later on the patient presented with symptoms typical for premature ovarian failure and male karyotype in peripheral lymphocytes. The cytogenetic examination for peripheral cells showed normal female karyotype. Therefore, it has been concluded that ovarian function impairment resulted rather from the gonadotoxic effect of oncological treatment than as a disorder of sexual differentiation. The survival rates of childhood cancer are very high and some of the patients will experience premature ovarian failure. It must be remembered that after bone marrow transplantation karyotype of peripheral lymphocytes may be misleading.
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Affiliation(s)
- Jagoda Kruszewska
- Department of Gynaecological Endocrinology, Students Scientific Society, Medical Unversity of Warsaw, Warsaw, Poland
| | - Sandra Krzywdzińska
- Department of Gynaecological Endocrinology, Students Scientific Society, Medical Unversity of Warsaw, Warsaw, Poland
| | - Monika Grymowicz
- Department of Gynaecological Endocrinology, Students Scientific Society, Medical Unversity of Warsaw, Warsaw, Poland
| | - Roman Smolarczyk
- Department of Gynaecological Endocrinology, Students Scientific Society, Medical Unversity of Warsaw, Warsaw, Poland
| | - Blazej Meczekalski
- Department of Gynaecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
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Eapen A, Chandramohan A, Simon B, Putta T, John R, Kekre A. Imaging Evaluation of Disorders of Sex Development. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2020. [DOI: 10.1055/s-0039-3402101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractDisorders of sex development (DSD) refer to congenital conditions with a typical development of chromosomal, gonadal, or anatomic sex. In the revised classification of DSD, there are three categories based on karyotype: 46,XX DSD; 46,XY DSD; and sex chromosome DSD. Imaging, as part of a multidisciplinary approach to management of DSD, has a key role in gender assignment. The main role of imaging is to help in identifying the gonads and the Müllerian structures. Ultrasound is useful, especially in the neonate with ambiguous genitalia. Magnetic resonance imaging is a useful modality to locate and characterize the gonads in young girls with primary amenorrhea and also to identify streak gonads, which have a risk of malignancy.
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Affiliation(s)
- Anu Eapen
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Betty Simon
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Tharani Putta
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Reetu John
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aruna Kekre
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
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Davies K. The XY Female: Exploring Care for Adolescent Girls with Complete Androgen Insensitivity Syndrome. Compr Child Adolesc Nurs 2019; 43:378-388. [DOI: 10.1080/24694193.2019.1691677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kate Davies
- Department of Advanced and Integrated Practice, London South Bank University, London, UK
- Queen Mary University of London/Barts and the London School of Medicine, London, UK
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10
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Jo HC, Park JK, Baek JC, Park JE, Kang MY, Cho IA. Clinicopathological features of premature ovarian insufficiency associated with chromosome abnormalities. ACTA ACUST UNITED AC 2019. [DOI: 10.5734/jgm.2019.16.1.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Hyen Chul Jo
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Ji Kwon Park
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Jong Chul Baek
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Ji Eun Park
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Min Young Kang
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - In Ae Cho
- Department of Obstetrics and Gynecology, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
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Meyer KF, Freitas Filho LG, Silva KI, Trauzcinsky PA, Reuter C, Souza MBM. The XY female and SWYER syndrome. Urol Case Rep 2019; 26:100939. [PMID: 31275808 PMCID: PMC6586948 DOI: 10.1016/j.eucr.2019.100939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/19/2022] Open
Abstract
SWYER syndrome or pure gonadal dysgenesis is a disease in which individuals with a female phenotype, with female external genital organs, have a 46 XY karyotype and streak gonads that ought to be removed given their high malignization potential. We present the case of a patient with Swyer syndrome, and compare them with other cases of patients with a 46 XY karyotype, phenotypically female, such as in Congenital Adrenal Hyperplasia from deficiency of the 17 α hydroxylase/17-20 Lyase enzyme and in the Congenital Androgenic Insensitivity Syndrome.
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Affiliation(s)
| | - Luiz G. Freitas Filho
- Universidade Federal de São Paulo, Surgery Department, Brazil
- Corresponding author. Rua Batista Cepelos 87, ap 61, 04109-120, São Paulo, Brazil. +55 11 983231200.
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12
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Shah JS, Viteri OA, Longo M, Abdallah M, Sibai B. Twin gestation in a Swyer syndrome patient with superimposed pre-eclampsia. J OBSTET GYNAECOL 2018; 38:719-720. [DOI: 10.1080/01443615.2017.1380615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jaimin S. Shah
- Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas at Houston McGovern Medical School, Houston, TX, USA
| | - Oscar A. Viteri
- Department of Maternal-Fetal Medicine, The University of Texas at Houston McGovern Medical School, Houston, TX, USA
| | - Monica Longo
- Department of Maternal-Fetal Medicine, The University of Texas at Houston McGovern Medical School, Houston, TX, USA
| | - Mazen Abdallah
- Department of Reproductive, Endocrinology and Infertility, The University of Texas at Houston McGovern Medical School, Houston, TX, USA
| | - Baha Sibai
- Department of Maternal-Fetal Medicine, The University of Texas at Houston McGovern Medical School, Houston, TX, USA
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Female with 46, XY karyotype. Obstet Gynecol Sci 2017; 60:378-382. [PMID: 28791271 PMCID: PMC5547087 DOI: 10.5468/ogs.2017.60.4.378] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/28/2017] [Accepted: 04/14/2017] [Indexed: 11/17/2022] Open
Abstract
Disorders of sex development (DSD) are congenital conditions characterized by atypical development of chromosomal, gonadal, and phenotypic sex. 46, XY DSD can result from disorders of testicular development or disorders of androgen synthesis/action. Prophylactic gonadectomy should be considered in patients with 46, XY DSD because of the increased risk of gonadal malignancy. We report two rare cases of 46, XY DSD, including XY pure gonadal dysgenesis and complete androgen insensitivity syndrome, who underwent a prophylactic gonadectomy.
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De Sousa SMC, Kassahn KS, McIntyre LC, Chong CE, Scott HS, Torpy DJ. Case report of whole genome sequencing in the XY female: identification of a novel SRY mutation and revision of a misdiagnosis of androgen insensitivity syndrome. BMC Endocr Disord 2016; 16:58. [PMID: 27821113 PMCID: PMC5100246 DOI: 10.1186/s12902-016-0141-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 10/21/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The 46,XY female is characterised by a male karyotype and female phenotype arising due to any interruption in the sexual development pathways in utero. The cause is usually genetic and various genes are implicated. CASE PRESENTATION Herein we describe a 46,XY woman who was first diagnosed with androgen insensitivity syndrome (testicular feminisation) at 18 years; however, this was later questioned due to the presence of intact Müllerian structures. The clinical phenotype suggested several susceptibility genes including SRY, DHH, NR5A1, NR0B1, AR, AMH, and AMHR2. To study candidate genes simultaneously, we performed whole genome sequencing. This revealed a novel and likely pathogenic missense variant (p.Arg130Pro, c.389G>C) in SRY, one of the major genes implicated in complete gonadal dysgenesis, hence securing this condition over androgen insensitivity syndrome as the cause of the patient's disorder of sexual development. CONCLUSION This case highlights the emerging clinical utility of whole genome sequencing as a tool in differentiating disorders of sexual development.
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Affiliation(s)
- Sunita M. C. De Sousa
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA Australia
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and UniSA alliance, Adelaide, SA Australia
- School of Medicine, University of Adelaide, Adelaide, SA Australia
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW Australia
| | - Karin S. Kassahn
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and UniSA alliance, Adelaide, SA Australia
- School of Biological Sciences, University of Adelaide, Adelaide, SA Australia
| | - Liam C. McIntyre
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and UniSA alliance, Adelaide, SA Australia
| | - Chan-Eng Chong
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and UniSA alliance, Adelaide, SA Australia
| | - Hamish S. Scott
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, an SA Pathology and UniSA alliance, Adelaide, SA Australia
- School of Medicine, University of Adelaide, Adelaide, SA Australia
- School of Biological Sciences, University of Adelaide, Adelaide, SA Australia
- ACRF Cancer Genomics Facility, Centre for Cancer Biology, SA Pathology, Adelaide, SA Australia
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA Australia
| | - David J. Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA Australia
- School of Medicine, University of Adelaide, Adelaide, SA Australia
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Abstract
Disorders of sexual development (DSDs) are a group of disorders in which there is discordance between anatomic or hormonal sex and sex chromosome complement. These disorders present with ambiguity in the newborn period and require prompt evaluation to determine the underlying cause for treatment and appropriate sex assignment of the infant. Neonatologists should confer with a multidisciplinary team for the diagnostic evaluation and management of patients with DSDs. This article provides a review of normal sexual development, algorithms used for evaluating infants with ambiguous genitalia, and conditions that can present with ambiguous genitalia in the newborn period.
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Affiliation(s)
- Bonnie McCann-Crosby
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA.
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA
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Hanlon AJM, Kimble RM. Incidental gonadal tumors at the time of gonadectomy in women with Swyer syndrome: a case series. J Pediatr Adolesc Gynecol 2015; 28:e27-9. [PMID: 25532682 DOI: 10.1016/j.jpag.2014.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 07/23/2014] [Accepted: 07/30/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Swyer syndrome (46XY complete gonadal dysgenesis) is an uncommonly encountered condition in our population. Gonadectomy is recommended upon diagnosis due to a significant risk of malignant transformation of the dysgenetic gonads, typically to dysgerminoma. CASES We present 3 cases of women who underwent gonadectomy following a diagnosis of Swyer syndrome. Two of these patients had dysgerminoma confirmed on histopathology. In particular we discuss the macroscopic appearance of the affected gonads and the further management of each case. SUMMARY AND CONCLUSION Individuals with Swyer syndrome require gonadectomy upon diagnosis of their condition, as part of their multidisciplinary management. For treatment of early stage dysgerminoma, surgical resection of the involved gonad and fallopian tube is curative, again highlighting the need for early intervention.
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Affiliation(s)
- Amie J M Hanlon
- Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | - Rebecca M Kimble
- Statewide Paediatric and Adolescent Gynaecology Services, Royal Brisbane and Women's Hospital, University of Queensland School of Medicine, Brisbane, Queensland, Australia
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Mannaerts D, Muys J, Blaumeiser B, Jacquemyn Y. A rare cause of primary amenorrhoea, the XY female with gonadal dysgenesis. BMJ Case Rep 2015; 2015:bcr-2014-206609. [PMID: 25666240 DOI: 10.1136/bcr-2014-206609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Disorders of sexual development are conditions where sexual phenotype and genotype are discordant. Genetic sex is determined at conception as the ovum is fertilised by a spermatozoon that contains either an X or Y chromosome. A complex pathway determined by genes and hormones leads to gonadal differentiation into testis or ovary and promotes the development of internal and external genitalia. We present a case of an 18-year-old woman who presented with primary amenorrhoea. She was a virgin, and apart from hirsutism and overweight, had no complaints. Her family history was insignificant. The patient was tall and had underdeveloped breasts. Her blood results showed hypergonadotropic hypogonadism. A 46, XY genotype was detected with karyotype analysis. Ultrasound and MRI demonstrated the presence of a uterus, but no overt gonads. Laparoscopy was performed, with bilateral removal of streak ovaries.
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Affiliation(s)
| | - Joke Muys
- Department of Obstetrics, Antwerp University Hospital UZA, Edegem, Belgium
| | - Bettina Blaumeiser
- Department of Obstetrics, Antwerp University Hospital UZA, Edegem, Belgium
| | - Yves Jacquemyn
- Department of Genetics, Antwerp University Hospital UZA, Edegem, Belgium
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Meshkat B, Matcovici M, Buckley C, Salama M, Perthiani HK. Diagnostic laparoscopy in a twelve year old girl with right iliac fossa pain: A life changing diagnosis of complete androgen insensitivity syndrome. Int J Surg Case Rep 2014; 5:505-8. [PMID: 24995665 PMCID: PMC4147648 DOI: 10.1016/j.ijscr.2014.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/04/2014] [Accepted: 03/10/2014] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Right iliac fossa (RIF) pain is one of the most common presenting complaints faced by general surgeons in the emergency department. Correct diagnosis and appropriate surgical intervention can often pose a challenge. PRESENTATION OF CASE A 12-year-old girl presented to the emergency department with a four day history of initially central acute abdominal pain, now localised in the RIF. During laparoscopy, the following findings were made: macroscopically dilated appendix, right and left gonads at the internal opening of the inguinal canal, empty pelvis with a rudimentary uterus on the right side. No evidence of fallopian tubes or connection of uterus to the vagina and broad based, non-inflamed Meckel's diverticulum. An incidental diagnosis of complete androgen insensitivity syndrome was made. DISCUSSION Androgen insensitivity syndrome (AIS) is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens. CONCLUSION This case report highlights the advantage of laparoscopy as a diagnostic and treatment tool in a twelve year old girl with multiple intra-abdominal findings. While the ultimate diagnosis responsible for her symptom of RIF pain was acute appendicitis, the additional diagnosis of CAIS and incidental Meckel's would have otherwise likely gone undetected.
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Affiliation(s)
- Babak Meshkat
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland.
| | - Melania Matcovici
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
| | - Claire Buckley
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
| | - Muhammad Salama
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
| | - Haresh K Perthiani
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
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Nunes E, Rodrigues C, Geraldes F, Aguas F. Differentiating Swyer syndrome and complete androgen insensitivity syndrome: a diagnostic dilemma. J Pediatr Adolesc Gynecol 2014; 27:e67-8. [PMID: 24119655 DOI: 10.1016/j.jpag.2013.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 05/30/2013] [Accepted: 07/02/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Swyer syndrome and complete androgen insensitivity syndrome are disorders of sex development in which patients present a female phenotype and 46,XY karyotype. CASE The authors present a case report of an 18-year-old patient with primary amenorrhea and delayed puberty. The karyotype was 46,XY. No mutations of sex-determining region Y gene and androgen receptor genes were identified, and imaging methods failed to show müllerian structures. A diagnosis of complete androgen insensitivity syndrome was presumed, but after hormonal replacement therapy was started a "hidden" uterus developed, leading to the definite diagnosis of Swyer syndrome. SUMMARY AND CONCLUSION The diagnosis of Swyer syndrome can be challenging, because visualization of müllerian structures is sometimes difficult and analysis of genetic mutations is not helpful in the majority of cases.
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Affiliation(s)
- Elsa Nunes
- Department of Gynecology, Maternidade Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Carla Rodrigues
- Department of Gynecology, Maternidade Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Fernanda Geraldes
- Department of Gynecology, Maternidade Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Fernanda Aguas
- Department of Gynecology, Maternidade Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Portugal
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McCann-Crosby B, Mansouri R, Dietrich JE, McCullough LB, Sutton VR, Austin EG, Schlomer B, Roth DR, Karaviti L, Gunn S, Hicks MJ, Macias CG. State of the art review in gonadal dysgenesis: challenges in diagnosis and management. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2014; 2014:4. [PMID: 24731683 PMCID: PMC3995514 DOI: 10.1186/1687-9856-2014-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 03/14/2014] [Indexed: 11/25/2022]
Abstract
Gonadal dysgenesis, a condition in which gonadal development is interrupted leading to gonadal dysfunction, is a unique subset of disorders of sexual development (DSD) that encompasses a wide spectrum of phenotypes ranging from normally virilized males to slightly undervirilized males, ambiguous phenotype, and normal phenotypic females. It presents specific challenges in diagnostic work-up and management. In XY gonadal dysgenesis, the presence of a Y chromosome or Y-chromosome material renders the patient at increased risk for developing gonadal malignancy. No universally accepted guidelines exist for identifying the risk of developing a malignancy or for determining either the timing or necessity of performing a gonadectomy in patients with XY gonadal dysgenesis. Our goal was to evaluate the literature and develop evidence-based medicine guidelines with respect to the diagnostic work-up and management of patients with XY gonadal dysgenesis. We reviewed the published literature and used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) system when appropriate to grade the evidence and to provide recommendations for the diagnostic work-up, malignancy risk stratification, timing or necessity of gonadectomy, role of gonadal biopsy, and ethical considerations for performing a gonadectomy. Individualized health care is needed for patients with XY gonadal dysgenesis, and the decisions regarding gonadectomy should be tailored to each patient based on the underlying diagnosis and risk of malignancy. Our recommendations, based on the evidence available, add an important component to the diagnostic and management armament of physicians who treat patients with these conditions.
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Affiliation(s)
- Bonnie McCann-Crosby
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Roshanak Mansouri
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Jennifer E Dietrich
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Laurence B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Elise G Austin
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Bruce Schlomer
- Division of Pediatric Urology, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - David R Roth
- Division of Pediatric Urology, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Lefkothea Karaviti
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Sheila Gunn
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - M John Hicks
- Department of Pathology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Charles G Macias
- Evidence-Based Outcomes Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
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Güven A, Dursun F, Özkanlı S, Güçlüer B, Kuru Lİ. Complete androgen insensitivity syndrome and discordant Müllerian remnants: two cases with novel mutation in the androgen receptor. J Pediatr Endocrinol Metab 2013; 26:909-14. [PMID: 23729616 DOI: 10.1515/jpem-2013-0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 04/18/2013] [Indexed: 11/15/2022]
Abstract
Complete androgen insensitivity syndrome (CAIS) associated with Müllerian remnant is rare during childhood. The Müllerian system usually regresses because of the presence of the anti-Müllerian hormone (AMH) originating from the Sertoli cells of the gonads. Rarely, residual Müllerian structures may exist. We present two cases from the same family, raised as females. They were 12 and 18 years old, respectively, and they had Tanner V breast development but Tanner I-II pubic hair. The older patient had primary amenorrhea. Both have a 46,XY genotype. Pelvic ultrasonography revealed no uterus and ovaries. The patients underwent bilateral laporoscopic gonadectomy. Both had residual Müllerian structures. Mutation analyses were performed, and both patients were found to be carrying a point mutation in exon 4 of the AR gene consisting of a G nucleotide deletion at position c.1890delG, followed by a frame-shift mutation and a stop codon. This mutation has not been described yet in the literature. Although the association with CAIS and Müllerian remnant is rare, no genetic defect specific to androgen insensitivity with Müllerian remnants has been identified so far.
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Russo G, di Lascio A, Ferrario M, Meroni S, Hiort O, Chiumello G. 46,XY karyotype in a female phenotype fetus: a challenging diagnosis. J Pediatr Adolesc Gynecol 2012; 25:e77-9. [PMID: 22578489 DOI: 10.1016/j.jpag.2012.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 01/29/2012] [Accepted: 03/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The growing use of prenatal investigations allows an early detection of several inborn disorders, including disorders of sexual development. The management of these conditions is an arising problem. CASE 46,XY karyotype and female phenotype were detected in a fetus; 5α-reductase and androgen receptor gene analysis on chorionic villi revealed no relevant mutation. The newborn was assigned to female sex. The diagnosis of 17β-hydroxysteroid dehydrogenase-3 β-OL deficiency was reached at four months of age, by means of a low testosterone/Δ 4-androstenedione ratio after HCG test and HSD17B3 gene analysis. SUMMARY AND CONCLUSION A 46,XY fetus with female external genitalia suggests different conditions, some very rare. Specific genetic investigations should be performed prenatally when possible. A complete evaluation is mandatory after delivery to reach a correct diagnosis.
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Affiliation(s)
- Gianni Russo
- Department of Pediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy.
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