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Reisch N, Auchus RJ. Pregnancy in Congenital Adrenal Hyperplasia. Endocrinol Metab Clin North Am 2024; 53:391-407. [PMID: 39084815 DOI: 10.1016/j.ecl.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Over the last several decades, children with all forms of classic congenital adrenal hyperplasia (CAH) are identified early and treated appropriately throughout childhood. As adults, women with CAH may desire to become mothers and their usual chronic therapy and disease control is often inadequate for conception. Subsequently, little data exist on their management during pregnancy. Pregnancy in women with various forms of CAH is possible with appropriate treatment. Achieving pregnancy is more complex than disease management during pregnancy.
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Affiliation(s)
- Nicole Reisch
- Department of Medicine IV, Institute for Endocrinology, Diabetology & Metabolism, Klinikum der Universität München, Ziemssenstraße 1, München 80336, Germany
| | - Richard J Auchus
- Department of Pharmacology, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, MSRB II, 5560A, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA; Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, MSRB II, 5560A, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA.
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2
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Balen AH, Tamblyn J, Skorupskaite K, Munro MG. A comprehensive review of the new FIGO classification of ovulatory disorders. Hum Reprod Update 2024; 30:355-382. [PMID: 38412452 DOI: 10.1093/humupd/dmae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO). OBJECTIVE AND RATIONALE This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management. SEARCH METHODS We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess. OUTCOMES We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification. WIDER IMPLICATIONS Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.
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Affiliation(s)
- Adam H Balen
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | - Jennifer Tamblyn
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | | | - Malcolm G Munro
- Department of Obstetrics and Gynecology, The University of California, Los Angeles, Los Angeles, CA, USA
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Yu J, Lu S, Fang L, Kakongoma N, Hu W. Pregnancy management of IVF-ET pregnancies in a patient with classical 21-hydroxylase deficiency: A case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2024; 293:50-56. [PMID: 38104394 DOI: 10.1016/j.ejogrb.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To report a rare case of a woman with classical 21-hydroxylase deficiency who twice had singleton pregnancies with live births after in vitro fertilization and embryo transfer (IVF-ET). DESIGN Case report and literature review. PATIENT A 35-year-old woman with classical 21-hydroxylase deficiency underwent external genital plastic surgery during adolescence and achieved second pregnancy after IVF-ET with long-term glucocorticoid replacement therapy. METHODS During regular antenatal testing, we focus on monitoring patients' weight gain, blood pressure, increasing trend of uterine height and abdominal circumference, and fetal growth trend. Individualized glucocorticoid therapy during pregnancy, glucocorticoid stress dose at delivery, management of systemic metabolism to prevent maternal and infant complications, and newborn screening are realized. RESULT In the second pregnancy, the glucocorticoid dosage was not increased. 17-hydroxyprogesterone and testosterone tended to increase in late pregnancy, but they were lower than in the first pregnancy. Blood pressure and blood glucose were normal, but lipids were abnormally elevated, D-dimer also showed a sharp rise under labor stress. A mature male infant was delivered by cesarean at 33+4 weeks of gestation due to placental abruption. CONCLUSION Repeated pregnancies in patients with classical 21-hydroxylase deficiency are rare, especially with Assisted Reproductive Technology. We present a case including a comparison of her two pregnancy monitoring indicators, glucocorticoid medication and delivery to achieve a successful delivery. We review the available literature to analyze pregnancies with classical 21-hydroxylase deficiency.
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Affiliation(s)
- Junxin Yu
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Sha Lu
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou, China; The Affiliated Hangzhou Women's Hospital of Hangzhou Normal University, Hangzhou, China
| | - Lingya Fang
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Nisile Kakongoma
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wensheng Hu
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China; Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Gurpinar Tosun B, Guran T. Rare forms of congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023. [PMID: 38126084 DOI: 10.1111/cen.15009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/10/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders due to pathogenic variants in genes encoding enzymes and cofactors involved in adrenal steroidogenesis. Although 21-hydroxylase, 11β-hydroxylase, 3β-hydroxysteroid dehydrogenase type 2, 17α-hydroxylase/17,20-lyase, P450 oxidoreductase, steroidogenic acute regulatory protein, cholesterol side-chain cleavage enzyme deficiencies are considered within the definition of CAH, the term 'CAH' is often used to refer to '21-hydroxylase deficiency (21OHD)' since 21OHD accounts for approximately 95% of CAH in most populations. The prevalence of the rare forms of CAH varies according to ethnicity and geographical location. In most cases, the biochemical fingerprint of impaired steroidogenesis points to the specific subtypes of CAH, and genetic testing is usually required to confirm the diagnosis. Despite there are significant variations in clinical characteristics and management, most data about the rare CAH forms are extrapolated from 21OHD. This review article aims to collate the currently available data about the diagnosis and the management of rare forms of CAH.
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Affiliation(s)
- Busra Gurpinar Tosun
- Department of Paediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Turkey
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Turkey
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Concepción-Zavaleta MJ, Coronado-Arroyo JC, Quiroz-Aldave JE, Durand-Vásquez MDC, Ildefonso-Najarro SP, Rafael-Robles LDP, Concepción-Urteaga LA, Gamarra-Osorio ER, Suárez-Rojas J, Paz-Ibarra J. Endocrine factors associated with infertility in women: an updated review. Expert Rev Endocrinol Metab 2023; 18:399-417. [PMID: 37702309 DOI: 10.1080/17446651.2023.2256405] [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: 07/02/2023] [Revised: 08/09/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Infertility is defined as the inability to conceive after unprotected sexual intercourse for at least 12 consecutive months. Our objective is to present an updated narrative review on the endocrine causes of infertility in women. AREAS COVERED A comprehensive review was conducted using Scielo, Scopus, and EMBASE databases, comprising 245 articles. The pathophysiology of infertility in women was described, including endocrinopathies such as hypothalamic amenorrhea, hyperprolactinemia, polycystic ovary syndrome, primary ovarian insufficiency, obesity, thyroid dysfunction, and adrenal disorders. The diagnostic approach was outlined, emphasizing the necessity of hormonal studies and ovarian response assessments. Additionally, the treatment plan was presented, commencing with non-pharmacological interventions, encompassing the adoption of a Mediterranean diet, vitamin supplementation, moderate exercise, and maintaining a healthy weight. Subsequently, pharmacological treatment was discussed, focusing on the management of associated endocrine disorders and ovulatory dysfunction. EXPERT OPINION This comprehensive review highlights the impact of endocrine disorders on fertility in women, providing diagnostic and therapeutic algorithms. Despite remaining knowledge gaps that hinder more effective treatments, ongoing research and advancements show promise for improved fertility success rates within the next five years. Enhanced comprehension of the pathophysiology behind endocrine causes and the progress in genetic research will facilitate the delivery of personalized treatments, thus enhancing fertility rates.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - José Paz-Ibarra
- Department of Medicine, School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Perú
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Pan P, Zheng L, Huang J, Chen X, Ni R, Zhang Q, Yang D, Li Y. Endocrine profiles and cycle characteristics of infertile 17α-hydroxylase/17,20-lyase Deficiency Patients undergoing assisted Reproduction Treatment: a retrospective cohort study. J Ovarian Res 2023; 16:111. [PMID: 37316894 DOI: 10.1186/s13048-023-01190-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/18/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND 17α-hydroxylase/17,20-lyase deficiency (17-OHD) is a rare form of congenital adrenal hyperplasia caused by CYP17A1 gene variants. Female patients with 17-OHD demonstrate a broad clinical spectrum, including oligomenorrhea or amenorrhea and infertility, often as the sole manifestation. However, no spontaneous pregnancies in affected women have been reported. OBJECTIVE This retrospective cohort study aimed to explore the endocrine characteristics and assisted reproductive technique (ART) performance in women with 17-OHD. METHODS Five women were referred for primary infertility in a university-affiliated hospital over an eight-year period. The endocrine profiles and cycle characteristics during a total of nine cycles of ovarian stimulation and eight cycles of frozen-thawed embryo transfer (FET) were described in details. RESULTS Three cases had homozygous variants and two cases had compound heterozygous variants, including one novel missense variant (p.Leu433Ser) in the CYP17A1 gene. Despite dual-suppression of progesterone (P) production by glucocorticoid and gonadotropin releasing hormone agonist, gradually increased P level, relatively low estradiol concentrations and thin endometrium were observed, negating fresh embryo transfer. During FET cycles, appropriate treatment resulted in low serum P levels and adequate endometrial thickness, leading to four live births. CONCLUSIONS Our findings demonstrate that continuous elevation of serum P during follicular growth impairs endometrial receptivity, the likely cause of female infertility in 17-OHD. Therefore, female infertility caused by 17-OHD is suggested as an indication for freeze-all strategy, with promising reproductive prognoses following segmented ovarian stimulation and FET treatment.
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Affiliation(s)
- Ping Pan
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China
| | - Lingyan Zheng
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China
| | - Jia Huang
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China
| | - Xiaoli Chen
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China
| | - Renmin Ni
- Department of Reproductive Medicine, Kunming Angel Women's and Children's Hospital, Kunming, Yunnan, China
| | - Qingxue Zhang
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China
| | - Dongzi Yang
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China.
| | - Yu Li
- Reproductive Medicine Centre, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 West Yan Jiang Road, Guangzhou, 510120, Guangdong, China.
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Alkhatib B, Salimi S, Jabari M, Padmanabhan V, Vyas AK. Impact of Adverse Gestational Milieu on Maternal Cardiovascular Health. Endocrinology 2023; 164:bqad060. [PMID: 37042476 PMCID: PMC10164662 DOI: 10.1210/endocr/bqad060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/27/2023] [Accepted: 04/10/2023] [Indexed: 04/13/2023]
Abstract
Cardiovascular disease affects 1% to 4% of the nearly 4 million pregnancies in the United States each year and is the primary cause of pregnancy-related mortality. Adverse pregnancy outcomes are associated with cardiovascular complications during pregnancy persisting into the postpartum period. Recently, investigations have identified an altered sex hormone milieu, such as in the case of hyperandrogenism, as a causative factor in the development of gestational cardiovascular dysfunction. The mechanisms involved in the development of cardiovascular disease in postpartum women are largely unknown. Animal studies have attempted to recapitulate adverse pregnancy outcomes to investigate causal relationships and molecular underpinnings of adverse gestational cardiac events and progression to the development of cardiovascular disease postpartum. This review will focus on summarizing clinical and animal studies detailing the impact of adverse pregnancy outcomes, including preeclampsia, gestational diabetes mellitus, and maternal obesity, on gestational cardiometabolic dysfunction and postpartum cardiovascular disease. Specifically, we will highlight the adverse impact of gestational hyperandrogenism and its potential to serve as a biomarker for maternal gestational and postpartum cardiovascular dysfunctions.
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Affiliation(s)
- Bashar Alkhatib
- Department of Pediatrics, Washington University, St. Louis, MO 63110, USA
| | - Shadi Salimi
- College of Human Medicine, California Northstate University, Elk Grove, CA 95757, USA
| | - Mary Jabari
- College of Human Medicine, California Northstate University, Elk Grove, CA 95757, USA
| | | | - Arpita Kalla Vyas
- Department of Pediatrics, Washington University, St. Louis, MO 63110, USA
- College of Human Medicine, California Northstate University, Elk Grove, CA 95757, USA
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8
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Maher JY, Gomez-Lobo V, Merke DP. The management of congenital adrenal hyperplasia during preconception, pregnancy, and postpartum. Rev Endocr Metab Disord 2023; 24:71-83. [PMID: 36399318 PMCID: PMC9884653 DOI: 10.1007/s11154-022-09770-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/21/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders of steroidogenesis of the adrenal cortex, most commonly due to 21-hydroxylase deficiency caused by mutations in the CYP21A2 gene. Although women with CAH have decreased fecundity, they are able to conceive; thus, if pregnancy is not desired, contraception options should be offered. If fertility is desired, women with classic CAH should first optimize glucocorticoid treatment, followed by ovulation induction medications and gonadotropins if needed. Due to the possible pregnancy complications and implications on the offspring, preconception genetic testing and counseling with a high-risk obstetrics specialist is recommended. For couples trying to avoid having a child with CAH, care with a reproductive endocrinology and infertility specialist to utilize in vitro fertilization can be offered, with or without preimplantation genetic testing for monogenic disorders. Prenatal screening and diagnosis options during pregnancy include maternal serum cell free-DNA for sex of the baby, and chorionic villus sampling and amniocentesis for diagnosis of CAH. Pregnant women with classic CAH need glucocorticoids to be adjusted during the pregnancy, at the time of delivery, and postpartum, and should be monitored for adrenal crisis. Maternal and fetal risks may include chorioamnionitis, maternal hypertension, gestational diabetes, cesarean section, and small for gestational age infants. This review on CAH due to 21-hydroxylase deficiency highlights reproductive health including genetic transmission, contraception options, glucocorticoid management, fertility treatments, as well as testing, antenatal monitoring, and management during pregnancy, delivery, and postpartum.
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Affiliation(s)
- Jacqueline Yano Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Staff Clinician, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Veronica Gomez-Lobo
- Director of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 1-2740, Bethesda, MD, 20892, USA.
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Gusmano C, Cannarella R, Crafa A, Barbagallo F, La Vignera S, Condorelli RA, Calogero AE. Congenital adrenal hyperplasia, disorders of sex development, and infertility in patients with POR gene pathogenic variants: a systematic review of the literature. J Endocrinol Invest 2023; 46:1-14. [PMID: 35842891 PMCID: PMC9829634 DOI: 10.1007/s40618-022-01849-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/23/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND P450 oxidoreductase (POR) deficiency (PORD) is characterized by congenital adrenal hyperplasia (CAH) and disorders of sex development (DSD) in both sexes. PORD can also associate with skeletal defects. However, the prevalence of these phenotypes is unknown. AIM To evaluate the prevalence of CAH, DSD, and infertility of patients with POR gene pathogenic variants by a systematic review of the literature. METHODS The literature search was performed through PubMed, MEDLINE, Cochrane, Academic One Files, Google Scholar, and Scopus databases. All studies reporting information on CAH, DSD, testicular adrenal rest tumor (TARTs), and fertility in patients with POR gene pathogenic variants were included. Finally, the prevalence of abnormal phenotypes was calculated. RESULTS Of the 246 articles initially retrieved, only 48 were included for a total of 119 (46 males and 73 females) patients with PORD. We also included the case of a male patient who consulted us for CAH and TARTs but without DSD. This patient, found to be a carrier of combined heterozygous POR mutation, reached fatherhood spontaneously. All the patients found had CAH. The presence of DSD was found in 65.2%, 82.1%, and 82.1% of patients with compound heterozygosity, homozygosity, or monoallelic heterozygous variants, respectively. The prevalence was significantly higher in females than in males. The prevalence of TARTs in patients with PORD is 2.7%. Only 5 women with PORD became pregnant after assisted reproductive techniques and delivered a healthy baby. Except for the recently reported proband, no other studies focused on male infertility in patients with POR gene variants. CONCLUSION This systematic review of the literature reports the prevalence of CAH, DSD, and TARTs in patients with PORD. The unknown prevalence of POR gene pathogenetic variants and the paucity of studies investigating fertility do not allow us to establish whether PORD is associated with infertility. Further studies on both women and men are needed to clarify this relationship.
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Affiliation(s)
- C Gusmano
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - R Cannarella
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - A Crafa
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - F Barbagallo
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - S La Vignera
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - R A Condorelli
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - A E Calogero
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy.
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Cera G, Locantore P, Novizio R, Maggio E, Ramunno V, Corsello A, Policola C, Concolino P, Paragliola RM, Pontecorvi A. Pregnancy and Prenatal Management of Congenital Adrenal Hyperplasia. J Clin Med 2022; 11:jcm11206156. [PMID: 36294476 PMCID: PMC9605322 DOI: 10.3390/jcm11206156] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/26/2022] [Accepted: 10/15/2022] [Indexed: 11/21/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive diseases that may cause cortisol insufficiency together with other hormonal alterations. The most common form is 21-hydroxylase deficiency, in which the lack of pituitary negative feedback causes an increase in ACTH and adrenal androgens. Classical forms of CAHs can lead to severe adrenal failure and female virilization. To date, the appropriate management of pregnant CAH patients is still debated regarding appropriate maternal therapy modifications during pregnancy and the risks and benefits of prenatal treatment of the fetus. We conducted a literature search of relevant papers to collect current evidence and experiences on the topic. The most recent and significant articles were selected, and current international guidelines were consulted to update current recommendations and guide clinical practice. Given the lack of randomized clinical trials and other high-quality scientific evidence, the issue is still debated, and great heterogeneity exists in current practice in terms of risk/benefit evaluation and pharmacological choices for pregnancy and prenatal treatment. Glucocorticoid therapy is advised not only in classical CAH patients but also in non-classical, milder forms. The choice of which glucocorticoid to use, and the safety and benefits of dexamethasone therapy aimed at preventing genital virilization are still debated issues. Several advances, however, have been made, especially in terms of fertility and reproduction. This review aims to present the most recent scientific and real-world updates on pregnancy and prenatal management of CAH, with the presentation of various clinical scenarios and specific case-by-case recommendations.
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Affiliation(s)
- Gianluca Cera
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Pietro Locantore
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
- Correspondence:
| | - Roberto Novizio
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Ettore Maggio
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Vittoria Ramunno
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Andrea Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Caterina Policola
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Paola Concolino
- Unit of Clinical Chemistry, Biochemistry and Molecular Biology, Department of Laboratory and Infectiology Sciences, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
- Unicamillus, Saint Camillus International University of Medical Sciences, Via di S. Alessandro 10, 00131 Rome, Italy
| | - Alfredo Pontecorvi
- Unit of Endocrinology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore—Fondazione Policlinico “A. Gemelli” IRCCS, Largo Gemelli 8, 00168 Rome, Italy
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11
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Finlayson C, Johnson EK, Chen D, Fechner PY, Hirsch J, Rosoklija I, Schafer-Kalkhoff T, Shnorhavorian M, Gomez-Lobo V. Fertility in Individuals with Differences in Sex Development: Provider Knowledge Assessment. J Pediatr Adolesc Gynecol 2022; 35:558-561. [PMID: 35296452 PMCID: PMC9468186 DOI: 10.1016/j.jpag.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 02/04/2022] [Accepted: 02/19/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Infertility is common among individuals with differences in sex development (DSD), and affected individuals and families desire fertility counseling. This survey sought to assess fertility knowledge and experiences with fertility counseling among DSD specialists for DSD conditions excluding congenital adrenal hyperplasia. DESIGN, SETTING, PARTICIPANTS, AND MEASURES A survey was iteratively developed by members of the DSD-Translational Research Network (DSD-TRN) Fertility Preservation Workgroup and disseminated to 5 clinician groups: the DSD-TRN, the Society for Pediatric Psychology DSD Special Interest Group (SIG), the Pediatric Endocrine Society DSD-SIG, the Societies for Pediatric Urology, and the North American Society for Pediatric and Adolescent Gynecology. RESULTS Completed surveys (n = 110) were mostly from pediatric urology (40.3%), gynecology (25.4%), and endocrinology (20.9%) specialists. Most (73/108, 67.6%) respondents reported discussing fertility potential. Sixty-seven responded to questions regarding fertility potential. Many participants answered questions about the presence of a uterus in individuals with 46,XY complete gonadal dysgenesis and about the potential for viable oocytes in individuals with 46,XY partial gonadal dysgenesis incorrectly. Comments acknowledged the need for further education on fertility in individuals with DSD. CONCLUSIONS Many DSD providers have some knowledge of fertility potential, but knowledge gaps remain. Experts expressed a desire for education and accessible resources to counsel effectively about fertility potential for individuals with DSD.
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Affiliation(s)
- Courtney Finlayson
- Division of Endocrinology, Ann & Robert H. Luire Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Luire Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Diane Chen
- Division of Adolescent Medicine, Ann & Robert H. Luire Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; Department of Psychiatry and Behavioral Health Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Y Fechner
- Department of Pediatrics, University of Washington School of Medicine, Division of Pediatric Endocrinology, Seattle Children's Hospital, Seattle, Washington
| | - Josephine Hirsch
- Division of Urology, Ann & Robert H. Luire Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Luire Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margarett Shnorhavorian
- Department of Urology, University of Washington School of Medicine, Division of Pediatric Urology, Seattle Children's Hospital, Seattle, Washington
| | - Veronica Gomez-Lobo
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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12
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Wang YJ, Liu C, Xing C, Zhang L, Xu WF, Wang HY, Wang FT. Congenital lipoid adrenal hyperplasia with Graves' disease: A case report. World J Clin Cases 2022; 10:9390-9397. [PMID: 36159444 PMCID: PMC9477664 DOI: 10.12998/wjcc.v10.i26.9390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/03/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH), which is caused by a mutation of the steroidogenic acute regulatory (StAR) gene. Affected patients are usually characterized by adrenal insufficiency in the first year of life, salt loss, glucocorticoid and mineralocorticoid deficiency, and female external genitalia, regardless of chromosomal karyotype. Patients with non-classical lipoid CAH usually develop glucocorticoid deficiency and mild mineralocorticoid deficiency at 2-4 years of age.
CASE SUMMARY Herein, We report the case of a woman with non-classic lipoid CAH combined with Graves' disease. Her chromosome karyotype was 46, XX, and high-throughput sequencing revealed two missense variants in the StAR gene: c.229C > T (p.Q77X) and c.814C > T (p.R272C), which were inherited from both parents (non-close relatives). The patient was treated for Graves' disease in a timely manner and the dosage of glucocorticoid was adjusted during the treatment of Graves' disease.
CONCLUSION This is the first case of non-classic lipoid CAH combined with Graves' disease reported in the Chinese population. In addition to conventional glucocorticoid replacement therapy, timely adjustments were made to the dosages of thyroid hormone and glucocorticoid to avoid adrenal crisis as a consequence of the increased demand and accelerated metabolism of glucocorticoids when the patient was diagnosed with Graves' disease.
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Affiliation(s)
- Yan-Jun Wang
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Cong Liu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Chuan Xing
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Le Zhang
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Wan-Feng Xu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Hai-Ying Wang
- Department of Endocrinology, the Second Hospital of Chaoyang, Chaoyang 110000, Liaoning Province, China
| | - Fu-Tao Wang
- Department of Endocrinology, Changchun Central Hospital, Changchun 110000, Jilin Province, China
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13
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Guo X, Zhang Y, Yu Y, Zhang L, Ullah K, Ji M, Jin B, Shu J. Getting pregnant with congenital adrenal hyperplasia: Assisted reproduction and pregnancy complications. A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:982953. [PMID: 36120452 PMCID: PMC9470834 DOI: 10.3389/fendo.2022.982953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Many patients with congenital adrenal hyperplasia (CAH) refrain from seeking pregnancy, suffer from infertility or worry about pregnancy complications, mainly due to genitalia abnormalities, anovulation, unreceptive endometrium and metabolic disturbances. Despite those challenges, many live births have been reported. In this systematic review, we focused on the key to successful assisted reproduction strategies and the potential pregnancy complications. We did a systematic literature search of Pubmed, Medline and Scopus for articles reporting successful pregnancies in CAH other than 21-hydroxylase deficiency, and found 25 studies reporting 39 pregnancies covering deficiency in steroidogenic acute regulatory protein, 17α-hydroxylase/17,20-lyase, 11β-hydroxylase, P450 oxidoreductase, cytochrome b5 and 3β-hydroxysteroid dehydrogenase. We summarized various clinical manifestations and tailored reproduction strategy for each subtype. Furthermore, a meta-analysis was performed to evaluate the pregnancy complications of CAH patients. A total of 19 cross-sectional or cohort studies involving 1311 pregnancies of classic and non-classic CAH patients were included. Surprisingly, as high as 5.5% (95% CI 2.3%-9.7%) of pregnancies were electively aborted, and the risk was significantly higher in those studies with a larger proportion of classic CAH than those with only non-classical patients (8.43% (4.1%-13.81%) VS 3.75%(1.2%-7.49%)), which called for better family planning. Pooled incidence of miscarriage was 18.2% (13.4%-23.4%) with a relative risk (RR) of 1.86 (1.27-2.72) compared to control. Glucocorticoid treatment in non-classical CAH patients significantly lowered the miscarriage rate when compared to the untreated group (RR 0.25 (0.13-0.47)). CAH patients were also more susceptible to gestational diabetes mellitus, with a prevalence of 7.3% (2.4%-14.1%) and a RR 2.57 (1.29-5.12). However, risks of preeclampsia, preterm birth and small for gestational age were not significantly different. 67.8% (50.8%-86.9%) CAH patients underwent Cesarean delivery, 3.86 (1.66-8.97) times the risk of the control group. These results showed that fertility is possible for CAH patients but special care was necessary when planning, seeking and during pregnancy. Systematic Review Registration PROSPERO https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=342642, CRD42022342642.
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Affiliation(s)
- Xiaoyan Guo
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yu Zhang
- School of Nursing, Hangzhou Medical College, Hangzhou, China
| | - Yiqi Yu
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Ling Zhang
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Kamran Ullah
- Department of Biology, The University of Haripur, Haripur, Pakistan
| | - Mengxia Ji
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Bihui Jin
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Jing Shu
- Center for Reproductive Medicine, Department of Reproductive Endocrinology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
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Abstract
The term CAH-X was coined to describe a subset of patients with 21-hydroxylase deficiency displaying a phenotype compatible with the hypermobility type of Ehlers Danlos syndrome. The genetic defect is due to the monoallelic presence of a CYP21A2 deletion extending into the gene encoding tenascin X (TNXB), a connective tissue extracellular matrix protein. The result is a chimeric TNXA/TNXB gene causing tenascin-X haploinsufficiency. The prevalence of CAH-X was estimated to be around 14-15% in large cohorts of patients with 21-hydroxylase deficiency. However, population studies are still scarce and the clinical picture of the syndrome has yet to be fully defined. In this review, we discuss the current knowledge regarding the genetic and clinical profile of the CAH-X syndrome.
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15
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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16
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Boettcher C, Flück CE. Rare forms of genetic steroidogenic defects affecting the gonads and adrenals. Best Pract Res Clin Endocrinol Metab 2022; 36:101593. [PMID: 34711511 DOI: 10.1016/j.beem.2021.101593] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pathogenic variants have been found in all genes involved in the classic pathways of human adrenal and gonadal steroidogenesis. Depending on their function and severity, they cause characteristic disorders of corticosteroid and/or sex hormone deficiency, may result in atypical sex development at birth and/or puberty, and mostly lead to sexual dysfunction and infertility. Genetic disorders of steroidogenesis are all inherited in an autosomal recessive fashion. Loss of function mutations lead to typical phenotypes, while variants with partial activity may manifest with milder, non-classic, late-onset disorders that share similar phenotypes. Thus, these disorders of steroidogenesis are diagnosed by comprehensive phenotyping, steroid profiling and genetic testing using next generation sequencing techniques. Treatment comprises of steroid replacement therapies, but these are insufficient in many aspects. Therefore, studies are currently ongoing towards newer approaches such as lentiviral transmitted enzyme replacement therapy and reprogrammed stem cell-based gene therapy.
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Affiliation(s)
- Claudia Boettcher
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland.
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17
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Finkielstain GP, Vieites A, Bergadá I, Rey RA. Disorders of Sex Development of Adrenal Origin. Front Endocrinol (Lausanne) 2021; 12:770782. [PMID: 34987475 PMCID: PMC8720965 DOI: 10.3389/fendo.2021.770782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/01/2021] [Indexed: 01/24/2023] Open
Abstract
Disorders of Sex Development (DSD) are anomalies occurring in the process of fetal sexual differentiation that result in a discordance between the chromosomal sex and the sex of the gonads and/or the internal and/or external genitalia. Congenital disorders affecting adrenal function may be associated with DSD in both 46,XX and 46,XY individuals, but the pathogenic mechanisms differ. While in 46,XX cases, the adrenal steroidogenic disorder is responsible for the genital anomalies, in 46,XY patients DSD results from the associated testicular dysfunction. Primary adrenal insufficiency, characterized by a reduction in cortisol secretion and overproduction of ACTH, is the rule. In addition, patients may exhibit aldosterone deficiency leading to salt-wasting crises that may be life-threatening. The trophic effect of ACTH provokes congenital adrenal hyperplasia (CAH). Adrenal steroidogenic defects leading to 46,XX DSD are 21-hydroxylase deficiency, by far the most prevalent, and 11β-hydroxylase deficiency. Lipoid Congenital Adrenal Hyperplasia due to StAR defects, and cytochrome P450scc and P450c17 deficiencies cause DSD in 46,XY newborns. Mutations in SF1 may also result in combined adrenal and testicular failure leading to DSD in 46,XY individuals. Finally, impaired activities of 3βHSD2 or POR may lead to DSD in both 46,XX and 46,XY individuals. The pathophysiology, clinical presentation and management of the above-mentioned disorders are critically reviewed, with a special focus on the latest biomarkers and therapeutic development.
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Affiliation(s)
- Gabriela P. Finkielstain
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Rodolfo A. Rey
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
- Universidad de Buenos Aires, Facultad de Medicina, Departamento de Biología Celular, Histología, Embriología y Genética, Buenos Aires, Argentina
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18
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Allis K. A Broken Pathway: Understanding Congenital Adrenal Hyperplasia in the Newborn. Neonatal Netw 2021; 40:286-294. [PMID: 34518380 DOI: 10.1891/11-t-694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 06/13/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder that leads to the partial or complete deficiency of cortisol and aldosterone production from the adrenal glands. The lack of these key hormones can precipitate acute adrenal crisis during the newborn period. This disorder can further lead to the development of virilized female genitalia from exposure to increased levels of androgens during fetal development. Nonclassical CAH is a common autosomal disorder, affecting 1/200 live births. The classical form of CAH affects 1/10,000-16,000 live births. Infants affected by classic CAH manifest with severe complications and an increased mortality risk. Early identification of CAH is critical to prevent significant sequela of adrenal crisis and to support families of affected females as they work through decisions of gender assignment. Newborn and pediatric nurses, as well as advanced practice providers, should maintain an active working knowledge of CAH to identify affected individuals early, implement needed interventions, and support families through education.
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19
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Abstract
CONTEXT Pregnancy achievement in an infertile patient with 17,20-lyase deficiency. OBJECTIVE To study and describe the achievement of successful pregnancy and delivery in a patient with 17,20-lyase deficiency. METHOD Controlled ovarian stimulation (COS) and in vitro fertilization (IVF), cryopreservation of embryos and frozen-thawed embryo transfer (ET). Controlled ovarian stimulation, follicular aspiration egg retrieval, IVF, embryo cryopreservation, thawed ET. A 24-year-old, infertile patient with 17,20-lase deficiency. RESULTS Isolated 17,20-lyase deficiency is caused by mutations in the CYP17A1 gene (coding for cytochrome P450c17), POR (coding for cytochrome P450 oxidoreductase), and CYB5A (coding for microsomal cytochrome b5) genes. A 24-year-old patient with 17,20-lyase deficiency had undergone IVF with gonadotropin releasing hormone agonist (GnRHa) protocol, prednisone, and gonadotropins. After the human chorionic gonadotropin (hCG) trigger, 37 oocytes were retrieved, 25 ova fertilized, and 17 embryos cryopreserved. After menstrual bleeding, the endometrium was stimulated with oral estradiol, under progesterone suppression with long acting GnRHa and prednisone. When endometrial width of 8.5 mm was reached, vaginal progesterone was added, while gradually decreasing prednisone. On the fourth day of progesterone supplement, 2 thawed embryos were transferred. After 11 days of human menopausal gonadotropin (hMG), estradiol concentration moderately increased, but progesterone levels remained high; therefore, no fresh ET was performed. Twelve days after thawed ET, hCG was positive, and 7 days later, an intrauterine gestational sac was detected, but the pregnancy ended in missed abortion. After 2 months, another frozen-thawed embryo transfer (FET) was performed, generating a normal gestation, which ended in successful delivery. CONCLUSION Pregnancy can be achieved in patients with 17,20-lyase deficiency, by IVF, freezing all embryos, and ET in a subsequent cycle, while suppressing endogenous ovarian progesterone with a GnRHa and adrenal suppression with high-dose glucocorticoids.
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Affiliation(s)
- Zeev Blumenfeld
- Reproductive Endocrinology, Ob/Gyn, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ilana Koren
- Pediatric Endocrinology Unit, Clalit Health Services, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruch Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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20
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Mizusawa Y, Katayama K, Matsumoto Y, Kokeguchi S, Shiotani M. Masked high progesterone levels during in vitro fertilization and embryo transfer treatment in a patient with 21-hydroxylase deficiency: A case report. J Obstet Gynaecol Res 2021; 47:1909-1913. [PMID: 33648018 DOI: 10.1111/jog.14719] [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: 11/02/2020] [Revised: 01/12/2021] [Accepted: 02/06/2021] [Indexed: 12/01/2022]
Abstract
The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD). Women with 21OHD have reduced fertility because of excessive production of adrenal androgen and progesterone, which can inhibit folliculogenesis, disturb the normal gonadotropin secretion pattern and development of the endometrium, and affect endometrial receptivity. Here, we report on an infertile woman with 21OHD who initially showed normal progesterone levels and spontaneous ovulation with the treatment by an endocrinologist. However, in vitro fertilization and embryo transfer repeatedly failed because of a gradual elevation in progesterone, which was masked by fertility treatment. The case underlines that close coordination is required between the endocrinologist and reproductive specialist for the total treatment for woman with 21OHD.
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Affiliation(s)
- Yuri Mizusawa
- Medical Corporation/Reproduction Center, Hanabusa Women's Clinic, Kobe, Hyogo, Japan
| | - Kazuaki Katayama
- Medical Corporation/Reproduction Center, Hanabusa Women's Clinic, Kobe, Hyogo, Japan
| | - Yukiko Matsumoto
- Medical Corporation/Reproduction Center, Hanabusa Women's Clinic, Kobe, Hyogo, Japan
| | - Shoji Kokeguchi
- Medical Corporation/Reproduction Center, Hanabusa Women's Clinic, Kobe, Hyogo, Japan
| | - Masahide Shiotani
- Medical Corporation/Reproduction Center, Hanabusa Women's Clinic, Kobe, Hyogo, Japan
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21
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Hirschberg AL, Gidlöf S, Falhammar H, Frisén L, Almqvist C, Nordenskjöld A, Nordenström A. Reproductive and Perinatal Outcomes in Women with Congenital Adrenal Hyperplasia: A Population-based Cohort Study. J Clin Endocrinol Metab 2021; 106:e957-e965. [PMID: 33135723 DOI: 10.1210/clinem/dgaa801] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Reduced fertility has been reported for women with congenital adrenal hyperplasia (CAH), especially for those with the salt-losing form. However, data are sparse on reproductive and perinatal outcomes in these women. OBJECTIVE To investigate reproductive and perinatal outcomes in women with CAH. DESIGN AND SETTING Population-based and nationwide study using the National CAH Register, the Total Population Register, and the Medical Birth Register of Sweden. PARTICIPANTS A total of 272 women with CAH due to 21-hydroxylase deficiency and 27 200 controls matched by sex, age, and place of birth. The median age was 31 years. MAIN OUTCOME MEASURES The proportion of CAH women that have given birth, and reproductive and perinatal outcomes. RESULTS Of the 272 women with CAH, 69 gave birth to at least 1 child (25.4%), which was a lower frequency than for the controls (45.8%) (P < .001). Furthermore, women with CAH had fewer children than controls and were slightly older at birth of their first child. More women with CAH were diagnosed with gestational diabetes than controls, 4.9% versus 1.4% (P < .05), and more women with CAH were delivered through cesarean section, 51.4% versus 12.3% (P < .05). There was no difference in Apgar score or frequency of small-for-gestational age between children born to mothers with CAH and controls. CONCLUSIONS This is, to our knowledge, the largest cohort designed to investigate reproductive and perinatal outcomes in women with CAH. We found the birth rate to be lower in women with CAH; gestational diabetes and cesarean section were more common, but perinatal outcomes were comparable with controls.
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Affiliation(s)
- Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sebastian Gidlöf
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Stockholm South General Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Lung and Allergy Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Surgery, Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
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22
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Burman P, Falhammar H, Waldenström E, Sundin A, Bitzén U. 11C-Metomidate PET/CT Detected Multiple Ectopic Adrenal Rest Tumors in a Woman With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e675-e679. [PMID: 33245336 DOI: 10.1210/clinem/dgaa870] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Indexed: 02/02/2023]
Abstract
CONTEXT Women with congenital adrenal hyperplasia (CAH) may present with androgen excess that is difficult to control with conventional suppressive doses of glucocorticoids. Clinical management is challenging, and the woman is at great risk of developing steroid-induced complications. PATIENTS AND METHODS A 32-year-old woman with salt-wasting CAH due to 21-hydroxylase deficiency underwent right-sided adrenalectomy because of a large myelolipoma. Over the years, androgens became increasingly difficult to suppress on prednisolone 5 + 0 + 2.5 mg daily, and at age 39 years the left adrenal with an enlarging myelolipoma was removed. A month later serum testosterone levels had increased from 4.1 preoperatively to 18.3 nmol/L (reference 0.2-1.8 nmol/L), and adrenocorticotropin levels from 32 to 283 pmol/L (reference < 14 pmol/L). No adrenal parenchyma was visualized on computed tomography (CT). In the further search for the source of the markedly elevated testosterone, positron emission tomography (PET) was performed with 2 different tracers, 18fluorodeoxyglucose (18FDG) reflecting glucose metabolism and 11C-metomidate, an inhibitor of 11-β-hydroxylase targeting adrenocortical tissue. RESULTS 18FDG-PET/CT with cosyntropin stimulation showed ovarian/paraovarian hypermetabolism, suggestive of adrenal rest tumors. Further characterization with 11C-metomidate PET/CT showed uptakes localized to the ovaries/adnexa, behind the spleen, and between the right crus diaphragmaticus and inferior vena cava. CONCLUSION Adrenal rest tumors can give rise to high androgen levels in spite of suppressive supraphysiological glucocorticoid doses. This case illustrates, for the first time, the value of 11C-metomidate PET as a sensitive method in documenting adrenal rest tumors, currently considered rare in women with CAH.
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Affiliation(s)
- Pia Burman
- Department of Endocrinology, Skåne University Hospital, Malmö, Lund University, Malmö, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Erik Waldenström
- Department of Endocrinology, Skåne University Hospital, Malmö, Lund University, Malmö, Sweden
| | - Anders Sundin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrika Bitzén
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund, Sweden
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Kocova M, Concolino P, Falhammar H. Characteristics of In2G Variant in Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. Front Endocrinol (Lausanne) 2021; 12:788812. [PMID: 35140681 PMCID: PMC8818746 DOI: 10.3389/fendo.2021.788812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Substantial research has been performed during the last decades on the clinical and genetic variability of congenital adrenal hyperplasia (CAH) and its most common form, 21-hydroxylase deficiency (21OHD). CAH is one of the most prevalent autosomal recessive diseases in humans, and it can be divided into classic-further subdivided into salt wasting (SW) and simple virilizing (SV)-and non-classic (NC) forms. Pathogenic variants of CYP21A2 gene, encoding the 21-hydroxylase enzyme, have been reported with variable prevalence in different populations. NM_000500.9:c.293-13C/A>G (In2G) variant represents the most common CYP21A2 gene changes related to the classic 21OHD form. However, the phenotype of In2G carriers is variable depending on the variant homozygous/heterozygous status and combination with other CYP21A2 pathogenic variants. In addition, identical genotypes, harboring the homozygous In2G variant, can present with variable phenotypes including the SW and SV or rarely NC form of the disease. Here, we analyze and present the clinical aspects, genotype/phenotype correlations, and other characteristics related to the CYP21A2 In2G variant.
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Affiliation(s)
- Mirjana Kocova
- Medical Faculty, University “Cyril & Methodius” Skopje, Skopje, North Macedonia
- *Correspondence: Mirjana Kocova,
| | - Paola Concolino
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Unita' Operativa Complessa (UOC) Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Xiong W, Huang G, Wang X, Tan S. Successful pregnancy and live birth in woman with congenital adrenal hyperplasia: A case report. Medicine (Baltimore) 2020; 99:e23495. [PMID: 33327286 PMCID: PMC7738089 DOI: 10.1097/md.0000000000023495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Women with congenital adrenal hyperplasia (CAH) can suffer from impaired fertility rates as a result of increased androgen secretion or impaired sex steroid production. CAH patients have lower pregnancy rate compared to normal women. Only a few cases with successful pregnancy have been reported in the literature. This report described a case of CAH with successful pregnancy and live birth. PATIENT CONCERNS A 23-year-old woman visited our endocrinology department for clitoral hypertrophy and primary amenorrhea. DIAGNOSES The patient was diagnosed as CAH. INTERVENTION Prednisone was initially started to improve the patient's symptoms. Then she underwent clitoral resection and vaginoplasty several months later. She continuously took the prednisolone after the operation and had been undergoing regular checkups. OUTCOMES She was pregnant spontaneously without assisted reproductive technology and had a successful live birth. Her baby had shown normal external genitalia with normal karyotype and normal development up to 6 years of age. LESSONS Some mild CAH patients with certain types can achieved successful pregnancy without any assisted reproductive technology after treatment with steroid. The pregnancy rate among CAH women who wish to conceive may be much more optimistic than previous researches.
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25
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Uyanıkoglu H, Ozer G, Kahraman S. A spontaneous pregnancy and live birth in a woman with primary infertility following the excision of an ovarian adrenal rest tumor: A rare case. Clin Exp Reprod Med 2020; 47:319-322. [PMID: 33105528 PMCID: PMC7711094 DOI: 10.5653/cerm.2020.03692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/26/2020] [Indexed: 11/06/2022] Open
Abstract
Adrenal rest tumors are a rare extra-adrenal complication of congenital adrenal hyperplasia (CAH) in women although they are more commonly found in the testes of male patients with CAH. An ovarian adrenal rest tumor (OART) may coexist with CAH or imitate its symptoms without CAH. In this case report, we present the case of a woman with OART without CAH, whose main complaint was infertility and who had a baby after successful surgical treatment.
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Affiliation(s)
- Hacer Uyanıkoglu
- Department of Obstetrics and Gynecology and IVF Unit, Harran University Medical Faculty, Sanliurfa, Turkey
| | - Gonul Ozer
- In Vitro Fertilization Unit, Istanbul Memorial Hospital, Istanbul, Turkey
| | - Semra Kahraman
- In Vitro Fertilization Unit, Istanbul Memorial Hospital, Istanbul, Turkey
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26
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Engberg H, Möller A, Hagenfeldt K, Nordenskjöld A, Frisén L. Identity, Sexuality, and Parenthood in Women with Congenital Adrenal Hyperplasia. J Pediatr Adolesc Gynecol 2020; 33:470-476. [PMID: 32473322 DOI: 10.1016/j.jpag.2020.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To explore how women with congenital adrenal hyperplasia (CAH) describe their experiences of gender role behavior, psychosexual development, and intimate relationships. CAH results in increased androgen exposure in affected females, and is the most common reason for unclear sex at birth. Women with CAH have been studied to find answers to the role of androgens in psychosexual development. Nevertheless, factors that may account for the variability of outcomes in women with CAH are unclear. DESIGN, SETTING AND PARTICIPANTS This was a qualitative study with 13 Swedish women (aged ≥18 years) with CAH. Semi-structured interviews were analyzed using inductive content analysis. MAIN OUTCOME MEASURES Direct quotes of patients' experiences derived from interview transcripts were sorted in categories, subcategories, and according to latent theme. RESULTS The main categories were "forming identity" and "establishing relationships." Forming identity encompasses that of a girl, a tomboy, and/or a woman. Establishing relationships focuses on intimate relationships, pregnancy, and parenthood. A latent theme was interpreted as "shifting perspectives," with CAH being the main focus of some participants' lives but a side issue for others. CONCLUSION These women's experiences are varied and describe shifting perspectives on how much CAH affects their lives. Health care providers can play an important role in helping women with CAH to separate what is caused by the condition and what is not. The long-term goal is to help girls and women to feel in control of their condition across their whole life.
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Affiliation(s)
- Hedvig Engberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden; Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden.
| | - Anders Möller
- Ersta Sköndal University College, Campus Bräcke, Gothenburg, Sweden
| | - Kerstin Hagenfeldt
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Pediatric Surgery Unit and Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden
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Lajic S, Karlsson L, Zetterström RH, Falhammar H, Nordenström A. The Success of a Screening Program Is Largely Dependent on Close Collaboration between the Laboratory and the Clinical Follow-Up of the Patients. Int J Neonatal Screen 2020; 6:68. [PMID: 33117907 PMCID: PMC7569867 DOI: 10.3390/ijns6030068] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/24/2020] [Indexed: 02/05/2023] Open
Abstract
Neonatal screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency is now performed in an increasing number of countries all over the world. The main goal of the screening is to achieve early diagnosis and treatment in order to prevent neonatal salt-crisis and death. The screening laboratory can also play an important role in increasing the general awareness of the disease and act as the source of information and education for clinicians to facilitate improved initial care, ensure prompt and correct glucocorticoid dosing to optimize the long-term outcome for the patients. A National CAH Registry and CYP21A2 genotyping provide valuable information both for evaluating the screening program and the clinical outcome. The Swedish experience is described.
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Affiliation(s)
- Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Leif Karlsson
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
| | - Rolf H Zetterström
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176 Stockholm, Sweden;
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176 Stockholm, Sweden;
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-17176 Stockholm, Sweden
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
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Kocova M, Anastasovska V, Falhammar H. Clinical outcomes and characteristics of P30L mutations in congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Endocrine 2020; 69:262-277. [PMID: 32367336 PMCID: PMC7392929 DOI: 10.1007/s12020-020-02323-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/18/2020] [Indexed: 01/07/2023]
Abstract
Despite numerous studies in the field of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, some clinical variability of the presentation and discrepancies in the genotype/phenotype correlation are still unexplained. Some, but not all, discordant phenotypes caused by mutations with known enzyme activity have been explained by in silico structural changes in the 21-hydroxylase protein. The incidence of P30L mutation varies in different populations and is most frequently found in several Central and Southeast European countries as well as Mexico. Patients carrying P30L mutation present predominantly as non-classical CAH; however, simple virilizing forms are found in up to 50% of patients. Taking into consideration the residual 21-hydroxulase activity present with P30L mutation this is unexpected. Different mechanisms for increased androgenization in patients carrying P30L mutation have been proposed including influence of different residues, accompanying promotor allele variability or mutations, and individual androgene sensitivity. Early diagnosis of patients who would present with SV is important in order to improve outcome. Outcome studies of CAH have confirmed the uniqueness of this mutation such as difficulties in phenotype classification, different fertility, growth, and psychologic issues in comparison with other genotypes. Additional studies of P30L mutation are warranted.
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Affiliation(s)
- Mirjana Kocova
- Medical Faculty, University"Cyril&Methodius", Skopje, Republic of North Macedonia
| | - Violeta Anastasovska
- Genetic Laboratory, University Pediatric Hospital, Skopje, Republic of North Macedonia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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29
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Xia Q, Li Q, Gan S, Guo X, Zhang X, Zhang J, Chu M. Exploring the roles of fecundity-related long non-coding RNAs and mRNAs in the adrenal glands of small-tailed Han Sheep. BMC Genet 2020; 21:39. [PMID: 32252625 PMCID: PMC7137433 DOI: 10.1186/s12863-020-00850-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/30/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Long non-coding RNAs (lncRNAs) can play important roles in uterine and ovarian functions. However, little researches have been done on the role of lncRNAs in the adrenal gland of sheep. Herein, RNA sequencing was used to compare and analyze gene expressions in adrenal tissues between follicular phases and luteal phases in FecBBB (MM) and FecB++ (WW) sheep, respectively, and differentially expressed lncRNAs and genes associated with reproduction were identified. RESULTS In MM sheep, 38 lncRNAs and 545 mRNAs were differentially expressed in the adrenal gland between the luteal and follicular phases; In WW sheep, 513 differentially expressed lncRNAs and 2481 mRNAs were identified. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses indicated that differentially expressed lncRNAs and their target genes are mainly involved in the circadian rhythm, the mitogen activated protein kinase, thyroid, ovarian steroidogenesis and transforming growth factor beta signaling pathways. Differentially expressed lncRNAs can regulate reproduction by modulating genes involved in these signaling pathways and biological processes. Specifically, XLOC_254761, XLOC_357966, 105,614,839 and XLOC_212877 targeting CREB1, PER3, SMAD1 and TGFBR2, respectively, appear to play key regulatory roles. CONCLUSION These results broaden our understanding of lncRNAs in adrenal gland of sheep and provide new insights into the molecular mechanisms underlying sheep reproduction.
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Affiliation(s)
- Qing Xia
- Key Laboratory of Animal Genetics and Breeding and Reproduction of the Ministry of Agriculture and Rural Affairs, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing, 100193, P. R. China
| | - Qiuling Li
- College of Life Sciences, Langfang Normal University, Langfang, 065000, P.R. China
| | - Shangquan Gan
- State Key Laboratory of Sheep Genetic Improvement and Healthy Production, Xinjiang Academy of Agricultural and Reclamation Sciences, Shihezi, 832000, P. R. China
| | - Xiaofei Guo
- Tianjin Institute of Animal Sciences, Tianjin, 300381, P. R. China
| | - Xiaosheng Zhang
- Tianjin Institute of Animal Sciences, Tianjin, 300381, P. R. China
| | - Jinlong Zhang
- Tianjin Institute of Animal Sciences, Tianjin, 300381, P. R. China
| | - Mingxing Chu
- Key Laboratory of Animal Genetics and Breeding and Reproduction of the Ministry of Agriculture and Rural Affairs, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing, 100193, P. R. China.
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30
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Cicalini I, Tumini S, Guidone PI, Pieragostino D, Zucchelli M, Franchi S, Lisi G, Lelli Chiesa P, Stuppia L, De Laurenzi V, Rossi C. Serum Steroid Profiling by Liquid Chromatography-Tandem Mass Spectrometry for the Rapid Confirmation and Early Treatment of Congenital Adrenal Hyperplasia: A Neonatal Case Report. Metabolites 2019; 9:metabo9120284. [PMID: 31766536 PMCID: PMC6950672 DOI: 10.3390/metabo9120284] [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: 10/03/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive disorders of steroid biosynthesis, in 95% of cases due to 21-hydroxylase deficiency. The resulting hormonal imbalances lead to increased 17-hydroxyprogesterone and androgens levels, at the expense of decreased concentrations of glucocorticoids and, in some cases, of mineralocorticoids. A variety of clinical presentations accompany a range of severities, which are described as different forms of CAH, and are the result of these hormonal imbalances. The incidence of CAH worldwide is approximately 1 in 15,000 live births, and is population-dependent; thus, its inclusion in neonatal screening tests is widely discussed. Diagnosis of CAH is based on the quantification of 17-hydroxyprogesterone, usually by immunoassay, which has low specificity and high false-positive rates, resulting in a relatively high demand for a second-tier confirmation test. We report a case of a newborn recognized as female at birth, but showing ambiguous genitalia and other CAH clinical features, including hypernatremia, in the first days of life. In addition to the classical assays, liquid chromatography–tandem mass spectrometry was used to determine the serum steroid profile, allowing for the accurate and simultaneous quantification of seven steroids in the same analysis. Such an application immediately revealed an alteration in the levels of specific steroids related to CAH, leading to an early intervention by hormone replacement therapy. Subsequently, the diagnosis of classic CAH due to 21-hydroxylase deficiency was further confirmed by molecular testing.
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Affiliation(s)
- Ilaria Cicalini
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
| | - Stefano Tumini
- Department of Pediatrics, “G. d’Annunzio” University, 66100 Chieti, Italy;
| | - Paola Irma Guidone
- Department of Pediatrics, “Ospedale della Murgia—Fabio Perinei ”, 70022 Altamura, Italy;
| | - Damiana Pieragostino
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Mirco Zucchelli
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Sara Franchi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Psychological, Healthand Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Gabriele Lisi
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
- Department of Pediatric Surgery, Pescara Hospital, 65124 Pescara, Italy
| | - Pierluigi Lelli Chiesa
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
- Department of Pediatric Surgery, Pescara Hospital, 65124 Pescara, Italy
| | - Liborio Stuppia
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Psychological, Healthand Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Vincenzo De Laurenzi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Claudia Rossi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
- Correspondence:
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Abstract
Fertility rates in classic congenital adrenal hyperplasia caused by 21-hydroxylase deficiency are substantially decreased for various reasons, including hormonal, anatomic, psychosocial, and psychosexual causes. However, fecundity is comparable with the general population. Under optimal hormone replacement, the course and outcome of pregnancies is also good. This article summarizes successful gestational management, including preconceptional considerations, adjustment of hormone replacement during pregnancy, delivery and lactation, as well as the prevention of adrenal crises. In nonclassic 21-hydroxylase deficiency, preconceptional low-dose hydrocortisone replacement normalizes the otherwise increased miscarriage rate. Pregnancy reports in rarer forms of congenital adrenal hyperplasia are summarized as well.
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Affiliation(s)
- Nicole Reisch
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Ziemssenstraße 1, München 80336, Germany.
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New MI, Rosenwaks Z. Introduction: Contemporary perspectives on congenital adrenal hyperplasia: impacts on reproduction. Fertil Steril 2019; 111:4-6. [PMID: 30611412 DOI: 10.1016/j.fertnstert.2018.11.031] [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: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
Abstract
Congenital adrenal hyperplasia, an endocrine autosomal recessive disorder caused by several deficiencies of enzymes and/or proteins involved in adrenal cortisol biosynthesis, is often associated with reproductive dysfunction. While the most common disorder is due to 21-hydroxylase deficiency, several other enzymes in the steroidogenesis pathway have been described, all of which can result in a range of reproductive disorders in both males and females. Although for many enzymes the phenotypic presentation is associated with a particular genotype, the severity of disease cannot always be predicted.
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Affiliation(s)
- Maria I New
- Division of Pediatric Endocrinology Division of Genetics and Genomic Sciences, Mount Sinai Hospital, New York, New York.
| | - Zev Rosenwaks
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York
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