1
|
Misakian A, McLoughlin M, Pyle LC, Kolon TF, Kelly A, Vogiatzi MG. Case Report: Low Bone and Normal Lean Mass in Adolescents With Complete Androgen Insensitivity Syndrome. Front Endocrinol (Lausanne) 2021; 12:727131. [PMID: 34526969 PMCID: PMC8435790 DOI: 10.3389/fendo.2021.727131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/22/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Osteopenia and osteoporosis have been reported in adults with Complete Androgen Insensitivity Syndrome (CAIS). Little is known about changes in bone mineral density (BMD) in adolescents with CAIS and whether it is affected by early gonadectomy. Body composition data have not been reported. METHODS Single-center, retrospective study of CAIS adolescents who underwent dual-energy x-ray absorptiometry (DXA) (Hologic, Horizon A). Body composition is presented as lean and fat mass indices (LMI, FMI). Z-scores for lumbar spine areal BMD (LBMD), total body less head (TBLH), bone mineral content (BMC), LMI, and FMI were calculated using female normative data. Results are expressed as median and min, max. RESULTS Six females with genetically confirmed CAIS were identified-one with intact gonads and five with history of gonadectomy at 2-11 months. In the subject with intact gonads, LBMD-Z and TBLH BMC-Z were -1.56 and -1.26, respectively, at age 16 years. Among those with gonadectomy, LBMD-Z was -1.8 (-3.59 to 0.49) at age 15.6 years (12-16.8) and decreased in all three subjects who had longitudinal follow-up despite hormone replacement therapy (HRT). Adherence to HRT was intermittent. LMI-Z and FMI-Z were 0.1 (-1.39 to 0.7) and 1.0 (0.22 to 1.49), respectively. CONCLUSIONS These limited data indicate that adolescents with CAIS have bone mass deficit. Further studies are needed to understand the extent of BMD abnormalities and the effect of gonadectomy, especially early in childhood, and to establish the optimal HRT regimen for bone accrual. Data on lean mass are reassuring.
Collapse
Affiliation(s)
- Aaron Misakian
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Aaron Misakian,
| | - Michelle McLoughlin
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Louisa C. Pyle
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Thomas F. Kolon
- Division of Urology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Andrea Kelly
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Maria G. Vogiatzi
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
2
|
Hegarty P, Prandelli M, Lundberg T, Liao LM, Creighton S, Roen K. Drawing the Line Between Essential and Nonessential Interventions on Intersex Characteristics With European Health Care Professionals. REVIEW OF GENERAL PSYCHOLOGY 2020. [DOI: 10.1177/1089268020963622] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Human rights statements on intersex characteristics distinguish legitimate “medically necessary” interventions from illegitimate normalizing ones. Ironically, this binary classification seems partially grounded in knowledge of anatomy and medical interventions; the very expertise that human rights statements challenge. Here, 23 European health professionals from specialist “disorder of sex development” (DSD) multidisciplinary teams located medical interventions on a continuum ranging from “medically essential” to nonessential poles. They explained their answers. Participants mostly described interventions on penile/scrotal, clitoral/labial, vaginal, and gonadal anatomy whose essential character was only partially grounded in anatomical variation and diagnoses. To explain what was medically necessary, health care professionals drew on lay understandings of child development, parental distress, collective opposition to medicalization, patients “coping” abilities, and patients’ own choices. Concepts of “medical necessity” were grounded in a hybrid ontology of patients with intersex traits as both physical bodies and as phenomenological subjects. Challenges to medical expertise on human rights grounds are well warranted but presume a bounded and well-grounded category of “medically necessary” intervention that is discursively flexible. Psychologists’ long-standing neglect of people with intersex characteristics, and the marginalization of clinical psychologists in DSD teams, may contribute to the construction of some controversial interventions as medically necessary.
Collapse
|
3
|
Morin J, Peard L, Saltzman AF. Gonadal malignancy in patients with differences of sex development. Transl Androl Urol 2020; 9:2408-2415. [PMID: 33209714 PMCID: PMC7658134 DOI: 10.21037/tau-19-726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Differences of sexual development (DSD) are known to be associated with an elevated risk of malignant and pre-malignant tumors. However, given the rarity of DSD and tumors in patients with DSD, more robust, large scale, prospective literature is required to truly determine the extent of this association, long-term outcomes and the nuances associated with the wide variety of DSD diagnoses. In addition, the spectrum of diagnoses and nomenclature has been ever-changing, limiting assessment of long-term patient outcomes. This review aims to provide an overview of the pathogenesis of DSD conditions, potential malignancies associated with the diagnoses, the available screening for malignancy, and the most recent data on stratification for each DSD diagnosis and association with malignancy.
Collapse
Affiliation(s)
- Jacqueline Morin
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Leslie Peard
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | | |
Collapse
|
4
|
Morin J, Peard L, Vanadurongvan T, Walker J, Dönmez Mİ, Saltzman AF. Oncologic outcomes of pre-malignant and invasive germ cell tumors in patients with differences in sex development - A systematic review. J Pediatr Urol 2020; 16:576-582. [PMID: 32564942 DOI: 10.1016/j.jpurol.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/14/2020] [Accepted: 05/04/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe the rates of GCNIS-free and GCT-free pathology based on age at gonadal surgery and to describe long-term oncologic outcomes in patients with DSD who have GCNIS or GCT at the time of gonadal surgery. STUDY DESIGN A systematic review was conducted using MEDLINE to identify patients with DSD who underwent gonadal surgery. DSD diagnoses were stratified based on malignancy risk. GCNIS/GCT and GCT-free survival by age of gonadal surgery, RFS and OS were calculated using the Kaplan-Meier method, with groups compared using log-rank testing. RESULTS 386 articles from 1951 to 2017 were included (2037 patients). Median age at gonadal surgery was 17 years (y) (IQR 11-20), median follow-up was 60 months (m) (IQR 30-68.1). GCNIS/GCT- and GCT-free survival at the time of gonadal surgery was lowest for those in the high/intermediate risk group (p < 0.001) but decreased sharply around age 15y, regardless of risk category. 5y RFS and OS was similar for those with no GCNIS/GCT and GCNIS and was worse for those with GCT (p < 0.001). DISCUSSION When patients undergo gonadal surgery, regardless of indication (i.e. prophylactic vs. tumor), it appears that GCTs are more commonly found when surgery is done around age 15 y or older, despite risk category. This is similar to ovarian and testicular GCTs. Patients with GCNIS can be reassured that long-term oncologic outcomes are excellent. While RFS and OS for GCTs are not as good as for ovarian and testicular GCTs (95%), they are still >80%. This similar trend was found in a COG review of 9 patients with DSD and ovarian GCT. There were several limitations to this study. This is a retrospective analysis that included aa wide time frame of publications. The indication for surgical intervention was not addressed in the majority of publications. Thus these data provide pathologic outcomes based on age at gonadal surgery rather than the age at which GCNIS/GCT develops over a lifetime, if at all. CONCLUSIONS The risk of GCNIS or GCT at the time of gonadal surgery appears to increase with age, accelerating between 15 and 20y regardless of risk category. 5y RFS and OS for those with GCNIS is equivalent to those without GCNIS/GCT but is worse for those with GCT. These data may be used when counseling families on timing of gonadal surgery and quantification of outcomes should GCNIS or malignancy be identified.
Collapse
Affiliation(s)
- Jacqueline Morin
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Leslie Peard
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Timothy Vanadurongvan
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Walker
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | - M İrfan Dönmez
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | | |
Collapse
|
5
|
Wang Z, Sa YL, Ye XX, Zhang J, Xu YM. Complete androgen insensitivity syndrome in juveniles and adults with female phenotypes. J Obstet Gynaecol Res 2014; 40:2044-50. [PMID: 25170741 DOI: 10.1111/jog.12455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/17/2014] [Indexed: 11/28/2022]
Abstract
AIM To report on six cases of the diagnosis and treatment of patients with complete androgen insensitivity syndrome (CAIS) and a review of the relevant published work. METHODS A retrospective analysis was performed on the clinical features, diagnosis and treatment of a total of six patients with CAIS who were admitted to our hospital between September 1985 and June 2012. All surgical patients were examined for sex chromosomes and sex hormone levels pre- and postoperatively, respectively, and underwent lower abdominal B ultrasounds and pathological examinations among other tests. RESULTS Five of the patients were treated with castration, one patient aged 5 years was treated conservatively Tissue from surgical resections showed normal testicular tissue that comprised Leydig cells and Sertoli cells, and pathological examinations showed no sign of testicular cancer. Following corrective operations, postoperative complications, such as female secondary sexual characteristics, stagnation and osteoporosis, have not developed. Sex hormone level ratio changed significantly after being treated with castration compared with preoperative levels; mainly testosterone and estrogen decreased significantly (P < 0.05), while luteinizing hormone and follicle-stimulating hormone significantly increased (P < 0.05). However, prolactin did not change significantly (P > 0.05). CONCLUSION The study show that removal of the testes in CAIS patients after puberty is safe and reliable. Meanwhile, it is essential to provide a hormone drug after being treated with castration. Further studies are needed to evaluate the safety and the quality of life for CAIS patients.
Collapse
Affiliation(s)
- Zhou Wang
- Department of Urology, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | | | | | | | | |
Collapse
|
6
|
Massanyi EZ, Gearhart JP, Kolp LA, Migeon CJ. Novel Mutation Among Two Sisters With 17β Hydroxysteroid Dehydrogenase Type 3 Deficiency. Urology 2013; 81:1069-71. [DOI: 10.1016/j.urology.2012.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Revised: 12/12/2012] [Accepted: 12/14/2012] [Indexed: 12/01/2022]
|
7
|
Mattila AK, Fagerholm R, Santtila P, Miettinen PJ, Taskinen S. Gender identity and gender role orientation in female assigned patients with disorders of sex development. J Urol 2012; 188:1930-4. [PMID: 22999536 DOI: 10.1016/j.juro.2012.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE Gender identity and gender role orientation were assessed in 24 female assigned patients with disorders of sex development. MATERIALS AND METHODS A total of 16 patients were prenatally exposed to androgens, of whom 15 had congenital adrenal hyperplasia and 1 was virilized due to maternal tumor. Eight patients had 46,XY karyotype, of whom 5 had partial and 3 had complete androgen insensitivity syndrome. Gender identity was measured by the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults with 167 female medical students as controls, and gender role was assessed by the femininity and masculinity subscales of the 30-item Bem Sex Role Inventory with 104 female and 64 male medical students as controls. RESULTS No patient reached the cutoff for gender identity disorder on the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. However, patients with 46,XY karyotype demonstrated a somewhat more conflicted gender identity, although the overall differences were relatively small. As to gender role orientation, patients with complete androgen insensitivity syndrome had high scores on the femininity and masculinity scales of the Bem Sex Role Inventory, which made them the most androgynous group. CONCLUSIONS Our findings, although clinically not clear cut, suggest that patients with disorders of sex development are a heterogeneous group regarding gender identity and gender role outcomes, and that this issue should be discussed with the family when treatment plans are made.
Collapse
Affiliation(s)
- Aino K Mattila
- School of Health Sciences, University of Tampere and Gender Identity Unit, Department of Adult Psychiatry, University Hospital of Tampere, Tampere, Finland
| | | | | | | | | |
Collapse
|
8
|
Palmer BW, Wisniewski AB, Schaeffer TL, Mallappa A, Tryggestad JB, Krishnan S, Chalmers LJ, Copeland K, Chernausek SD, Reiner WG, Kropp BP. A model of delivering multi-disciplinary care to people with 46 XY DSD. J Pediatr Urol 2012; 8:7-16. [PMID: 22078657 DOI: 10.1016/j.jpurol.2011.08.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 08/31/2011] [Indexed: 11/17/2022]
Abstract
In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) [1]. A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team's interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.
Collapse
Affiliation(s)
- Blake W Palmer
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Barthold JS. Disorders of Sex Differentiation: A Pediatric Urologist's Perspective of New Terminology and Recommendations. J Urol 2011; 185:393-400. [DOI: 10.1016/j.juro.2010.09.083] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Indexed: 11/30/2022]
|
10
|
Karkazis K, Rossi WC. Ethics for the pediatician: disorders of sex development: optimizing care. Pediatr Rev 2010; 31:e82-5. [PMID: 21041421 DOI: 10.1542/pir.31-11-e82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Katrina Karkazis
- Center for Biomedical Ethics, Stanford University, Palo Alto, Calif., USA
| | | |
Collapse
|