Female pseudohermaphroditism secondary to a maternal virilizing tumor. Case report and review of the literature

Safety of testosterone treatment in postmenopausal women

OBJECTIVE

To critically examine the safety of T therapy given to postmenopausal women.

DESIGN

MEDLINE literature review, cross-reference of published data, and review of Food and Drug Administration transcripts.

RESULT(S)

Although some retrospective and observational studies provide some long-term safety data, most prospective studies have had a duration of 2 years or less. In addition, with the exception of the female-to-male transsexuals, T was administered in conjunction with estrogens or estrogens and progestins, which confound the interpretation of some of the studies. The major adverse reactions are the androgenic side effects of hirsutism and acne. There does not appear to be an increase in cardiovascular risk factors, with the exception of a lowering of high-density lipoprotein with oral T. There are little data on endometrial safety, and most of the experimental data support a neutral or beneficial effect in regards to breast cancer. There does not appear to be an increased risk of hepatotoxicity, neurobehavioral abnormalities, sleep apnea, or fetal virilization (in premenopausal women) with the physiologic treatment doses of T.

CONCLUSION(S)

Except for hirsutism and acne, the therapeutic administration of T in physiologic doses is safe for up to several years. However, prospectively collected long-term safety studies are needed to provide a greater degree of assurance.

Female pseudohermaphroditism with phallic urethra in the offspring of a mother with an adrenal tumor

BACKGROUND

Female pseudohermaphroditism is a disorder in which 46,XX females with ovaries do not develop as normal women. This disorder is caused by overexposure of a female fetus to androgens during intrauterine life. We describe a masculinized female infant who was born to a mother who had virilizing signs.

PATIENT REPORT

The patient had a normally formed phallus and a completely fused scrotum. Baseline as well as stimulated adrenal hormones and testosterone values were in the normal range in the infant. No androgens were given to the mother during pregnancy. Serum 17-OHP, DHEA-S, and testosterone levels were all elevated in the mother. Imaging studies revealed a tumor mass over the left kidney pole. Histologically it was an adrenal tumor.

CONCLUSIONS

Although a maternal adrenal tumor is a rare cause of female pseudohermaphroditism, the physician must bear this in mind when confronted with a newborn or infant with 46,XX karyotype and cryptorchidism with a phallic urethra.

Pregnancy outcomes in women with congenital virilizing adrenal hyperplasia

Although low fertility rates have traditionally been reported among women with classic CAH and especially among women with the salt-wasting variant, more recent data suggest that fertility rates are significantly improved, largely owing to earlier treatment of CAH, improved compliance with therapy, and surgical advances in genital reconstruction. Furthermore, ovulation induction and assisted reproductive techniques are now available to women who remain infertile despite effective adrenal androgen suppression. Although the pregnancy experience in women with classic CAH remains limited, it is apparent that, once pregnant, these women have a high probability of successful outcome. Key issues should be emphasized in the management of CAH during gestation, including the need for assessing adrenal steroid replacement and adrenal androgen suppression, particularly in light of the interplay between maternal hyperandrogenism and the protective effect of placental aromatase activity, which provides a relatively large margin of safety for the female fetus. Maternal hormone levels should be evaluated in the context of laboratory-specific reference ranges for pregnancy. The infant should be examined for ambiguous genitalia and monitored for evidence of adrenal insufficiency. Although an affected female infant with classic CAH has not been reported as a pregnancy outcome of a mother with classic virilizing CAH, these concerns should be discussed during preconception counseling. Patients should also be aware of the importance of medication compliance and careful hormonal monitoring during the entire pregnancy. In most cases, successful gestational management requires the close coordination of care between the obstetrician and endocrinologist.

Surgical correction of external genitalia and lower genitourinary tract of markedly virilized child

Three children who were seen with marked androgenization, including clitoromegaly, labial fusion, and absent vaginal introitus are presented. In each, the vagina was found to be entering at the level of the posterior urethra. Vaginoplasty was performed in each child utilizing a transperineal "pull through" technique. Reduction clitoroplasty was performed in 1 patient. The advantages and optimal timing of these techniques are discussed.

The diagnosis and management of intersex

The patient whose genitalia are ambiguous or are inappropriate for the assigned sex presents the physician with a set of problems requiring a thorough grasp of sexual differentiation, development and function. Although several reviews have covered various aspects of these matters, these texts do not cover recent advances in understanding normal and abnormal sexual development nor do they provide an integrated guide to the management of intersex cases. Our objectives are to show the clinical relevance of recent advances in understanding the determinants of normal and abnormal sexual differentiation, to indicate the improved diagnostic procedures now available and to provide specific guidelines for optimal case management in the light of current medical knowledge and psychological and ethical understanding.

Masculinization of a female fetus by Krukenberg tumor during pregnancy

A case of fetal masculinization resulting from a Krukenberg tumor in a pregnant woman is reported in a newborn infant with a sexual ambiguity of the external genitals, of the feminine pseudohermaphrodite type. She also had an incarceration of both ovaries and tubes in a right inguinoscrotal hernia that was surgically corrected.