The syndromes of androgen resistance

The NIMH Intramural Longitudinal Study of the Endocrine and Neurobiological Events Accompanying Puberty: Protocol and rationale for methods and measures

Delineating the relationship between human neurodevelopment and the maturation of the hypothalamic-pituitary-gonadal (HPG) axis during puberty is critical for investigating the increase in vulnerability to neuropsychiatric disorders that is well documented during this period. Preclinical research demonstrates a clear association between gonadal production of sex steroids and neurodevelopment; however, identifying similar associations in humans has been complicated by confounding variables (such as age) and the coactivation of two additional endocrine systems (the adrenal androgenic system and the somatotropic growth axis) and requires further elucidation. In this paper, we present the design of, and preliminary observations from, the ongoing NIMH Intramural Longitudinal Study of the Endocrine and Neurobiological Events Accompanying Puberty. The aim of this study is to directly examine how the increase in sex steroid hormone production following activation of the HPG-axis (i.e., gonadarche) impacts neurodevelopment, and, additionally, to determine how gonadal development and maturation is associated with longitudinal changes in brain structure and function in boys and girls. To disentangle the effects of sex steroids from those of age and other endocrine events on brain development, our study design includes 1) selection criteria that establish a well-characterized baseline cohort of healthy 8-year-old children prior to the onset of puberty (e.g., prior to puberty-related sex steroid hormone production); 2) temporally dense longitudinal, repeated-measures sampling of typically developing children at 8-10 month intervals over a 10-year period between the ages of eight and 18; 3) contemporaneous collection of endocrine and other measures of gonadal, adrenal, and growth axis function at each timepoint; and 4) collection of multimodal neuroimaging measures at these same timepoints, including brain structure (gray and white matter volume, cortical thickness and area, white matter integrity, myelination) and function (reward processing, emotional processing, inhibition/impulsivity, working memory, resting-state network connectivity, regional cerebral blood flow). This report of our ongoing longitudinal study 1) provides a comprehensive review of the endocrine events of puberty; 2) details our overall study design; 3) presents our selection criteria for study entry (e.g., well-characterized prepubertal baseline) along with the endocrinological considerations and guiding principles that underlie these criteria; 4) describes our longitudinal outcome measures and how they specifically relate to investigating the effects of gonadal development on brain development; and 5) documents patterns of fMRI activation and resting-state networks from an early, representative subsample of our cohort of prepubertal 8-year-old children.

Congenital uterovaginal abnormalities, it's embryogenesis, surgical management and clinical implications

Objective

Congenital Mullerian duct malformations are a challenging group of conditions for surgeons and need surgical experience and skill. Accordingly, the aim of this study is to present the diagnosis, surgical management, and clinical implications of congenital uterovaginal abnormalities.

Methods

Between 1980 and 2015, 8 patients with congenital uterovaginal abnormalities were diagnosed. In one patient a unique case of an unusual horseshoe shaped double uterus communicating via a transverse canal along with agenesis of the cervix and vagina was noted, and utero-vaginal agenesis was diagnosed in 6 patients. Complete androgen insensitivity syndrome with its female phenotype associated with bilateral testicular tissue in the inguinal canal with an accompanying absence of the ovaries, uterus, uterine tubes, vagina, and an imperforate hymen, was diagnosed in one patient. Clinical examination of all the patients revealed well-developed secondary sexual characteristics. A modified McIndoe vaginoplasty procedure was the surgical treatment common to all patients to treat vaginal agenesis. The surgery was performed by a consultant (Dr. K.G. Paul) using the standardized surgical technique.

Results

An unusual Mullerian duct anomaly, uterus bicornisacollis, was successfully corrected by uteroplasty and a new cervix was constructed. Complete vaginal agenesis was corrected by a modified McIndoe vaginoplasty technique. None of the patients had any significant post-operative complications.

Conclusion

Knowledge of congenital uterovaginal abnormalities diagnosed in this study is essential for surgeons, clinical anatomists, radiologists, and morphologists who may increase the success of their diagnostic evaluations and surgical approaches to the region.

Androgen-Induced Immunosuppression

In addition to determining biological sex, sex hormones are known to influence health and disease via regulation of immune cell activities and modulation of target-organ susceptibility to immune-mediated damage. Systemic autoimmune disorders, such as systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis are more prevalent in females, while cancer shows the opposite pattern. Sex hormones have been repeatedly suggested to play a part in these biases. In this review, we will discuss how androgens and the expression of functional androgen receptor affect immune cells and how this may dampen or alter immune response(s) and affect autoimmune disease incidences and progression.

Perils and pitfalls of reporting sex differences

The idea of sex differences in the brain both fascinates and inflames the public. As a result, the communication and public discussion of new findings is particularly vulnerable to logical leaps and pseudoscience. A new US National Institutes of Health policy to consider both sexes in almost all preclinical research will increase the number of reported sex differences and thus the risk that research in this important area will be misinterpreted and misrepresented. In this article, I consider ways in which we might reduce that risk, for example, by (i) employing statistical tests that reveal the extent to which sex explains variation, rather than whether or not the sexes 'differ', (ii) properly characterizing the frequency distributions of scores or dependent measures, which nearly always overlap, and (iii) avoiding speculative functional or evolutionary explanations for sex-based variation, which usually invoke logical fallacies and perpetuate sex stereotypes. Ultimately, the factor of sex should be viewed as an imperfect, temporary proxy for yet-unknown factors, such as hormones or sex-linked genes, that explain variation better than sex. As scientists, we should be interested in discovering and understanding the true sources of variation, which will be more informative in the development of clinical treatments.

Perspectives in Pediatric Pathology, Chapter 6. Male Undermasculinization

Normal male development requires three conditions: (1) adequate differentiation of the fetal testis; (2) synthesis and secretion of testicular hormones; and (3) effective action of these hormones on target organs. This requires the combined action of the inhibitory anti-müllerian hormone (AMH, secreted by Sertoli cells) to block the development of the uterus and fallopian tubes from the müllerian duct, together with the trophic stimulus of testosterone (a Leydig cell product), which leads to virilization of the wolffian ducts. Additionally, the development of external genitalia depends on the conversion of testosterone to dihydrotestosterone by the enzyme 5-α-reductase. Failure of any of these mechanisms leads to deficient virilization or the so-called "male pseudohermaphroditism" syndromes.

Clinical biochemistry of dihydrotestosterone

Dihydrotestosterone (DHT) is the most potent natural androgen in humans. There has been an increasing interest in this androgen and its role in the development of primary and secondary sexual characteristics as well as its potential roles in diseases ranging from prostate and breast cancer to Alzheimer's disease. Despite the range of pathologies shown to involve DHT there is little evidence for measurement of serum DHT in the management of these diseases. In this review we describe the physiology of DHT production and action, summarize current concepts in the role of DHT in the pathogenesis of various disorders of sexual development, compare current methods for the measurement of DHT and conclude on the clinical utility of DHT measurement. The clinical indications for the measurement of DHT in serum are: investigation of 5α reductase deficiency in infants with ambiguous genitalia and palpable gonads; men with delayed puberty and/or undescended testes; and to confirm the presence of active testicular tissue. Investigation is aided by the use of human chorionic gonadotrophin stimulation. Due to paucity of published data on this procedure, it is important to follow guidelines prescribed by the laboratory performing the analysis to ensure accurate interpretation.

Androgen actions on the human hair follicle: perspectives

Androgens stimulate beard growth but suppress hair growth in androgenetic alopecia (AGA). This condition is known as 'androgen paradox'. Human pilosebaceous units possess enough enzymes to form the active androgens testosterone and dihydrotestosterone. In hair follicles, 5α-reductase type 1 and 2, androgen receptors (AR) and AR coactivators can regulate androgen sensitivity of dermal papillae (DP). To regulate hair growth, androgens stimulate production of IGF-1 as positive mediators from beard DP cells and of TGF-β1, TGF-β2, dickkopf1 and IL-6 as negative mediators from balding DP cells. In addition, androgens enhance inducible nitric oxide synthase from occipital DP cells and stem cell factor for positive regulation of hair growth in beard and negative regulation of balding DP cells. Moreover, AGA involves crosstalk between androgen and Wnt/β-catenin signalling. Finally, recent data on susceptibility genes have provided us with the impetus to investigate the molecular pathogenesis of AGA.

Embryonal carcinoma in androgen insensitivity syndrome

Embryonal cell carcinoma is a rare clinical entity. We report a case of a 20-year-old patient who presented with lump lower abdomen for last two months with primary amenorrhea and poorly developed secondary sexual characteristics. Ultrasonography (USG) whole abdomen showed lower abdominal mass approximately 15×15×10 cm, probably neoplastic changes in intra-abdominal testis, with mild ascites, no uterus and ovaries. Fine needle aspiration cytology from the tumor mass reported the possibility of non-seminomatous germ cell tumor, possibly embryonal carcinoma. The patient received three cycles of neo-adjuvant chemotherapy (Regime Bleomycin, Etoposide and Cisplatin) followed by laparotomy, at laparotomy (L) orchidectomy with removal of tumor, (R) orchidectomy, omentectomy and appendisectomy was performed. Postoperatively the patient received two more cycles of chemotherapy of the same regime. The patient has been under close follow-up for the last three years with no evidence of disease.

Female feathering in sebright cocks is due to conversion of testosterone to estradiol in skin

Sebright cocks develop a female feathering pattern but revert to normal male feathering after castration. Administration of testosterone to castrated cocks causes male comb development and reappearance of female feathering. Dihydrotes-tosterone treatment supports development of a male comb but does not induce female feathering. Since testosterone but not dihydrotestosterone is converted to estradiol in the skin of the Sebright, the female feathering appears to be the result of increased conversion of testosterone to estradiol.

Androgen insensitivity syndrome

Over the past four years, major advances in the understanding of the aetiology and pathogenesis of the androgen insensitivity syndrome (AIS) have occurred. This review aims to summarize current information on clinical, diagnostic, therapeutic and molecular aspects of AIS.

Genetic studies at the receptor level: investigations in human twins and experimental animals

In receptors, as in enzymes, quantitative as well as qualitative genetic variation may exist. Studies in inbred strains of mice have shown for various receptors that the receptor density as determined by Bmax values is under genetic control. In healthy adult twins we have shown that the density of alpha-adrenoceptors on platelets is also influenced by genetic factors, since monozygotic twins were much more similar to one another than dizygotic twins. However, Bmax values are up-regulated and down-regulated by endogenous neurotransmitters and pharmacologically active agents. Thus, receptor densities are under considerable regulatory influences. Bmax values therefore reflect regulatory mechanisms rather than innate characteristics of the receptor protein. In another twin study we failed to find evidence for a genetic influence on the density of imipramine-binding sites on platelets. Since qualitative variation (polymorphism) is well known in enzymes, it may also apply to receptors. Qualitative differences in the receptor protein within one species would be of particular interest because of possible functional implications. As a first approach we examined central benzodiazepine receptors by photoaffinity labelling and sodium dodecyl sulphate-polyacrylamide gel electrophoresis. A comparison of fish, frog, chicken, mouse, rat and calf led to the detection of variation between species. Investigations in five inbred mouse and rat strains have not so far revealed genetic variation in benzodiazepine receptors. Nevertheless variation may be detectable by more sensitive methods such as peptide mapping after limited proteolysis or two-dimensional electrophoresis.

Endocrine regulation of HOX genes

Hox genes have a well-characterized role in embryonic development, where they determine identity along the anteroposterior body axis. Hox genes are expressed not only during embryogenesis but also in the adult, where they are necessary for functional differentiation. Despite the known function of these genes as transcription factors, few regulatory mechanisms that drive Hox expression are known. Recently, several hormones and their cognate receptors have been shown to regulate Hox gene expression and thereby mediate development in the embryo as well as functional differentiation in the adult organism. Estradiol, progesterone, testosterone, retinoic acid, and vitamin D have been shown to regulate Hox gene expression. In the embryo, the endocrine system directs axial Hox gene expression; aberrant Hox gene expression due to exposure to endocrine disruptors contributes to the teratogenicity of these compounds. In the adult, endocrine regulation of Hox genes is necessary to enable such diverse functions as hematopoiesis and reproduction; endocrinopathies can result in dysregulated HOX gene expression affecting physiology. By regulating HOX genes, hormonal signals utilize a conserved mechanism that allows generation of structural and functional diversity in both developing and adult tissues. This review discusses endocrine Hox regulation and its impact on physiology and human pathology.

Androgen insensitivity syndrome: in utero diagnosis by four-dimensional sonography and amniotic fluid karyotype

We describe a fetus with androgen insensitivity syndrome diagnosed at 16 weeks' gestation with two-dimensional (2D) and four-dimensional (4D) sonography and karyotype analysis in a 37-year-old pregnant woman. Two-dimensional (2D) sonography revealed a female phenotype. Karyotype analysis revealed an unremarkable 46,XY chromosomal complement. Repeat 4D sonography confirmed a female phenotype with edematous labia majora, consistent with androgen insensitivity syndrome.

Huge seminoma developed in a patient with testicular feminization

We report a 36-year-old patient who presented with primary amenorrhea and was found to have a giant abdominal tumor. There was a family history of primary amenorrhea in her two aunts. Physical and hormonal examinations as well as chromosomal analysis led to a diagnosis of testicular feminization. The patient underwent tumorectomy along with pelvic and para-aortic lymphadectomy. The pathological diagnosis was bilateral seminoma of the testis with metastasis to para-aortic lymph nodes. Nowadays, cases of undiagnosed seminoma developing into a huge abdominal mass in patients with testicular feminization are rarely encountered, since surgical castration is generally recommended as early as possible after puberty. In testicular feminization, the risk of malignant transformation of the dysgenetic male gonads increases substantially after puberty. Early and correct diagnosis together with careful follow-up are critically important in managing testicular feminization, a rare congenital disorder.

Androgen receptor isoforms AR-A and AR-B display functional differences in cultured human bone cells and genital skin fibroblasts

Two isoforms of the androgen receptor (AR-A and AR-B), differing by a lack of the first 187 amino acids in the NH2-terminal transactivation domain of AR-A, are expressed in connective tissue and bone. Transient transfections of normal human osteoblastic cells (HOB) and of genital skin fibroblasts defective in AR (GSF-540) were utilized to compare the functional properties of AR isoforms in mesenchymal tissues. Overexpression of AR-B or AR-A did not significantly affect type I collagen secretion. However, overexpression of AR-B (but not AR-A) restored androgen-dependent DNA synthesis in AR-defective fibroblasts and increased DHT-mediated DNA synthesis three-fold in osteoblastic cells. Overexpression of AR-A did not affect DHT action but reduced DHT-dependent DNA synthesis when transfected together with AR-B. The need for an NH2-terminal sequence of the AR for complete receptor function was demonstrated using electrophoretic mobility shift assay. A peptide coding for the amino terminus of the complete AR was able to decrease the binding affinity of AR-B and increase the binding affinity of AR-A to the androgen response element. Our results suggest that AR-A lacks the ability to stimulate cell proliferation possibly due to reduced binding of AR co-activating proteins to the truncated N-terminal transactivation domain rather than due to impaired stability of the AR-A isoform.

Role of estrogen receptor-alpha in pharmacogenetics of estrogen action

PURPOSE OF REVIEW

To summarize recent data regarding the role of estrogen receptor-alpha polymorphisms in determining the response to estrogen therapy or the risk of clinical cardiovascular events.

RECENT FINDINGS

Recent clinical trials of hormone replacement therapy for cardiovascular disease have yielded surprisingly negative results, shifting clinical opinions from a position of presumed cardiovascular benefit to one of confirmed harm. Understanding why hormone replacement therapy has beneficial effects on intermediate risk markers for cardiovascular disease, but produces an increase in cardiovascular events, is an important public health question with the potential to elucidate fundamentally important aspects on atherogenesis, cardiovascular disease, and the biology of estrogen action. One question concerning the cardiovascular effects of hormone replacement therapy is whether genetic factors can substantially modify individual responses to estrogen treatment. New clinical trial evidence is emerging that links the presence of particular variants in the estrogen receptor to the response of HDL and other intermediate endpoints to hormone replacement therapy.

SUMMARY

One or more common variants in estrogen receptor-alpha are associated with a differential response to hormone replacement therapy in several domains of estrogen action. However, the effect of these variants on the risk of clinical cardiovascular events in the setting of hormone replacement therapy is not yet known. Additional research focusing on the clinical impact of common variants in estrogen receptor-alpha, estrogen receptor-beta and the progesterone receptor promise to improve clinical decision-making concerning the use of hormone replacement therapy and other novel estrogen agonists.

Stable maintenance of 5alpha-reductase activity in long-term subcultures of fibroblasts derived from the foreskin

BACKGROUND

There is up to a 50-fold variation in control subjects in current assays of 5alpha-reductase activity which makes interpretation difficult. It was therefore attempted in this study to establish an assay method which produced stable 5alpha-reductase activity in long-term subcultured foreskin fibroblasts.

METHODS

Foreskin fibroblasts were obtained from three boys with phimosis (control subjects), three patients with Reifenstein syndrome and one patient with 5alpha-reductase deficiency (due to mutation L113P in exon 2 of the SRD5A2 gene). To maximize the number of cells in the DNA synthesis phase, cells were subcultured consistently to approximately 70% confluency. Thawed cells, frozen after the third subculture, were incubated for 24 h with [1beta,2beta-3H] testosterone. 5alpha-Reductase activity was expressed as the sum of formed [3H] 5alpha-reduced metabolites (separated by thin-layer chromatography).

RESULTS

The full range of 5alpha-reductase activity in controls and patients with Reifenstein syndrome was 3.44-15.59 pmol/h per mg protein: a 4.53-fold variation. The activity in the patient with 5alpha- reductase deficiency was 0.52 pmol/h per mg protein.

CONCLUSION

By the cell culture methods used in this study, which aimed to increase the number of cells in the DNA synthesis phase, foreskin fibroblasts maintained a considerably stable level of 5alpha-reductase activity during long-term subculture. Therefore, this assay method can be used for differential diagnosis of 5alpha-reductase deficiency from other relevant entities.

Estrogen-receptor polymorphisms and effects of estrogen replacement on high-density lipoprotein cholesterol in women with coronary disease

BACKGROUND

Sequence variants in the gene encoding estrogen receptor alpha (ER-alpha) may modify the effects of hormone-replacement therapy on levels of high-density lipoprotein (HDL) cholesterol and other outcomes related to estrogen treatment in postmenopausal women.

METHODS

We characterized 309 women with coronary artery disease who were enrolled in the Estrogen Replacement and Atherosclerosis trial with respect to eight previously described and two newly identified ER-alpha polymorphisms, and we examined the association between these polymorphisms and the response of HDL cholesterol and other lipids to treatment with estrogen alone or estrogen plus progestin.

RESULTS

After adjustment for age, race, diabetes status, body-mass index, smoking status, alcohol intake, and frequency of exercise, the 18.9 percent of the women who had the IVS1-401 C/C genotype (i.e., with C on both chromosomes in intervening sequence 1 at position 401 before exon 2) had an increase in the HDL cholesterol level with hormone-replacement therapy that was more than twice the increase observed in the other women (13.1 mg per deciliter vs. 6.0 mg per deciliter, P for treatment-by-genotype interaction = 0.004); this effect was limited to changes in the HDL subfraction 3 (HDL3) (P for interaction=0.04). Similar patterns of response were observed for three other highly linked ER-alpha intron 1 polymorphisms close to the IVS1-401 site (range of P values for interaction = 0.07 to 0.005). The pattern of increased response of HDL cholesterol in women with the IVS1-401 C/C genotype was evident in both the women receiving estrogen and those receiving estrogen plus progestin, was preserved across racial and ethnic groups, and was significant among women who were compliant with the study medication (P<0.001).

CONCLUSIONS

Postmenopausal women with coronary disease who have the ER-alpha IVS1-401 C/C genotype, or several other closely related genotypes, have an augmented response of HDL cholesterol to hormone-replacement therapy.

Simultaneous sertoli cell tumor and adenocarcinoma of the tunica vaginalis testis in a patient with testicular feminization

BACKGROUND

The association of testicular feminization with late diagnosis in a patient with a large Sertoli cell tumor and a metastasizing adenocarcinoma of the tunica vaginalis testis is unusual.

CASE

Testicular feminization was diagnosed in a 72-year-old patient, who was admitted with a large lower abdominal mass. Histologically, we found a well-differentiated Sertoli cell tumor and an adenocarcinoma of the tunica vaginalis testis with metastases in the sigmoid colon, rectum, and omentum. Explorative laparotomy revealed a large pelvic tumor mass and extensive peritoneal carcinosis. After debulking surgery to optimal residual disease and four courses of chemotherapy (cisplatin and etoposide), there was no evidence of disease (clinically) for 24 months before an intraabdominal and inguinal relapse occurred. Due to the unwillingness of the patient to receive salvage chemotherapy or palliative abdominal surgery, the disease progressed rapidly and she died 27 months after the initial operation.

CONCLUSION

This is the first reported case of an advanced carcinoma of the tunica vaginalis testis occurring simultaneously with a large Sertoli cell tumor in a patient with testicular feminization. Surgical debulking and platinum-based chemotherapy rendered the patient clinically free of disease for 2 years.

INGUINAL HERNIA IN FEMALES

9 patients of inguinal hernia in females were diagnosed in a total of 50 patients who presented with congenital groin problems, 8 of these were managed surgically. There were 6 small children, 1 young girl and 2 elderly ladies. All children were managed by herniotomy and herniorrhaphy was done in women. 2 patients under one year presented with irreducible hernia, one of them on exploration was found to be having sliding hernia with incarcerated ovary and tube as contents while other one had incarcerated loop of small intestine. Contents were reduced in both the patients after division of external ring as there was no sign of strangulation. One of our patients never turned up for surgery. All the operated patients were asymptomatic during the follow up period of 6 months to one year with no recurrence or wound infection. None presented on the contralateral side on follow up. Repair of inguinal hernia in females should be carried out at the earliest after a diagnosis is made, because incarceration occurs more frequently in the first year of life, as seen in this study.

Ala/Thr60 variant of the Leydig insulin-like hormone is not associated with cryptorchidism in the Japanese population

BACKGROUND

Leydig insulin-like hormone (Insl3), a member of the insulin-like superfamily, is specifically expressed in Leydig cells of fetal and postnatal murine testis. Recently, the absence of the Insl3 gene has been reported to result in bilateral cryptorchidism in male mice and it has been suggested that mutations of the INSL3 gene may cause cryptorchidism in humans.

METHODS

We sequenced the INSL3 gene from five Japanese patients with sporadic bilateral cryptorchidism. Patients' genome DNA was prepared from blood leukocytes. Two exons of the INSL3 gene were amplified by polymerase chain reaction and were sequenced directly. A restriction fragment length polymorphism assay was performed on 70 control samples for analysis of polymorphism.

RESULTS

Three of five cases had a heterozygous single-base change, a G to A transition at position 178 of the INSL3 gene, which predicts an alanine (GCC) to threonine (ACC) change at codon 60 (designated A60T). However, the A60T mutation was also found in the normal Japanese population at an allele frequency of 26%, which suggests that this mutation is a common polymorphism and is not associated with the occurrence of cryptorchidism.

CONCLUSIONS

No mutation has been found in the INSL3 gene from Japanese patients with idiopathic cryptorchidism. We did find the A60T polymorphism, which was not associated with the occurrence of cryptorchidism.

Hormones in male sexual development

Classical embryology has provided a clear view of the timing and hormonal cues that govern sexual differentiation. Molecular biology has added important details to this picture. The cloning of SRY, MIS, and INSL3 provide insight into the molecular signals that provide important cues at the cellular level. Continued understanding of these pathways may provide the necessary information to one day reverse defects of sexual differentiation.

A molecular basis for estrogen-induced cryptorchidism

Male sexual differentiation relies upon testicular secretion of the hormones testosterone, Mullerian inhibiting substance, and insulin-3 (Insl3). Insl3 is responsible for testicular descent through virilization and outgrowth of the embryonic gubernaculum. In mouse, prenatal exposure to 17beta-estradiol and the nonsteroidal synthetic estrogen diethylstilbestrol (DES) disturbs the endocrine balance, causing demasculinizing and feminizing effects in the male embryo, including impaired testicular descent (cryptorchidism). In the current study, we show that maternal exposure to estrogens, including 17alpha- and beta-estradiol, as well as DES, specifically down regulates Insl3 expression in embryonic Leydig cells, thereby providing a mechanism for cryptorchidism. These experiments may have implications for the widespread use of estrogenic substances in agriculture and the environment.

Idiopathic hirsutism

Hirsutism, the presence of terminal (coarse) hairs in females in a male-like pattern, affects between 5% and 10% of women. Of the sex steroids, androgens are the most important in determining the type and distribution of hairs over the human body. Under the influence of androgens hair follicles that are producing vellus-type hairs can be stimulated to begin producing terminal hairs (i.e., terminalized). The activity of local 5alpha-reductase (5alpha-RA) determines to a great extent the production of dihydrotestosterone (DHT), and consequently the effect of androgens on hair follicles. While there are two distinct 5alpha-RA isoenzymes, type 1 and type 2, the activity of these in the facial or abdominal skin of hirsute women remains to be determined. Although the definition of idiopathic hirsutism (IH) has been an evolving process, the diagnosis of IH should be applied only to hirsute patients with normal ovulatory function and circulating androgen levels. A history of regular menses is not sufficient to exclude ovulatory dysfunction, since up to 40% of eumenorrheic hirsute women are anovulatory. The diagnosis of IH, when strictly defined, will include less than 20% of all hirsute women. The pathophysiology of IH is presumed to be a primary increase in skin 5alpha-RA activity, probably of both isoenzyme types, and possibly an alteration in androgen receptor function. Therapeutically, these patients respond to antiandrogen or 5alpha-RA inhibitor therapy. Pharmacological suppression of ovarian or adrenal androgen secretion may be of additional, albeit limited, benefit. New therapeutic strategies such as laser epilation or the use of new biological response modifiers may play an important role in offering a more effective means of treatment to remove unwanted hair. Further investigations into the genetic, molecular, and metabolic aspects of this disorder, including only well defined patients, are needed.

Laparoscopic gonadectomy in a patient with testicular feminization syndrome

A laparoscopic technique is reported as an operative approach for gonadectomy in a case of testicular feminization syndrome. A 17-year-old phenotypic female presented with primary amenorrhea and was evaluated through a diagnostic protocol that included clinical, cytogenetic, and hormonal examinations. The findings supported the diagnosis of testicular feminization syndrome. The left gonad was found at the internal opening of the inguinal canal and removed laparoscopically. No gonad was found at the contralateral side. No complications occurred during the operation and the patient left the hospital the same day. A long-term hormonal replacement treatment was initiated postoperatively.

Expression of mRNA for androgen receptor, 5alpha-reductase and 17beta-hydroxysteroid dehydrogenase in human dermal papilla cells

In order to determine whether adrenal and gonadal weak androgens are utilized to form active androgens in human hair, we studied the expression of mRNA for androgen receptor (AR), 5alpha-reductase and 17beta-hydroxysteroid dehydrogenase (17beta-HSD) in cultured dermal papilla cells (DPCs) from various body sites. AR mRNA was expressed in beard (Be) and axillary hair (Ax) DPCs from both sexes, but only at a low level in DPCs from occipital scalp hair (OS). Type I 5alpha-reductase mRNA was expressed by all DPCs. Type II 5alpha-reductase mRNA was identified in beard DPCs, but was absent from OS and Ax DPCs. Type II 17beta-HSD mRNA was strongly expressed in outer root sheath cells (ORSCs), while DPCs except for male Ax expressed no type II 17beta-HSD mRNA. In contrast, type III 17beta-HSD mRNA was strongly expressed in Be DPCs and Ax DPCs from both sexes; ORSCs showed a low level of expression. Expression of type III 17beta-HSD mRNA was not regulated by androgen in DPCs. These results suggest that the sensitivity of hairs to androgen is partially controlled by the site-specific expression of AR, 5alpha-reductase and 17beta-HSD in DPCs.

Androgen insensitivity syndrome: an immunohistochemical, ultrastructural, and morphometric study

OBJECTIVE

To evaluate the morphometric, immunohistochemical, and ultrastructural lesions of the testes in prepubertal and adult patients with androgen insensitivity syndrome.

METHODS

We examined the testicular biopsy using immunohistochemistry for vimentin, smooth muscle actin, and collagen IV antigens. Quantification of seminiferous tubules and testicular interstitium was performed in prepubertal and adult patients with androgen insensitivity syndrome and results were compared with normal testes from both infants and adults.

RESULTS

The adult testes presented nodular and diffuse lesions that consisted of Sertoli-cell-only seminiferous tubules. Two types of Sertoli cells could be distinguished, namely, immature vimentin-positive Sertoli cells and nearly mature Sertoli cells. In the nodules, the lamina propria was thin and contained a scant number of actin-positive peritubular cells. Leydig cells were hyperplastic. The prepubertal patients showed only diffuse lesions characterized by Sertoli cell hyperplasia, decreased germ cell numbers, and a discontinuous immunoreaction to collagen IV.

CONCLUSIONS

The testicular lesions in androgen insensitivity syndrome are probably caused by primary alterations that begin during gestation. These lesions become progressively more pronounced at puberty, when the nodular lesion pattern (adenomas) is completely developed.

Genetic abnormalities and male infertility. A comprehensive review

The development of assisted reproductive technologies, such as intracytoplasmic sperm injection (ICSI) substantially improved the outlook for patients with severe male fertility problems. However this implies that for the first time genetic defects associated with male in- or subfertility might be transmitted to offspring and result in genetic disease [de Kretser DM, The potential of intracytoplasmic sperm injection (ICSI) to transmit genetic defects causing male infertility. Reprod. Fertil. Dev. 1995;7:137-142]. The knowledge of male specific fertility genes on the Y chromosome increased enormously in the last decade. The SRY gene plays a critical role in gonadal differentiation. DAZ, SPGY and related genes on the Y chromosome are very important for spermatogenesis. Interstitial Y-chromosomal microdeletions encompassing the AZFa, b or c region have become an additional class of genetic abnormalities causing male infertility. A review is given of the different genetic aspects of male infertility.

Ambiguous genitalia: etiology, treatment, and nursing implications

The infant presenting with ambiguous genitalia is a challenge to both the medical and nursing staff. The birth of any infant with ambiguous genitalia is considered a physical and psychologic emergency requiring prompt recognition and treatment for a positive outcome. A review of the etiology, presentation, diagnosis, and treatment of ambiguous genitalia is presented. The important aspects of family care also are discussed.

The genitofemoral nerve may link testicular inguinoscrotal descent with congenital inguinal hernia

The genitofemoral nerve (GFN) hypothesis for inguinoscrotal testicular descent proposes that calcitonin gene-related peptide (CGRP), released from the genitofemoral nerve, controls the migration of the gubernaculum from the inguinal region to the scrotum between 26 and 40 weeks of gestation. The processus vaginalis provides a channel through which the testis descends from the abdomen to the scrotum. Following descent of the testis the processus vaginalis undergoes luminal obliteration and disappearance between the internal inguinal ring and the upper pole of the testis. The mechanism underlying closure of the processus is unknown and failure for it to occur normally results in congenital inguinal hernia, scrotal hydrocele and possibly even an 'ascending' testis. Recent work in our laboratory suggests that CGRP, released from the genitofemoral nerve, may cause fusion and disappearance of the processus vaginalis. We propose that abnormalities in the GFN link a spectrum of disorders encompassing congenital undescended testis, inguinal hernia, scrotal hydrocele and ascending testis.

A clinician looks at androgen resistance

Androgen resistance in genetic males occurs when gonadotropins and testosterone are normal, but the physiological androgen response in androgen target organs is absent or decreased. In androgen-dependent target tissues two main defects may be found: 1) defective testosterone metabolism (5 alpha-reductase type 2 deficiency) and 2) anomalies in androgen receptors (androgen insensitivity syndrome (AIS)). The clinical manifestations of these defects vary from subjects with female external genitalia to subjects with mild forms of impaired masculinization. In particular, in the complete form of AIS (CAIS) the phenotype is feminine, and in the partial form (PAIS) the external genitalia are ambiguous with an extremely variable phenotype. The diagnosis requires clinical, hormonal, genetic, and molecular investigation for appropriate gender assignation and treatment. In AIS, cloning of androgen receptor cDNA using the polymerase chain reaction, denaturing gradient gel electrophoresis, and nucleotide sequencing have enabled a variety of molecular defects in the androgen receptor to be identified. The complexity of phenotypic presentation of AIS probably reflects the heterogeneity of androgen receptor gene mutations, but to date a relationship between genotype/phenotype has been difficult to establish, with the same point mutation reported to be associated with different phenotypic expressions. Other factors must therefore also contribute to the clinical presentation of AIS, although none have yet been identified. Establishing the functional consequences of androgen receptor mutations in vitro systems and correlating them with clinical presentation may ultimately provide an explanation for the variable clinical presentation of AIS and perhaps enable prediction of the response to androgen therapy in infants with PAIS.

A frame-shift mutation of the androgen receptor gene in a patient with receptor-negative complete testicular feminization: comparison with a single base substitution in a receptor-reduced incomplete form

Mutations of the androgen receptor that impair the action of androgens result in abnormal male sexual development. We studied the structure of the androgen receptor gene in a patient with the receptor-negative form of complete testicular feminization and another patient with a receptor-reduced form of incomplete testicular feminization. In the subject with complete testicular feminization, the deletion of a single nucleotide occurred at nucleotide number 1893 at exon 2. The subsequent frame-shift mutation changes the sense of codon 622 from cysteine to a translational stop signal. Codon 622 is exon 3, so the mutation predicts the synthesis of a truncated receptor that lacks the entire androgen-binding domain. Analysis of a subject with incomplete testicular feminization revealed a single substitution (CGT --> CAT) at nucleotide 2675 of exon 7, resulting in the conversion of an arginine at amino acid 840 to a histidine. This mutation in the androgen-binding domain may impair, but not remove, the androgen binding to its receptor. These results suggest that the phenotypes in our subjects are due to the mutations, and that single amino acid substitution and premature termination codon can cause variably severe functional abnormalities.

La sindrome di Reifenstein: Evoluzione, trattamento e decorso di un caso clinico particolare: Reifenstein's syndrome: Development, treatment and course of a special clinical case

The Authors describe the clinical case of a patient with Reifenstein's syndrome who presented other diseases (breast cancer, Berger's syndrome, renal insufficiency). For the treatment they utilised a scrotal tubular flap prepared in another hospital 15 years before.

Laparoscopic orchiectomy in a patient with complete androgen insensitivity

Many procedures that were once approached exclusively through large abdominal incisions are now accomplished using operative laparoscopic techniques with shorter, less expensive hospital stays and significantly reduced convalescence. This report describes a laparoscopic orchiectomy in a patient with complete androgen insensitivity and discusses the indications for gonadectomy in phenotypic females with an XY karyotype.

The androgen resistance syndromes: clinical and biochemical aspects

The genetic, biochemical, clinical and endocrinological features of syndromes associated with androgen resistance (insensitivity) are described. The clinical appearance of these syndromes covers the whole spectrum of phenotypically female patients to normal appearing men with infertility. In these disorders testosterone formation and regression of the Müllerian duct derivates are normal, but male development is absent or impaired as a result of total or partial resistance to androgen action in the target cell. Based on studies with cultured genital skin fibroblasts three defects on the level of the androgen target organ can be differentiated in these syndromes: 1. Defective testosterone metabolism, 2. anomalies of the androgen receptor and 3. a postreceptor defect.

Ambiguous genitalia: diagnosis, evaluation, and treatment

The pediatric radiologist plays a significant role in the evaluation and the treatment of infants with ambiguous genitalia. On the first day of life, an investigation should be initiated that includes studies, in particular a sonogram, to demonstrate the presence or absence of a uterus, and a genitogram to define the presence of a vagina. Once gender assignment has been made, information regarding the size of the vagina and its position in regard to the urogenital sinus becomes essential to the pediatric urologist when planning a course for reconstruction. Herein we break down intersex states into four major categories: female pseudohermaphroditism, male pseudohermaphroditism without müllerian structures, and male hermaphroditism with müllerian structures and true hermaphroditism. The role of the radiologist in each of these states is discussed.