Hormone replacement treatment choices in complete androgen insensitivity syndrome: an audit of an adult clinic

Metabolic effects of estradiol versus testosterone in complete androgen insensitivity syndrome

PURPOSE

To study differences in metabolic outcomes between testosterone and estradiol replacement in probands with complete androgen insensitivity syndrome (CAIS).

METHODS

In this multicentre, double-blind, randomized crossover trial, 26 women with CAIS were included of whom 17 completed the study. After a two-months run in phase with estradiol, probands either received transdermal estradiol followed by crossover to transdermal testosterone or vice versa. After six months, differences in lipids, fasting glucose, insulin, hematocrit, liver parameters and blood pressure between the treatment phases were investigated.

RESULTS

Linear mixed models adjusted for period and sequence did not reveal major group differences according to treatment for the investigated outcomes. In each treatment group, there were however significant uniform changes in BMI and cholesterol. BMI increased significantly, following six months of estradiol ( + 2.7%; p = 0.036) as well as testosterone treatment ( + 2.8%; p = 0.036). There was also a significant increase in total ( + 10.4%; p = 0.001) and LDL-cholesterol ( + 29.2%; p = 0.049) and a decrease in HDL-cholesterol (-15.8%; p < 0.001) following six months of estradiol as well as six months of testosterone treatment (total cholesterol: + 14.6%; p = 0.008; LDL-cholesterol: + 39.1%; p = 0.005, HDL-cholesterol: -15.8%; p = 0.004). Other parameters remained unchanged.

CONCLUSION

Transdermal estradiol as well as testosterone treatment in women with CAIS results in worsening in lipid profiles. Given the relatively small sample size, subtle group differences in other metabolic parameters may have remained undetected.

Participant- and Clinician-Reported Long-Term Outcomes After Surgery in Individuals with Complete Androgen Insensitivity Syndrome

STUDY OBJECTIVE

To evaluate the outcomes of genital surgery through participant's and observer's satisfaction with the anatomical and functional result.

DESIGN AND SETTING

Multicenter cross-sectional study in 14 clinics in 6 European countries in 2014-2015.

PARTICIPANTS

Seventy-one individuals with complete androgen insensitivity syndrome (≥16 years old).

INTERVENTIONS

Data from clinical report files, an optional gynecological examination, patient-reported outcomes on received surgical interventions, satisfaction with appearance and function after surgery, and effect of the surgical procedure on life.

MAIN OUTCOME MEASURES

Outcomes were calculated per different surgical treatments. Linear regression models were used for associations with vaginal satisfaction.

RESULTS

Sixty-three participants had received surgery: 62 gonadectomies, 12 vaginal surgeries with or without vaginal dilations, 9 vaginal dilations only, and 2 breast enlargements. More than half of the participants took part in the gynecological examination. Vaginal length was similar in those without (60 mm) and with (67 mm) vaginoplasty and/or vaginal dilations. Participant- and observer-reported appearance of the genitals were generally satisfactory to good. Sexual complaints (pain or bleeding during/after intercourse) were common. Vaginal satisfaction was strongly associated with satisfaction with sex life in general, whereas vaginal interventions and number of surgeries were not. Many participants reported a negative effect of gonadectomy on their life.

CONCLUSION

Despite good genital appearance, functional problems are commonly reported, across the different nonsurgical and surgical regimens. Patient-reported outcomes should be evaluated before and after surgical procedures. Because of the negative effect on life and the low risk of malignancy, gonadectomy should be deferred to adulthood with regular follow-up.

Androgen Insensitivity Syndrome: A rare genetic disorder

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Androgen Insensitivity Syndrome is a rare X-linked recessive genetic disorder caused by mutation in Androgen Receptor (AR) gene.

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Individuals with Complete Androgen Insensitivity Syndrome have 46XY karyotype and present as female appearance and bilateral undescended testis.

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17 year old patient, presented with swelling in bilateral inguinal region and primary amenorrhea.

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Karyotype was mapped as 46 XY, elevated serum testosterone level.

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Bilateral orchidectomy was performed and patient was advised hormonal substitution therapy and provided psychological counselling.

Background

Androgen Insensitivity Syndrome (AIS) is a rare X-linked recessive androgen receptor (AR) disorder with 46XY karyotype. Partial AIS affects 5–7 per 1,000,000 genetically male individuals whereas Complete AIS affects 2–5 per 100,000 genetically male individuals. CAIS CAIS is characterized by complete resistance to the action of androgens.

Presentation of case

17-year patient presented with swelling in bilateral inguinal region. Patient also complained of primary amenorrhea with serum FSH and LH levels being raised, serum testosterone level much above normal range. MRI Pelvis revealed agenesis of vagina, uterine body, both ovaries and cervix. Bilateral testes were noted in bilateral superficial inguinal ring. Bilateral orchidectomy was done and the patient was advised estrogen substitution therapy.

Discussion

CAIS is usually diagnosed at puberty, when the patient presents with primary amenorrhea. Karyotype has to be mapped in order to differentiate from other genetic disorders. Orchidectomy should be done to avoid risk of malignancy of undescended intra-abdominal testes (3.6 % at 25 years old, and 33 % at 50 years old, reported by various studies). Hormonal substitution therapy should be administered. Comprehensive psychiatric assessment and intervention go a long way in alleviating distress and enhancing quality of life.

Conclusion

Androgen Insensitivity Syndrome requires expert and sympathetic handling. Close collaboration between surgeon, gynaecologist and psychologist is essential for proper management of complete androgen insensitivity syndrome.