Complete testicular feminization with normal gonadotropin and high androgen secretion: a case report

A patient with a complete form of testicular feminization with normal gonadotropin and high testosterone levels is described here. These findings are in contrast to previous reports that have shown high circulating luteinizing hormone (LH) levels in adults affected by this syndrome. Testicular histology revealed tubular atrophy and hyperplastic Leydig cells which are in accordance with the high testosterone levels and the difficulty in visualization of the testes. Because of the increased risk of gonadal malignancy, a laparoscopic gonadectomy was performed.

[Androgen insensitivity]

Manifestations of resistance to androgens vary within a wide range from an almost normal female phenotype to men whose only complaint is infertility. Insensitivity is caused by mutation of the gene for androgenic receptors, located on the X chromosome. Androgenic insensitivity is associated of all known hormonal resistances with the most varied mutational changes-some hundred of the latter were described. Mutations do not correlate with the clinical picture. Insensitivity to androgens is not necessarily associated with the inability of androgens to bind with the appropriate receptor, because mutations can affect any of the three receptor domains, i.e. not only the domain binding the ligand but also the domain by which the steroid receptor complex is linked to the DNA of the regulated gene or N-terminal, the so-called transactivation domain, responsible for the transfer of the hormone-borne signal to the initiation site of the controlled gene. Androgenic insensitivity can be associated with some tumourous diseases depending on steroid sex hormones such as prostate or breast cancer and also-as reported for the first time in this paper-e.g. with lymphogranuloma. Some neurodegerative diseases are also associated with a certain degree of androgenic insensitivity. For detection of androgenic resistance in addition to molecular genetic analysis dynamic tests were recommended which involve the follow-up of androgen-dependent indicators after androgen administration. These indicators are e.g. nitrogen retention or the SHBG level. The original modification of the SHBG test for androgen insensitivity is described.

A substance secreted by rat Sertoli cells induces feminization of embryonic chick testes in vitro

Male and female gonads from 7- to 9-day-old chick embryos were cultured for 6 days in Sertoli cell-conditioned medium or in serum-free medium to investigate the possible effect of substances secreted by rat Sertoli cells on chick gonad development. Histological analysis showed that whereas all female gonads proceed through normal ovarian development in both culture media, most of male gonads showed clear feminization only when cultured in Sertoli cell-conditioned medium; male gonads cultured in serum-free medium developed as normal testes. Because the only substance detected in our conditioned medium with the potential to cause these effects was sex-specific antigen (Sxs), our results provide further evidence that Sxs antigen may play a role in sexual differentiation in birds, and probably in mammals.

[Molecular and clinical aspects of androgen insensitivity syndrome]

The syndrome of androgen insensitivity is a genetically determined illness occurring in subjects with a karyotype 46XY and female or male phenotype. The insensitivity to androgens is caused by the mutations in the androgen receptor gene, comprising 8 exons and localized on chromosome X near the centromere, between Xq13 and Xp11. The androgen receptor belongs to a family of steroid hormone receptors which possess common structural features since it comprises six functional regions (domains) of which the DNA binding domain has a characteristic zinc fingers motif. The lack, deficiency or the disturbance in the function of the receptor, results in a set of clinical symptoms which allow to distinguish four distinct clinical forms of the illness: complete and incomplete testicular feminization syndromes, Reifenstein syndrome and the syndrome of male infertility. In this review data from literature were presented and discussed, regarding the structure and action of the androgen receptor in target cells and the significance of the investigations on the structure-function relationship of this receptor in understanding the pathogenesis of the syndrome of androgen insensitivity was emphasized.

The XY female in sport: the controversy continues

The summer and winter Olympic Games have been accompanied by much press coverage of the controversy and confusion over sex tests for sportswomen. Much of this has centred on the eligibility of subjects with androgen insensitivity to compete in women's events. The purpose of this paper is to review the process of sex differentiation and its abnormalities, highlighting those conditions in which biologically active testosterone is secreted which might confer an advantage in women's sporting events.

The relationship among calcitonin gene-related peptide, androgens and gubernacular development in 3 animal models of cryptorchidism

The relationship among calcitonin gene-related peptide (CGRP), a neurotransmitter in the genitofemoral nerve, androgens and gubernacular development was studied using rats treated prenatally with the antiandrogen flutamide and the mutant cryptorchid TS rat. We compared these 2 groups with the testicular feminization mouse with androgen insensitivity. Gubernacula from male TS rats and flutamide-treated rats were maintained in organ culture and examined for contractile response to CGRP. Controls were gubernacula from normal rats and vehicle-treated rats, respectively. TS rat gubernacula have an inhibited contractile response to CGRP, whereas flutamide-treated rat gubernacula have an exaggerated response. A similar exaggerated response to CGRP has previously been demonstrated in testicular feminization mouse gubernacula. These results revealed abnormalities in gubernacular contractile response to CGRP in these cryptorchid animal models, implying that CGRP and gubernacular contractility may have key roles in mediating normal inguinoscrotal testicular descent.

Testicular descent. III. The neonatal mouse gubernaculum shows rhythmic contraction in organ culture in response to calcitonin gene-related peptide

The effects of calcitonin gene-related peptide (CGRP) and CGRP 8-37 on the neonatal mouse gubernaculum were examined in organ culture, with the aim of seeing whether CGRP has a direct effect on the gubernaculum. A total of 440 gubernacula were studied. Two hundred and fifty gubernacula were treated with CGRP in concentrations ranging from 0-714 nM/liter. With increasing doses of CGRP the percentage of gubernacula showing vigorous contraction increased from 18-50%. The total percentage of gubernacula showing any form of contraction increased from 76-96%. One hundred and fifty gubernacula were exposed to the CGRP analog CGRP 8-37. Increasing concentrations of CGRP 8-37 from 179-714 nM/liter decreased the rate of vigorous contraction from 18-4%. The percentage of gubernacula showing any degree of contraction decreased from 76-14%. Forty gubernacula removed from testicular feminization (TFM) mice were exposed to varying concentrations of CGRP. In the absence of exogenous CGRP no contractility was observed. By contrast, in the presence of CGRP the gubernacula showed vigorous contractility increasing from 38-90%. The total number of gubernacula showing contraction increased from 75-100%. These studies demonstrated that the neonatal mouse gubernaculum exhibits a high level of endogenous contractility, which can be enhanced in a dose responsive manner with exogenous CGRP. CGRP 8-37 caused a dose responsive inhibition. The androgen-insensitive gubernaculum from the TFM mouse showed no endogenous contraction, but on exposure to CGRP showed an enhanced rate of contractility. These results are consistent with the hypothesis that androgens may control gubernacular migration indirectly via release of CGRP from the genitofemoral nerve in the inguinoscrotal region. The failure of gubernacular motility in vitro and migration in vivo in the TFM mouse may indicate lack of CGRP release from the genitofemoral nerve.

[Hermaphroditism and male pseudohermaphroditism]

In the human embryo, sex is all in the genes. Later on, the male and female sexual characters, which are products of the expression of all individual genomes, differentiate men from women. In this paper, the embryogenesis and morphology of true hermaphroditism and male pseudo-hermaphroditism are studied. These are intersexual states determined by errors in genital programme transmission. A relationship is established between the biochemical identification of substances secreted by the testis and the evolution of sexual characters. The genesis of sexual abnormalities according to the stage when the testicular deficit appears is envisaged. The clinical, anatomical, histological and biochemical aspects of these intersexual states are described.

Testicular feminization: the androgen insensitivity syndrome

Testicular feminization (TF) is a syndrome due to androgen insensitivity. It occurs in a complete (CTF) and an incomplete (ITF) form. We have treated 21 patients with TF over the last 24 years. Eight patients presented because of ambiguous genitalia, seven presented as "females" with inguinal hernia and testes were found at surgery, five were diagnosed by karyotyping performed for a family history of TF, and one presented with an incarcerated hernia and primary amenorrhea. Two patients had prior surgery for inguinal hernia but the diagnosis was not recognized. All patients had a 46,XY karyotype. Patients with CTF were phenotypically female while those with ITF had a variable appearance of the external genitalia depending on the degree of androgen insensitivity. Seventeen patients underwent gonadectomy and one patient planned for delayed gonadectomy was lost to follow-up. Seventeen patients had been raised as females since birth. One patient with ambiguous genitalia, who was initially raised as a male, was reassigned female gender at 1 year of age when the diagnosis of ITF was made. Three patients were raised as males even after the diagnosis of ITF was made. Patients raised as males underwent multiple genital reconstructive procedures with poor results. In view of the poor anatomic and functional results of genital reconstructive surgery and the consequent psychological problems, patients with TF should be raised as female. Careful evaluation of infants with ambiguous genitalia and documentation of absent fallopian tubes in "females" presenting with inguinal hernia will lead to early diagnosis of TF, correct sex assignment, and early gonadectomy.

[Androgen resistance related to receptor disorders]

It is the review of literature data on various phenotypic anomalies consequent to the absent or reduced ability of the target tissues to response to androgens (A) due to defects in receptor A structure and function. Clinical forms of resistance to A, quantitative and qualitative abnormalities in hormone-receptor interaction detectable in relevant patients are described as well as markers of target tissue sensitivity to A action suggested for use in prognosticating the response to A treatment.

Effect of androgen insensitivity on diabetogenesis in db/db male mice with testicular feminization (Tfm)

In C3H mice, a major component of susceptibility to the diabetogenic action of an obesity mutation (diabetes, db) is male gender associated. We tested whether increased male susceptibility was an androgen receptor mediated process. C3H.SW/Lt-derived db/db males were rendered androgen-receptor function-deficient by introducing the testicular feminization (Tfm) mutation of the X-linked androgen receptor gene. The db/db Tfm/Y males (phenotypically female in appearance) developed severe diabetes indistinguishable from that observed in standard db/db X + Y males. Castration of standard C3H.SW/Lt-db/db males (producing mutants with normal androgen receptors but reduced serum testosterone) also failed to block the gender-enhanced susceptibility. In contrast, female db/db littermates exhibited a milder hyperglycemia, and were more resistant to pancreatic beta cell necrosis and islet atrophy than any of the groups of db/db males. Although these data indicated that male-enhanced sensitivity to diabetogenic stress was independent of circulating androgens, the possibility that the gender dimorphism is predicated upon tissue ratios of active estrogens to androgens in glucose-producing tissues such as liver is discussed.

[Ingestion of diethylstilbestrol during pregnancy. Its responsibility in the testicular feminization syndrome]

We report the cases of two women who had testicular feminization with remnants of Müllerian ducts and whose mothers had received diethylstilbestrol (DES) during the first trimester of pregnancy. At laparotomy, masses were removed which had the microscopic appearances of testes and Fallopian tubes, and were confirmed as such at histology. There were three possible explanations for these genetic abnormalities: deficient antimüllerian hormone (AMH) secretion (or lack of sensitivity of Müllerian ducts to AMH); early testicular descent with regression of Müllerian ducts beyond the efficacy margin of AMH; exposure to DES in utero during the first trimester of pregnancy. In these two women, the most likely explanation seems to be the last one.

[Biochemical and endocrine heterogeneity in the complete form of testicular feminization syndrome]

A familial variant of male pseudohermaphroditism different from the classical form of the complete testicular feminization syndrome was studied. The three affected 46, XY sibling (16,18 and 20 years old) exhibited female phenotype identical to that of a 17 years old patient with the classical form, included as a control. The major endocrine and biochemical differences observed in this family, as compared with the classical form, includes: a. Markedly elevated serum levels of LH and FSH; b. Non-elevated serum testosterone levels; c. Poor testicular hCG responsiveness; d. Abnormally elevated baseline and hCG-stimulated androstenedione: testosterone ratio; e. Slight pituitary responsiveness to androgens; f. presence of residual androgen uptake by cultured fibroblasts derived from genital skin. These differences were more evident in the two older patients. All subjects presented a lack of nitrogen retention following testosterone administration. These results were interpreted as demonstrating a testicular impairment of testosterone biosynthesis in the older subjects of this family, which resulted in an unusual gonadotropin profile. The altered androstenedione: testosterone ratio suggests a secondary partially decreased activity of testicular 17-hidroxysteroid dehydrogenase, as demonstrated in TFM mice and rats. The overall data indicate an age-dependent variability in the expression of androgen insensitivity in this family, thus demonstrating the wide biochemical heterogeneity of the androgen resistant syndromes.

Gonadotropin-releasing hormone-stimulated luteinizing hormone secretion by perifused pituitary cells from normal, gonadectomized, and testicular feminized rats

To elucidate further the manner in which gonadal steroids influence the secretion of LH, we examined the effects of gonadectomy and the absence of functional androgen receptors on GnRH-induced LH release from dispersed rat anterior pituitary cells. Intact and gonadectomized (GNX) normal rats and androgen-resistant, testicular feminized (Tfm) animals from the King x Holtzman strain (a mutant strain that possesses defective androgen receptors) were used. Dispersed pituitary cells were perifused with Medium 199 during a 4-h equilibration period and then subjected to eight 2.5-min pulses of GnRH introduced at 30-min intervals at concentrations ranging from 0.03-100 nM. Basal LH secretion by cells from intact male and female rats was indistinguishable (P = 0.79) and was substantially lower (P less than 0.0001) than that by cells from GNX male and female animals. Basal LH secretion by cells from Tfm rats was significantly higher (P less than 0.01) than that by cells from intact animals, but lower (P less than 0.005) than that by cells from GNX animals. In response to GnRH, perifused pituitary cells from animals representing all experimental groups demonstrated concentration-dependent LH release. Pituitary cells from intact female rats showed an overall greater (P less than 0.05) response to GnRH than cells from intact male rats. Pituitary cells from Tfm rats demonstrated a greater GnRH-stimulated LH mean response than cells from intact male (P less than 0.0001) or intact female (P less than 0.0001) rats. Gonadectomy of male rats resulted in an overall GnRH-stimulated LH release similar to that exhibited by cells from gonadectomized female rats (P = 0.61). Cells from Tfm animals released more LH in response to GnRH than those from gonadectomized male and female rats (P less than 0.001). These data demonstrate that the release of LH in response to GnRH by pituitary cells from intact male rats (i.e. in the presence of androgen and functional androgen receptors) is less than that seen by cells from intact females rats. Since circulating levels of testosterone and estradiol are known to be elevated in the testicular feminized rat, the heightened GnRH-stimulated LH release by cells from such animals may reflect either the long term lack of androgenic influence and/or the combined effects of androgen resistance and elevated levels of circulating estrogens.

[Endocrinological analysis of climacteric symptoms and gonadal dysfunction by CRF test]

Endocrinological studies on stressed climacteric women and some cases of gonadal dysfunction were carried out by analysing blood levels of adrenocorticotropic hormone (ACTH), beta-lipotropin (beta-LPH) and beta-endorphin (beta-EP) after the administration of synthetic corticotropin releasing factor (CRF, CRF test). Our results can be summarized as follows: 1. The responsiveness to CRF in perimenopausal and ovariectomized women rose and it corresponded with those of post gonadectomy in testicular feminization. 2. Responsiveness to CRF was decreased as estrogen levels decreased with the patient's age, and a similar tendency was observed in gonadal dysfunction. 3. Climacteric women with non-specific complaints have a higher responsiveness to CRF than that of postmenopausal women without complaints. Subjects with a high K.I score and with severe hot flush showed higher responsiveness to CRF than other subjects. These data suggest that CRF and its related hormones may be correlative with stress and hot flushes in climacteric periods and endogenous CRF may play an important psychosomatic role by regulating the hypothalamo-pituitary-adrenal function where there is decreased estrogen.

Somatostatin inhibition of growth hormone secretion by somatotropes from male, female, and androgen receptor-deficient rats: evidence for differing sensitivities

To investigate the role of somatostatin (SRIF) in regulating sexually dimorphic GH secretion, we used a reverse hemolytic plaque assay and acutely dispersed somatotropes from age-matched normal male, normal female, and androgen receptor-deficient, testicular feminized (Tfm) rats. Hemolytic plaques were developed after a 90-min incubation in the presence of GH antiserum, 10 nM GH-releasing hormone (GHRH), and the following concentrations of SRIF: 0, 0.001, 0.003, 0.01, 0.03, 0.1, 0.3, 1, 3, 10, 30, and 100 nM. Additional studies were performed with 0 or 100 nM SRIF in the absence of GHRH. The absolute number of somatotropes (x10(6); mean +/- SEM) recovered from the pituitaries of Tfm rats (1.73 +/- 0.18) was significantly greater than that from the males (1.11 +/- 0.13; P = 0.01); the number from female rats (1.30 +/- 0.15) was not different from that of either male or Tfm animals. GHRH-stimulated GH secretion, as estimated by the mean GH plaque area (micron2 x 10(4); mean +/- SEM) in the absence of SRIF, was greater for somatotropes from male rats (3.36 +/- 0.41) than that for either Tfm (2.27 +/- 0.32; P = 0.02) or female (1.78 +/- 0.24; P = 0.001) rats; values for the latter two groups did not differ. However, mean GH plaque areas for each group during maximal SRIF inhibition in either the presence or absence of GHRH were indistinguishable from each other and from mean plaque areas obtained under basal conditions. As demonstrated by a lesser EC50 value (0.04 +/- 0.02 nM; mean +/- SEM), somatotropes from female rats were more sensitive to the inhibitory effect of SRIF than were those from either male (EC50 = 1.82 +/- 0.45; P = 0.0001) or Tfm (EC50 = 0.74 +/- 0.22, P = 0.0001) rats; values for the latter two groups were indistinguishable. These observed differences suggest that gender and/or the gonadal hormone environment may be important determinants of the inhibitory effects of SRIF on GH secretion by the somatotrope. While these gender-associated differences may represent effects of the gonadal hormones directly on the somatotrope, they could reflect modulation of the secretion of hypothalamic SRIF and/or GHRH by the prevailing gonadal hormone environment. Such gender-related differences may contribute to the overall sex-dependent patterns of GH secretion in the intact animal.

Testicular responsiveness to a single hCG dose in patients with testicular feminization

The suggestion that androgens may regulate testosterone (T) production in rat Leydig cells by a receptor-mediated feed-back mechanism, led us to investigate whether in vivo the absence of testicular androgen receptors, as it occurs in testicular feminization (TF), may modify the characteristic testicular response observed in men and prepubertal children after a single dose of hCG. Subjects consist of: 1) six normal men, 2) two adult patients with the complete form of androgen insensitivity syndrome (TF), 3) 12 normal prepubertal boys, 4) one prepubertal boy with the same form of TF. Each subject received i.m. a single dose of hCG 3500 IU/m2 b.s. and blood samples were collected basally and 2, 4, 24, 48, 72 and 96 hours after the hormonal stimulus. Serum levels of T, 17 alpha hydroxyprogesterone (17OHP) and 17 beta estradiol (E2) were measured at each collection time. In normal men a significant increase in T (M +/- SE) was observed at 4 h (758.6 +/- 135 ng/dl, P less than 0.05) and a more significant increase at 48 h (1082 +/- 60.3 ng/dl, P less than 0.001). E2 and 17OHP peaked significantly at 24 h (81.5 +/- 9.6 pg/ml and 460.7 +/- 90.9 ng/dl respectively). This response pattern is characteristic of the testicular desensitization which occurs in normal man after a single hCG dose. The same response pattern has been observed in the two TF adult patients suggesting that human testicular desensitization in vivo does not depend on androgen receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of the Tfm mutation on handedness in mice

The hyposthesis has been proposed that testosterone is involved in the determination of handedness in man: a high sensitivity to testosterone being associated with left handedness. Handedness in mice is tested according to Collins' paradigm: most mice present either a right or a left paw preference but others are ambilateral. The hypothesis that there is an association between a low neonatal imprinting by testosterone and a strong handedness (right or left) is tested here using Tfm male mice which are testosterone insensitive. Our results confirmed the hypothesis, since Tfm males were as well lateralized as their female siblings and significantly more strongly lateralized than their male siblings not carrying the mutation.

Growth hormone secretion by individual somatotropes of the testicular feminized rat

To investigate the cellular mechanisms underlying the unique GH secretory apparatus of the androgen-resistant testicular feminized (Tfm) rat we employed a reverse hemolytic plaque assay to assess GH secretion by individual cells from normal male, normal female, and Tfm rats. Acutely dispersed pituitary cells were incubated for 90 min with GH anti-serum in the presence of medium alone, 0.01, 0.1, 1, 10, or 100 nM GHRH, or 3 microM forskolin after which hemolytic plaques were developed over an additional 30 min. Body weights of the Tfm rats [318 +/- 7 g (mean +/- SEM)] were intermediate between intact males (372 +/- 18 g) and females (218 +/- 7 g). The total number of cells recovered from dispersion of Tfm rat pituitaries [3.20 +/- 0.42 X 10(6) (mean +/- SEM)] was greater than that from males (1.43 +/- 0.12 X 10(6); P = 0.001), but not distinguishable from that from females (2.31 +/- 0.30 X 10(6); P = 0.06). However, the absolute population of recovered somatotropes from the Tfm animals (1.24 +/- 0.22 X 10(6) exceeded both male (0.56 +/- 0.10 X 10(6); P = 0.002) and female (0.80 +/- 0.14 X 10(6); P = 0.046) values. Mean basal and maximal GH plaque areas were greater for cells from male rats than for those from either female or Tfm rats (P less than 0.05) regardless of whether GHRH or forskolin was used as the secretagogue. Plaque areas from female and Tfm cells were indistinguishable under all study conditions. These data suggest that a deficiency of androgen receptors prevents establishment of the greater GH secretory capacity of individual somatotropes characteristic of the adult male rat. This androgen receptor-dependent modulation of GH secretory capacity appears to occur at a step distal to the GHRH receptor. The data also suggest that an increase in the absolute population of somatotropes is an additional consequence of androgen receptor deficiency. This combination of individual somatotropes, each possessing a GH secretory capacity similar to that of cells from normal females, but present in greater absolute numbers, may explain the intermediate values found during previous studies of the Tfm rat GH axis which were based on assessment of large mixed populations of pituitary cells.

Patterns of lateralization and performance levels for verbal and spatial tasks in congenital androgen deficiency

The effects of congenital deficiency of gonadal hormones on verbal and spatial performance and on the establishment of hemispheric asymmetries were investigated in a group of patients with idiopathic hypogonadotropic hypogonadism. The patients showed a left hemispheric advantage for verbal material and were mildly impaired, mainly on tasks involving a short-term memory load, in comparison with a matched control group. These results do not indicate a specific role of gonadal hormones on the establishment of hemispheric asymmetries. Lack of exposure during brain development results in a decrease in memory functions which is not specific for verbal or spatial material.

Testicular feminization syndrome

The testicular feminization syndrome occurs as a result of faculty genetic programming. This inherited condition causes an XY male embryo to develop into a person who has an XY karyotype and a female appearance. The described individual appears "female" at birth and is naturally socialized as a female. A testicular feminized "female" may seek routine health care at a primary health care center. Upon examination, certain identifying physical characteristics may be observed. Primary amenorrhea and infertility are inherent characteristics of the condition. This article describes the testicular feminization syndrome, its etiology/pathophysiology and both subjective and objective findings. Nursing interventions such as data collection, family tree charts, Barr body screening, education, referral and counseling are suggested. Nurse practitioners have the opportunity to identify suspected cases and direct those individuals toward appropriate treatment and discreet counseling. Counseling generally will emphasize that the TFS individual may consider herself female.