Hormone replacement in disorders of sex development: Current thinking

Effects of Androgen Treatment on Growth in Patients with 5-α-Reductase Type 2 Deficiency

BACKGROUND

Patients with 5-α-reductase type 2 deficiency (5αRD2) require androgen treatment for the growth of normal male external genitalia. Since limited research has been conducted on the effects of androgen treatment on height in individuals with 5αRD2, we investigated the effect of androgen treatment on bone age (BA) and the height status in children with 5αRD2.

METHODS

Of the 19 participants who were followed up for an average of 10.6 years, 12 received androgen treatment. BA and height standard deviation scores (SDS) were compared between the treatment and non-treatment groups, as well as between the dihydrotestosterone (DHT) and testosterone enanthate (TE) treatment groups.

RESULTS

Despite the above-average height of the 19 patients with 5αRD2, the height SDS relative to BA (htSDS-BA) was below average, particularly in the androgen treatment group. DHT treatment did not lead to an increase in BA or htSDS-BA, whereas TE treatment resulted in BA advancement and decreased htSDS-BA, especially in the prepubertal period.

CONCLUSIONS

DHT treatment is more favorable for height than TE treatment in patients with 5αRD2, particularly during the prepubertal period. Therefore, age and the type of androgen used should be carefully considered to minimize the risk of height reduction in these patient groups.

Defining the role of pre-operative hormonal therapy in hypospadias

In hypospadias surgery, pre-operative hormonal therapy (PHT) is primarily used to increase penile dimensions and the vascularity of tissues available for reconstruction, but its use is non-uniform in clinical practice, with no consensus on application or utility. This review aims to summarise: (i) the penile tissue response to hormone therapy, (ii) its impact on hypospadias surgery outcomes, and (iii) the endocrinological considerations and sequelae. PHT is more often indicated for complex cases such as proximal hypospadias, hypospadias with microphallus and hypospadias reoperations. While PHT has clear effects on penile morphometry, and more recent controlled trials suggest improved surgical outcomes, the lack of consistent outcome definitions and generally inadequate follow-up periods continue to consign many of the potential long-term effects of PHT to the unknown. There is currently insufficient robust evidence to allow a clinical guideline to be constructed. The need for a well-powered multi-centre prospective randomised trial to address this question is evident but awaits a unified consensus on issues surrounding the understanding of aetiology, classification of hypospadias morphology, definition of important prognostic variables and uniform application of outcome measures. The effects of PHT may be utilised to improve outcomes in cases of proximal and severe hypospadias, which under the current paradigm represent a significant surgical challenge.

Efficacy of topical testosterone in management of scrotal hypoplasia and agenesis

BACKGROUND

Scrotal hypoplasia or agenesis may posses difficulty during orchidopexy or end with social anxiety around excessively small scrotal size when compared to peers, and where there may be concerns regarding the future sexual life.

OBJECTIVE

Any conservative modality applicable to ameliorate scrotal underdevelopment partially or completely will be useful either solely or before reconstructive surgery.

STUDY DESIGN

Seventeen child (3-8 years) were diagnosed with bilateral scrotal hypoplasia (SH) in 5 unilateral in 7, bilateral scrotal agenesis (SA) diagnosed in 4 cases, and unilateral in one. Testicles are either undescended, ectopic, or normal. All cases managed by Testogel 1% topical testosterone for 4 weeks. Clinical assessment by measurements of the scrotal skin surface area (scrotal length multiplied by width) and scrotal corrugations counting. Inguinal and renal ultrasound done for all cases and karyotyping for cases of agenesis and cases with bilateral undescended testicles. Total and free testosterone, LH, FSH and AMH hormones were assisted before treatment, weekly and one week after therapy. Data analyzed and evaluated, difference of means used to test for statistically significant differences between scores of scrotal development.

RESULTS

Free and total testosterone elevated in the 1st week of treatment, but restored to normal or higher levels in 60% of cases at the 2nd week. Satisfactory response (Increasing numbers of scrotal rugae or scrotal surface area by 30-50% above the pretreatment status) obtained in 85% and 60% of unilateral and bilateral SH, but only a partial response (10-20% increase) was gained in 40% of cases with agenesis. No major adverse effect was appreciated.

DISCUSSION

Response of some cases of SH to topical testosterone indicates presence of remnants of labioscrotal folds with testosterone receptors (Bell et al., 1971) [1]. Testosterone replacement therapy can improve the signs and well-being of a hypogonadal male by restoring serum testosterone concentrations to physiologic levels. In this study the mean average testosterone concentration one week after application of testogel was 13.47 ± 2.45 and 12.12 ± 2.5 within 2nd, 4th week, and after cessation of treatment. Anti-Mullerian hormone is significantly low in 12 cases; mainly in cases of SA (P-value <0.001).

CONCLUSION

Short term topical testosterone proved to be effective in a considerable percentage of cases of either bilateral or unilateral scrotal hypoplasia; with a subsequent increase in scrotal surface area and number of rugae, it may substitutes the indication for surgical reconstruction. Long term follow up is a limitation of this study.

The Health Care of Adults with Differences in Sex Development or Intersex Traits Is Changing: Time to Prepare Clinicians and Health Systems

Historically, the majority of differences in sex development or intersex trait (dsd/I)-specific medical care has been provided by pediatric clinicians, leading to a dearth of adult clinicians qualified to care for this vulnerable population, and pediatricians reticent to transition patients to adult care. Recent changes in routine care of children and infants with dsd/I, including reconsidering the role of early genital surgeries, highlight the critical need to address the gaps in adult dsd/I health care. In this perspective, we describe three key educational and research approaches that can be implemented to build competency to care for adults with dsd/I and improve care across the lifespan.

Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent

INTRODUCTION

Diverse sex development (dsd) is an umbrella term for different congenital conditions with incongruence of chromosomal, gonadal, and phenotypic sex characteristics. These are accompanied by various uncertainties concerning health-related, medical, psychosocial, and legal issues that raise controversial discussion.

AIM

The aim of this exploratory study was to investigate 3 questions: What are the most controversial and disputed issues in the context of intersex/dsd? Which issues are associated with the biggest knowledge gaps? Which issues involve the greatest difficulty or uncertainty in decision-making? A further aim was to investigate whether the group of persons concerned, the parents of intersex children, and the group of experts in the field had differing views regarding these questions.

METHODS

A self-developed questionnaire was distributed among persons concerned, parents of children with intersex/dsd, and experts in the field. It contained open and multiple-choice questions. The answers from 29 participants were entered into data analysis. A mixed-method approach was applied. Quantitative data were analysed descriptively. Qualitative data were analysed according to the principles of qualitative content analysis.

MAIN OUTCOME MEASURE

Participants answered questions on the most controversial and disputed issues, issues associated with the biggest knowledge gaps, and issues associated with the most difficulty or uncertainty in decision-making.

RESULTS

The findings indicate that controversial issues and uncertainties mainly revolve around surgical interventions but also around the question of how to adequately consider the consent of minors and how to deal with intersex in the family. Significant differences were found between persons concerned and parents vs academic experts in the field regarding the perceptions of procedure of diagnostic investigation and/or treatment in adulthood, on legal questions concerning marriage/registered civil partnerships, and on lack of psychosocial counseling close to place of residence.

CONCLUSION

The necessity of irreversible gonadal and genital surgery in early childhood is still a matter of strong controversy. To ensure the improvement in well-being of intersex persons, including a sexual health perspective, the positive acceptance of bodily variance is an important prerequisite. Psychosocial support regarding one-time decisions as well as ongoing and changing issues of everyday life appears to be an important means in reaching overall quality of life. Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent-A Pilot Study. Sex Med 2020;8:472-489.

Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life

Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.

Hormone therapy and patient satisfaction with treatment, in a large cohort of diverse disorders of sex development

OBJECTIVES

To describe and investigate the hormone treatments in individuals with different forms of disorders of sex development (DSD) and the patients' own views on their treatment.

DESIGN

Multicentre cross-sectional clinical evaluation, dsd-LIFE in 6 European countries from February 2014 to September 2015.

PARTICIPANTS

A total of 1040 adolescents and adults (≥16 years) with different DSD conditions.

MAIN OUTCOMES MEASURES

Hormone replacement, information received and patient satisfaction.

RESULTS

Included were women with Turner syndrome (301), 46,XX GD (n = 20), and women with 45,X/46XY (n = 24). Individuals with Klinefelter syndrome (n = 218), 46,XX males (n = 6), individuals with different forms of 46,XY DSD (n = 243): 46,XY DSD conditions (n = 222), men with 45,X/46XY (n = 21) 46,XX CAH, (n = 226). Oestrogen ± progestin was used by 306 (81%) individuals, 72 (19%) received ethinylestradiol and 198 had testosterone treatment. The overall adherence was good, with 10% of women with oestrogen and 5% of those on testosterone had stopped the medication despite 20% reporting dissatisfaction with the treatment, mostly because of psychological side effects. Glucocorticoid replacement in patients with CAH was very seldom stopped. More than 75% were satisfied with the information about the treatment, but the satisfaction with information about treatment options and side effects was lower.

CONCLUSIONS

More than 50% in the total cohort had hormone replacement. Although adherence was generally good, this study shows that hormone replacement therapy may be improved. This may be achieved by better individualization of the treatment and by providing specific information to patients regarding both long-term and short-term hormonal effects and side effects.

Efficacy and safety of percutaneous administration of dihydrotestosterone in children of different genetic backgrounds with micropenis

BACKGROUND

Exogenous androgen supplement is an optional treatment for micropenis; however, its use in childhood is controversial due to potential side effects.

METHODS

Twenty-three children (mean age: 4.07±3.4 years) with micropenis of unknown causes harboring the 46,XY karyotype were recruited in an open prospective study. Androgen receptor (AR), steroid 5α-reductase-2 (SRD5A2), and SRY genes were sequenced; 2.5% dihydrotestosterone (DHT) transdermal gel (0.1-0.3 mg/kg/day) was applied and titrated within the normal DHT serum reference ranges. Stretched penile length (SPL) was measured before therapy, and after 1, 3 and 6 months of DHT gel treatment, respectively.

RESULTS

Two patients were found with AR gene mutations and five patients with SRD5A2 gene mutations. Average stretched penile lengths (SPLs) were 1.68±0.6 cm at baseline and 2.2±0.66 cm, 2.6±0.59 cm and 2.9±0.55 cm (mean ± 1 SD) after 1, 3 and 6 months of treatment, respectively. Fourteen cases (61%) reached standard penile length ranges (>-2.5 SD) and medication was discontinued; six cases (26%) were satisfied with the improved penile lengths despite failing to reach the aged matched standards. Three infants (13%) discontinued the medication after 3 months due to anxiety about the potential side effects. No significant side effects were found except the elevated DHT serum levels after therapy.

CONCLUSIONS

Short term and local application of DHT at low doses in patients with micropenis could accelerate penile growth effectively without evident side effects; however, precautions still need be taken due to the paucity of long term study and the lack of ideal DHT dosage.

Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma

INTRODUCTION

Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development.

AIMS

(1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis.

METHODS

A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors' expertise.

RESULTS

A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD.

CONCLUSIONS

Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.