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Erginel B, Ozdemir B, Karadeniz M, Poyrazoglu S, Keskin E, Soysal FG. Long-term 10-year comparison of girls with congenital adrenal hyperplasia who underwent early and late feminizing genitoplasty. Pediatr Surg Int 2023; 39:222. [PMID: 37386261 DOI: 10.1007/s00383-023-05498-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES The appropriate time to perform feminizing genitoplasty in patients with congenital adrenal hyperplasia (CAH) with the 46, XX genotype is still debatable. The aim of our study was to evaluate the relationship between age at surgery and long-term surgical outcomes of patients who underwent feminizing genitoplasty. METHODS We retrospectively analyzed 14 patients with CAH and 46, XX genotypes with feminizing genitoplasty (clitoroplasty + vaginoplasty) between 2005 and 2022. The patients were divided into two groups. Group 1 consisted of seven girls (n = 7/14) who have been operated before the age of 2 years. Group 2 consisted of seven girls (n = 7/14) who have been operated after the age of 2 years. The two groups are compared regarding anatomical assessments, overall cosmetic results, need for additional intervention using Creighton's criteria. Additionally, the cosmetical satisfaction of the patients/parents is questioned. RESULTS The mean age of the girls was 32.42 months (10-96 months) during operation time. The mean age of Group 1 patients (n = 7/14) who have been operated before the age of 2 years was 11.71 months (10-19 months). The mean age of Group 2 patients (n = 7/14) who have been operated after the age of 2 years was 53.14 months (36-96 months). The mean follow-up time was 10.57 years (3-18 years). There was no statistically significant difference between those operated on before and after two years in terms of anatomical assessments, overall cosmetic results and patient/parent satisfaction except the need for additional intervention (p = 0.049). In Group1 (operation age < 2 years old), five out of seven (71.42%) patients needed additional major surgery (four urogenital sinus re-mobilization, one redo-clitoroplasty). Those who received additional major surgery were the ones who were not satisfied. In Group 2 (operation age > 2 years old), two patients out of seven patients (28.57%) received major surgery (two redo-urethroplasties) and those patients were not satisfied. When patient/parent satisfaction was compared with additional surgical intervention, as expected, patients'/parents' satisfaction increased as major surgical intervention decreased. This was statistically significant (p = 0.007). The main source of dissatisfaction was repeated surgery among the parents. CONCLUSIONS The possibility of this additional surgical intervention increases, and patient/parent satisfaction decreases in patients below the age of 2 years. The corrective surgeries can be differed until the gender identity of the patient matures and the patient autonomy in deciding whether this surgery should occur.
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Affiliation(s)
- Basak Erginel
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey.
| | - Banu Ozdemir
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey
| | - Meltem Karadeniz
- Istanbul Medical Faculty, Department of Anesthesiology, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Istanbul Medical Faculty, Department of Pediatric Endocrinology, Istanbul University, Istanbul, Turkey
| | - Erbug Keskin
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey
| | - Feryal Gun Soysal
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey
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Almasri J, Zaiem F, Rodriguez-Gutierrez R, Tamhane SU, Iqbal AM, Prokop LJ, Speiser PW, Baskin LS, Bancos I, Murad MH. Genital Reconstructive Surgery in Females With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:4089-4096. [PMID: 30272250 DOI: 10.1210/jc.2018-01863] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Females with congenital adrenal hyperplasia (CAH) and atypical genitalia often undergo complex surgeries; however, their outcomes remain largely uncertain. METHODS We searched several databases through 8 March 2016 for studies evaluating genital reconstructive surgery in females with CAH. Reviewers working independently and in duplicate selected and appraised the studies. RESULTS We included 29 observational studies (1178 patients, mean age at surgery, 2.7 ± 4.7 years; mostly classic CAH). After an average follow-up of 10.3 years, most patients who had undergone surgery had a female gender identity (88.7%) and were heterosexual (76.2%). Females who underwent surgery reported a sexual function score of 25.13 using the Female Sexual Function Index (maximum score, 36). Many patients continued to complain of substantial impairment of sensitivity in the clitoris, vaginal penetration difficulties, and low intercourse frequency. Most patients were sexually active, although only 48% reported comfortable intercourse. Most patients (79.4%) and treating health care professionals (71.8%) were satisfied with the surgical outcomes. Vaginal stenosis was common (27%), and other surgical complications, such as fistulas, urinary incontinence, and urinary tract infections, were less common. Data on quality of life were sparse and inconclusive. CONCLUSION The long-term follow-up of females with CAH who had undergone urogenital reconstructive surgery shows variable sexual function. Most patients were sexually active and satisfied with the surgical outcomes; however, some patients still complained of impairment in sexual experience and satisfaction. The certainty in the available evidence is very low.
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Affiliation(s)
- Jehad Almasri
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Feras Zaiem
- Department of Pathology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital Dr. Jose E. Gonzalez, Autonomous University of Nuevo Leon, Monterrey, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | | | - Anoop Mohamed Iqbal
- Division of Pediatrics and Adolescent Medicine, Department of Pediatric Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Phyllis W Speiser
- Division of Pediatric Endocrinology, Cohen Children's Medical Center and Zucker Hofstra Northwell School of Medicine, Lake Success, New York
| | - Laurence S Baskin
- Department of Urology, University of California, San Francisco, California
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Boyle ME, Smith S, Liao LM. Adult Genital Surgery for Intersex: A Solution to What Problem? J Health Psychol 2016; 10:573-84. [PMID: 16014393 DOI: 10.1177/1359105305053431] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The desirability of routine genital surgery for infants with ambiguous genitalia is increasingly debated. But there is less discussion about intersex adults who choose genital surgery, despite evidence suggesting that the results are often unsatisfactory. This study reports on how six women with intersex conditions decided to have feminizing genital surgery and how they evaluated the outcomes. The initial analysis highlighted a chronological transition from surgery as nondilemmatic to surgery as a serious dilemma; a version of Foucauldian discourse analysis was then used to place the women’s experiences in a cultural context. The implications for psychological involvement in services for women with intersex conditions are discussed.
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Affiliation(s)
- Mary E Boyle
- Department of Psychology, University of East London, UK.
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4
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Slijper FME, van der Kamp HJ, Brandenburg H, Keizer-Schrama SMPFDM, Drop SLS, Molenaar JC. Evaluation of Psychosexual Development of Young Women with Congenital Adrenal Hyperplasia: A Pilot Study. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/01614576.1992.11074053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome: A historical perspective. Gene 2015; 555:33-40. [DOI: 10.1016/j.gene.2014.09.045] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 09/19/2014] [Accepted: 09/21/2014] [Indexed: 12/15/2022]
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Lesma A, Bocciardi A, Corti S, Chiumello G, Rigatti P, Montorsi F. Sexual function in adult life following Passerini-Glazel feminizing genitoplasty in patients with congenital adrenal hyperplasia. J Urol 2013; 191:206-11. [PMID: 23933397 DOI: 10.1016/j.juro.2013.07.097] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE We assessed external genitalia sensitivity and sexual function in adults with congenital adrenal hyperplasia who had undergone Passerini-Glazel feminizing genitoplasty as children, and compared them to a control group of healthy counterparts. MATERIALS AND METHODS Inclusion criteria were congenital adrenal hyperplasia, Passerini-Glazel feminizing genitoplasty, adult age and penetrative vaginal intercourse. Thermal and vibratory sensitivity of the clitoris, vagina and labia minora were analyzed using the Genito Sensory Analyzer (Medoc Ltd., Minnetonka, Minnesota). Psychosexual outcome was assessed with the Beck Depression Inventory, Zung Self-Rating Anxiety Scale, Female Sexual Distress Scale and Female Sexual Function Index. Matched analyses were performed to compare outcomes in patients to controls (healthy medical students). All statistical tests were performed using SPSS®, version 18.0 RESULTS: A total of 12 patients (10%) entered the study. Thermal and vibratory clitoral sensitivity was significantly decreased in all patients compared to healthy controls (p <0.01). There was no difference in thermal or vibratory vaginal sensitivity between patients and controls. On the Female Sexual Distress Scale 11 patients (91.6%) and 11 controls (91.6%) described a stable satisfactory relationship. All patients reported active sexual desire, good arousal, adequate lubrication and orgasm. No significant difference in Female Sexual Function Index global score or single domain scores was observed between patients and controls. CONCLUSIONS Although clitoral sensitivity in sexually active patients with congenital adrenal hyperplasia treated with Passerini-Glazel feminizing genitoplasty is significantly reduced compared to controls, sexual function in those patients is not statistically or clinically significantly different from their healthy counterparts. Finally, 1-stage Passerini-Glazel feminizing genitoplasty seems to allow normal adult sexual function.
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Affiliation(s)
- Arianna Lesma
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Aldo Bocciardi
- Department of Urology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Stefano Corti
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Giuseppe Chiumello
- Department of Pediatrics, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Patrizio Rigatti
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesco Montorsi
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Callens N, van der Zwan YG, Drop SLS, Cools M, Beerendonk CM, Wolffenbuttel KP, Dessens AB. Do surgical interventions influence psychosexual and cosmetic outcomes in women with disorders of sex development? ISRN ENDOCRINOLOGY 2012; 2012:276742. [PMID: 22462013 PMCID: PMC3313564 DOI: 10.5402/2012/276742] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 12/25/2011] [Indexed: 11/28/2022]
Abstract
Clinical practice developed to promote psychosexual well-being in DSD is under scrutiny. Although techniques for genital surgery have much improved lately, long-term studies on psychosexual functioning and cosmetic outcome on which to base treatment and counseling are scarce. We studied 91 women with a DSD. Feminizing surgery was performed in 64% of the women; in 60% of them, resurgery in puberty was needed after a single-stage procedure. Both patients and gynecologists were satisfied with the cosmetic appearance of the genitalia. However, forty percent of these females experienced sexuality-related distress and 66% was at risk for developing a sexual dysfunction, whether they had surgery or not. Recognizing the difficulty of accurate assessment, our data indicate that feminizing surgery does not seem to improve nor hamper psychosexual outcome, especially in patients with severe virilization.
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Affiliation(s)
- Nina Callens
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University and University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
| | - Yvonne G. van der Zwan
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Stenvert L. S. Drop
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Martine Cools
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University and University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
| | - Catharina M. Beerendonk
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Katja P. Wolffenbuttel
- Department of Urology, Erasmus MC-Sophia, P.O. Box 1738, 3000 CB Rotterdam, The Netherlands
| | - Arianne B. Dessens
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Abstract
The past several decades have seen multiple advances in the surgical reconstruction for girls born with Disorders of Sexual Differentiation. This surgery can be technically very demanding, and must be individualized for each patient, as the degree of virilization and level of confluence of the vagina and urogenital sinus will dictate the surgical approach. In this manuscript we present our approach and experience in the surgical options for girls born with Congenital Adrenal Hyperplasia, with special attention regarding clitoroplasty, urogenital mobilization, and vaginoplasty.
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Affiliation(s)
- Jeffrey A Leslie
- Department of Urology, University of Texas Health Science, 7703 Floyd Curl Dr., MC 7845, San Antonio-78229, Texas - USA
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Nordenström A, Frisén L, Falhammar H, Filipsson H, Holmdahl G, Janson PO, Thorén M, Hagenfeldt K, Nordenskjöld A. Sexual function and surgical outcome in women with congenital adrenal hyperplasia due to CYP21A2 deficiency: clinical perspective and the patients' perception. J Clin Endocrinol Metab 2010; 95:3633-40. [PMID: 20466782 DOI: 10.1210/jc.2009-2639] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Females with congenital adrenal hyperplasia (CAH) due to a CYP21A2 deficiency are exposed to androgens during fetal development, resulting in virilization of the external genitalia. Little is known about how these women feel that the disease has affected their lives regarding surgery and psychosexual adaptation. OBJECTIVE Our objective was to investigate the correlation between the surgical results, the self-perceived severity of the disease, and satisfaction with sexual life and relate the results to the CYP21A2 genotype. DESIGN AND PARTICIPANTS Sixty-two Swedish women with CAH and age-matched controls completed a 120-item questionnaire, and a composite score for sexual function was constructed. The surgical outcome, including genital appearance and clitoral sensitivity, was evaluated by clinical examination. The patients were divided into four CYP21A2 genotype groups. RESULTS The sexual function score, but not for genital appearance, was higher in the patients satisfied with their sexual life. This was also true of the patients who were satisfied with the surgical result. There were discrepancies between the patients' perception of the impact of the condition on their sexual life and what health professionals would assume from clinical examination. The patients in the null genotype group scored lower on sexual function and satisfaction with their sexual life and had more surgical complications, also compared with the slightly less severe I2-splice genotype group. CONCLUSION Our data show that the null genotype group was considerably more affected by the condition than the other groups and should be regarded as a subgroup, both psychologically and from a surgical perspective. Genotyping adds clinically valuable information.
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Affiliation(s)
- Anna Nordenström
- Department of Pediatrics, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
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Diamond M. Clinical implications of the organizational and activational effects of hormones. Horm Behav 2009; 55:621-32. [PMID: 19446079 DOI: 10.1016/j.yhbeh.2009.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 03/12/2009] [Accepted: 03/12/2009] [Indexed: 10/20/2022]
Abstract
Debate on the relative contributions of nature and nurture to an individual's gender patterns, sexual orientation and gender identity are reviewed as they appeared to this observer starting from the middle of the last century. Particular attention is given to the organization-activation theory in comparison to what might be called a theory of psychosexual neutrality at birth or rearing consistency theory. The organization-activation theory posits that the nervous system of a developing fetus responds to prenatal androgens so that, at a postnatal time, it will determine how sexual behavior is manifest. How organization-activation was or was not considered among different groups and under which circumstances it is considered is basically understood from the research and comments of different investigators and clinicians. The preponderance of evidence seems to indicate that the theory of organization-activation for the development of sexual behavior is certain for non-human mammals and almost certain for humans. This article also follows up on previous clinical critiques and recommendations and makes some new suggestions.
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Affiliation(s)
- Milton Diamond
- University of Hawaii, John A. Burns School of Medicine, Pacific Center for Sex and Society, 1960 East-West Road, Honolulu, HI 96822, USA.
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Bachelot A, Chakhtoura Z, Rouxel A, Dulon J, Touraine P. Hormonal treatment of congenital adrenal hyperplasia due to 21-hydroxylase deficiency. ANNALES D'ENDOCRINOLOGIE 2007; 68:274-80. [PMID: 17689481 DOI: 10.1016/j.ando.2007.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
During childhood, the main aims of the medical treatment of congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency, are to prevent salt loss and virilization and to achieve normal stature and normal puberty. As such, there is a narrow therapeutic window through which the intended results can be achieved. In adulthood, the clinical management has received little attention, but recent studies have shown the relevance of long-term follow-up of these patients. Indeed, long-term evaluation of adult CAH patients enables the identification of multiple clinical, hormonal and metabolic abnormalities as bone mineral density alteration, overweight and disturbed reproductive functions. In women with classic CAH, low fertility rate is reported, and is probably the consequence of multiple factors, including neuroendocrine and hormonal factors, feminizing surgery, and psychological factors. Men with CAH may present hypogonadism either through the effect of adrenal rests or from suppression of gonadotropins resulting in infertility. These patients should therefore be carefully followed-up, from childhood through to adulthood, to avoid these complications and to ensure treatment compliance and tight control of the adrenal androgens, by multidisciplinary teams who have knowledge of CAH.
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Affiliation(s)
- A Bachelot
- Department of endocrinology and reproductive medicine (Centre de référence des maladies endocriniennes rares de la croissance), groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France
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Gastaud F, Bouvattier C, Duranteau L, Brauner R, Thibaud E, Kutten F, Bougnères P. Impaired sexual and reproductive outcomes in women with classical forms of congenital adrenal hyperplasia. J Clin Endocrinol Metab 2007; 92:1391-6. [PMID: 17284631 DOI: 10.1210/jc.2006-1757] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The objectives of the study were 2-fold: 1) a detailed description of sexual and reproductive outcomes in adult women with congenital adrenal hyperplasia (CAH) of different phenotypic severity at birth; and 2) comparisons of these outcomes among CAH subtypes and between CAH women and non-CAH control women. DESIGN This was a cross-sectional study using a face-to-face interview, a written questionnaire, the Female Sexual Function Index, and a gynecological examination. PATIENTS Patients included 35 women with CAH, representing Prader stages I-V at birth, aged 18-43 yr, who had been treated from birth to adolescence in the same pediatric endocrine clinics. Sixty-nine non-CAH healthy control women were selected from hospital-staff families. RESULTS None of the CAH women expressed doubts about their gender assignment. Twenty percent (seven of 35) had homosexual inclinations; 23% (eight of 35) were married; three reported a complete lack of sexual activity; and 37% (13 of 35) said they never had heterosexual intercourse with vaginal penetration. Sexual functioning as assessed by the Female Sexual Function Index was much lower in CAH women than controls and lowest in CAH women with high Prader stages. Eighty-one percent (18 of 22) experienced pain during vaginal penetration. Only eight women became pregnant, and 17% (six of 35) had children. CONCLUSIONS Despite expert medical and surgical care by physicians dedicated to this rare disease, women with CAH still suffer major limitations in their sexual function and reproductive life.
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Affiliation(s)
- F Gastaud
- Centre de Référence des Maladies Rares de la Différenciation Sexuelle, Lyon-Paris, Department of Pediatric and Adult Endocrinology, Necker Hospital, Paris V University, France
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Bachelot A, Plu-Bureau G, Thibaud E, Laborde K, Pinto G, Samara D, Nihoul-Fékété C, Kuttenn F, Polak M, Touraine P. Long-term outcome of patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. HORMONE RESEARCH 2006; 67:268-76. [PMID: 17170529 DOI: 10.1159/000098017] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Accepted: 10/27/2006] [Indexed: 11/19/2022]
Abstract
AIMS Conflicting results exist regarding bone mineral density (BMD), metabolism and reproductive function of adult patients with congenital adrenal hyperplasia (CAH). We evaluated the long-term outcome and the impact of chronic glucocorticoid replacement in these patients. METHODS Physical characteristics, serum hormone concentrations, BMD and metabolism were studied in 45 consecutive CAH adult patients. RESULTS Among the 36 women, only 14 (39%) had regular menses. Among the 27 women with classical CAH, the mean number of surgical reconstructions of virilized genitalia was 2.1 +/- 0.2. Twenty of them (74%) were sexually active. Three men presented with testicular adrenal rest tumors. Twenty-five patients (55%) had decreased BMD at the femoral neck and/or at the lumbar spine. BMI was correlated with the BMD T-score at the femoral neck (p < 0.001) and at the lumbar spine (p < 0.01). Hydrocortisone dose was negatively correlated with the BMD T-score at the femoral neck (p = 0.04). Subjects with osteopenia had a significantly lower BMI and received higher hydrocortisone dose than those with normal BMD. Overweight was found in 21 patients (47%). There was a significantly positive correlation between HOMA and BMI (p < 0.001), and between HOMA and 17-OHP levels (p = 0.016). CONCLUSIONS Adult patients with CAH treated with long-term glucocorticoids are at risk for decreased BMD, increased BMI, and disturbed reproductive function.
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Affiliation(s)
- Anne Bachelot
- Department of Endocrinology and Reproductive Medicine, Necker Hospital, AP-HP, Paris V University, Paris, France
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14
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Miranda ML, Oliveira Filho AGD, Lemos-Marini SHVD, Bustorff-Silva JM, Guerra-Júnior G. [Feminizing genitoplasty and congenital adrenal hyperplasia: analysis of anatomical results]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2006; 49:138-44. [PMID: 16544045 DOI: 10.1590/s0004-27302005000100018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the anatomical and cosmetic results of feminizing genitoplasty in girls with ambiguous genitalia due to Congenital Adrenal Hyperplasia (CAH). CASUISTIC AND METHOD Twenty-seven females with genital ambiguity (Prader III-V) due to CAH underwent an one-stage feminizing genitoplasty and were followed for a mean time of 4 years. In twelve girls, two cutaneous labioscrotal island-flaps were associated with the conventional genitoplasty, to decrease the excess of labia majora and to enlarge the vaginal introitus. Urinary tract infections were observed in sixteen girls in the preoperative and in only seven in the postoperative period. The cosmetic results were obtained by the systematic anatomical evaluation of the different structures that compose the genitalia. RESULTS The results of clitoroplasty were considered good in 63% of the cases; however, 4 girls developed clitoral atrophy. An excess of labia majora was present in 25% and persistence of the urogenital sinus occurred in 11% (three children without labioscrotal island flap). The labioscrotal island flap was considered technically feasible and reproducible. Five girls had to be re-operated. The cosmetic results were considered excellent or good in 63% of the cases, satisfactory in 18.5% and unsatisfactory or bad in 18.5%. CONCLUSIONS The anatomical and cosmetic results were good in majority of the cases; however, some technical aspects should be adjusted, to avoid irreversible sequels and re-operations.
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Affiliation(s)
- Márcio Lopes Miranda
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Hospital de Clínicas, UNICAMP, Campinas, SP.
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Ogilvie CM, Crouch NS, Rumsby G, Creighton SM, Liao LM, Conway GS. Congenital adrenal hyperplasia in adults: a review of medical, surgical and psychological issues. Clin Endocrinol (Oxf) 2006; 64:2-11. [PMID: 16402922 DOI: 10.1111/j.1365-2265.2005.02410.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Our knowledge of the experience of adults with congenital adrenal hyperplasia (CAH) as they pass through life is only now emerging. In this review we gather medical, surgical and psychological literature pertaining to adults with CAH and consider this alongside practical experience gained from a dedicated adult CAH clinic. There is increasing awareness for the need for multidisciplinary teams who have knowledge of CAH particularly with respect to gynaecological surgery and clinical psychology for women and testicular function in men. Routine management of CAH comprises adjustment of glucocorticoid and mineralocorticoid treatment according to individual needs balancing biochemical markers, compliance and long term risks. Bone density is one such long term concern and is not greatly reduced in most individuals with CAH. More recently, attention has turned to cardiovascular risk factors and catecholamine deficiency in adults with CAH. Women with CAH require access to an experienced gynaecologist, specialised pregnancy care and psychosexual support. The very low fertility rates for women with CAH previously reported appear to be improving with time. Men with CAH are often lost to follow up and therefore miss out on surveillance for hypogonadism either through the effect of adrenal rests of from suppression of gonadotrophins resulting in a high prevalence of oligospermia.
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Bocciardi A, Lesma A, Montorsi F, Rigatti P. PASSERINI-GLAZEL FEMINIZING GENITOPLASTY: A LONG-TERM FOLLOWUP STUDY. J Urol 2005; 174:284-8; discussion 288. [PMID: 15947668 DOI: 10.1097/01.ju.0000161211.40944.87] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We report our experience with early 1-stage Passerini-Glazel feminizing genitoplasty with special emphasis on long-term results of vaginoplasty. MATERIALS AND METHODS A total of 66 patients with ambiguous genitalia underwent 1-stage Passerini-Glazel feminizing genitoplasty. Long-term followup included an outpatient visit at 1 year postoperatively and a genital assessment with the patient under general anesthesia performed before menarche courses in those operated on at age 6 months to 8 years, and at 2 years postoperatively for those operated on at 9 years or older. RESULTS All patients underwent the first long-term followup evaluation and no major complications were observed. The second long-term followup evaluation was performed in 46 patients (70%). In all cases the vaginal introitus was located in the physiological position and was large and elastic. Vaginal caliber at the suture line between the tubularized flap and vaginal mucosa was the same size as the vaginal introitus and distal native vagina in 20 of 46 patients (43%), slightly smaller in 10 (22%) and stenotic in 16 (35%). Stenosis at the suture line was corrected with simple Y-V introitoplasty performed at the same followup visit. CONCLUSIONS Early 1-stage Passerini-Glazel feminizing genitoplasty is a safe and effective procedure that allows total surgical correction of ambiguous genitalia in infancy and good cosmetic results. Incidence of vaginal stenosis at the suture line is high but it can be repaired with simple introitoplasty performed before menarche occurs. Good functional results are presumed.
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Affiliation(s)
- Aldo Bocciardi
- Department of Urology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
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Warne G, Grover S, Hutson J, Sinclair A, Metcalfe S, Northam E, Freeman J. A long-term outcome study of intersex conditions. J Pediatr Endocrinol Metab 2005; 18:555-67. [PMID: 16042323 DOI: 10.1515/jpem.2005.18.6.555] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
CONTEXT Clinical management of intersex conditions is controversial because the available evidence is limited and conflicting, with no long-term population based studies comparing matched controls. OBJECTIVE To assess the long-term psychological, sexual and social outcomes of patients with intersex compared with two matched control populations. DESIGN, SETTING AND PARTICIPANTS Three different aged-matched (18-32 years) patient groups completed a self-administered questionnaire of established quality of life and well-being inventories measuring physical' health, psychological adjustment and sexuality, following a mail-out to all identified patients. The intersex group (n = 50) and the Hirschsprung disease, a congenital disorder, control group (n = 27), were patients who had attended the Royal Children's Hospital, a tertiary centre, for their clinical care. The insulin dependent diabetes mellitus control group was recruited from an adult tertiary hospital. The study was conducted at the hospital-based Murdoch Childrens Research Institute. MAIN OUTCOME MEASURES Psychological, sexual and social outcomes. RESULTS The intersex group did not differ from controls on physical or mental health, depression, state anxiety, neuroticism, psychoticism or stressful life events. Intersex participants were satisfied with their overall body appearance, although intersex males were less satisfied than controls with the size (p <0.05) and appearance (p <0.01) of their sex organs. The intersex group was less likely to experience orgasm (p <0.05), tended to experience more pain during intercourse (p = 0.06), had more difficulties with penetration (p <0.01) and were less likely to have sexual activity several times or more a week (p <0.05) than the combined control groups. Intersex participants did not differ from controls in level of sexual desire or enjoyment of sexual activities. CONCLUSIONS Most patients with intersex had positive psychosocial and psychosexual outcomes, although some problems were reported with sexual activity. These results overall suggest that a model of care including early genital surgery carried out at a centre of excellence with a multidisciplinary team can minimize long-term complication rates.
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Affiliation(s)
- Garry Warne
- Department of Endocrinology & Diabetes, The University of Melbourne, Melbourne, Australia.
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Zucker KJ, Bradley SJ, Oliver G, Blake J, Fleming S, Hood J. Self-reported sexual arousability in women with congenital adrenal hyperplasia. JOURNAL OF SEX & MARITAL THERAPY 2004; 30:343-355. [PMID: 15672602 DOI: 10.1080/00926230490465109] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
As part of a larger study of psychosexual development and sexual functioning in women with congenital adrenal hyperplasia (CAH), we assessed self-reported sexual arousability with the Sexual Arousability Inventory-Short Form (SAI-SF; Hoon & Chambless, 1998). Compared to their unaffected sisters/female cousins (n = 15), women with CAH (n = 30) reported significantly lower sexual arousability on the SAI, with an effect size, using Cohen's d, of 1.16. For both the CAH women alone and combined with the controls, higher self-reported sexual arousability was significantly associated with (a) relationship status (married or cohabitating with a man versus being single or not in a relationship); (b) higher levels of sexual attraction to men in fantasy in the past 12 months on the Erotic Response and Orientation Scale (Storms, 1980); (c) higher Kinsey interview ratings of a heterosexual orientation in behavior in the past 12 months; and (d) more sexual experiences with men, according to a modified version of the Zuckerman (1973) Heterosexual Experience Scale (HES), in the past 12 months and lifetime (all ps < .001-.05). CAH women who were simple virilizers (versus salt-wasters) and those assigned female at birth (versus delayed or male) tended to report higher levels of sexual arousability (p < .10). Self-reported degree of satisfaction with genital surgery and genital function was also associated with higher levels of arousability. For CAH women and both groups combined, multiple regression analysis showed that the sole predictor of self-reported sexual arousability was HES lifetime sexual experiences with men. We discuss the results in the context of assessing sexual function and dysfunction in women with CAH.
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Affiliation(s)
- Kenneth J Zucker
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
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Wisniewski AB, Migeon CJ, Malouf MA, Gearhart JP. Psychosexual outcome in women affected by congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Urol 2004; 171:2497-501. [PMID: 15126884 DOI: 10.1097/01.ju.0000125269.91938.f7] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency results in increased adrenal androgen secretion. When the deficiency is severe, the result is the salt losing (SL) form, and when the deficiency is partial, the result is the simple virilizing (SV) form of CAH. We documented long-term satisfaction with gender, cosmetic appearance and function of the genitalia, and surgical management practices in a group of women with CAH due to 21-hydroxylase deficiency. MATERIALS AND METHODS Psychosexual and surgical outcome were assessed in 41 women with CAH using an interview, a written questionnaire and a physical examination. When appropriate, outcome measures were compared to those in unaffected control women. RESULTS Women in the SL group were more likely to question their female gender and report sexual concerns, and less likely to have sexual relations with a partner than those with the SV form or control women. Overall women with CAH were moderately satisfied with the cosmetic appearance of the genitalia but the SL group reported worse genital function than the SV group. Physician rated appearance of the genitalia was better than ratings provided by patients and women with the SL form were judged to have a worse cosmetic outcome of genital reconstruction than women with the SV form. The most common response concerning the optimal timing for genital reconstruction was during infancy and early childhood, although a number of women favored waiting until later for these procedures or did not respond to this question. CONCLUSIONS Women with the SV form reported greater satisfaction and fewer concerns regarding their psychosexual and surgical outcome than women with the SL form.
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Affiliation(s)
- Amy B Wisniewski
- Department of Pediatrics, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA.
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Abstract
Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a disease with a varying phenotype depending on the mutation(s) present and the severity of the disease. All children with CAH need to be continuously cared for from birth or early infancy by specialists in paediatric endocrinology and surgery. Complications due to over- or under-treatment with corticosteroids are often seen during adolescence, and these problems often continue into adulthood. For the young woman with CAH, questions about menstruation, sexuality, fertility and the possible necessity of complementary surgery are always important issues that need to be discussed. To meet the needs of the young woman with CAH, it is important that the transition from paediatric to adult care be a process of parallel consultations over several years, always involving an experienced gynaecologic endocrinologist.
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Affiliation(s)
- Kerstin B Hagenfeldt
- Division of Obstetrics and Gynaecology, Department of Woman and Child Health, Karolinska Hospital, S 171 76 Stockholm, Sweden.
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Affiliation(s)
- C R J Woodhouse
- The Institute of Urology and Nephrology, University College London, and The Hospital for Children, Great Ormond Street, London, UK.
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Stikkelbroeck NMML, Beerendonk CCM, Willemsen WNP, Schreuders-Bais CA, Feitz WFJ, Rieu PNMA, Hermus ARMM, Otten BJ. The long term outcome of feminizing genital surgery for congenital adrenal hyperplasia: anatomical, functional and cosmetic outcomes, psychosexual development, and satisfaction in adult female patients. J Pediatr Adolesc Gynecol 2003; 16:289-96. [PMID: 14597017 DOI: 10.1016/s1083-3188(03)00155-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are only a few reports analyzing the long term outcome of feminizing surgery in females with congenital adrenal hyperplasia (CAH). Such analysis is crucial to evaluate the treatment and to make necessary adjustments. STUDY OBJECTIVES To evaluate the adult outcome after feminizing surgery in adult females with salt wasting CAH. DESIGN Retrospective observational followup investigation. SETTING Outpatient clinic of a University Medical Center, in 2002. PARTICIPANTS Eight patients (born 1973-1983) who underwent feminizing surgery in infancy by the same procedure and the same pediatric surgeon in our center, and 19 healthy female controls (for visual analog scales). METHODS (a) Study of patients' records (n=8); (b) Systematic evaluation of the current situation (n=6): uroflowmetry, a written questionnaire to screen for psychopathology (Youth Adult Self Report, YASR), structured gynecologic examination and a structured psychosexual interview, including scoring on visual analog scales. RESULTS (a) The first surgery (age 0.1-3.7 yr) consisted of clitoris reduction and vaginoplasty (single-stage) in 7 patients and clitoris reduction only in one patient. The latter patient had vaginoplasty in puberty. In puberty, 6 of the 7 patients with an initial single-stage procedure required re-vaginoplasty. All 6 patients who participated in this systematic evaluation had undergone (re-) vaginoplasty in puberty; (b) 2 of the 6 patients experienced some urinary incontinence, and in one of them, the uroflowmetry result was abnormal. The YASR showed no psychopathology, except for 1 patient with a slightly elevated externalizing score. Gynecologic examination (n=5) revealed vaginal strictures in 3 patients (1 severe, 2 mild). The 2 patients without vaginal strictures had coitus regularly. In the interview, 2 patients called themselves bisexual, the other 4 heterosexual. None of the patients had homosexual contacts. Sexual developmental milestones (romantic interest, falling in love, kissing and petting, coitus) had been reached by all, except for 1 patient who did not have coitus yet. In the patient group, satisfaction with height, body hair, and external genitalia and sexual fantasies and interest, measured with visual analog scales, was not different compared to the control group, except for satisfaction with total body appearance, which was significantly lower in the patients. CONCLUSION Despite the poor outcome of the initial single-stage surgery in infancy and the inevitable re-operation in puberty, the adult outcome in our study population seems more positive than the findings in the few previous reports, especially with respect to sexual development and activity.
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Affiliation(s)
- Nike M M L Stikkelbroeck
- Departments of Pediatric Endocrinology, University Medical Center Nijmegen, Nijmegen, The Netherlands
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McCullough LB. A framework for the ethically justified clinical management of intersex conditions. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 511:149-65; discussion 165-73. [PMID: 12575761 DOI: 10.1007/978-1-4615-0621-8_10] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
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Stikkelbroeck NMML, Hermus ARMM, Braat DDM, Otten BJ. Fertility in women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Obstet Gynecol Surv 2003; 58:275-84. [PMID: 12665708 DOI: 10.1097/01.ogx.0000062966.93819.5b] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED Fertility in women with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency appears to be reduced. The purpose of this review is to summarize the reported evidence about subfertility in women with CAH and to review the causes of reduced fertility. Compared with a non-CAH female population, pregnancy and live-birth rates are severely reduced in salt-wasting patients, mildly reduced in simple virilizing patients, and normal in nonclassical patients. Several factors have been suggested to contribute to the impaired fertility in CAH females: adrenal overproduction of androgens and progestins (17-hydroxyprogesterone and progesterone), ovarian hyperandrogenism, polycystic ovary syndrome, ovarian adrenal rest tumors, neuroendocrine factors, genital surgery, and psychological factors such as delayed psychosexual development, reduced sexual activity and low maternal feelings. It is obvious that these factors are interrelated. Improving endocrine, surgical, and psychological management could contribute to improving fertility chances in these patients. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to define the various types of CAH, to describe the fertility issues in the CAH patients, to outline the various other causes of hyperandrogenism, and to list the treatment options for the patient with CAH.
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Affiliation(s)
- Nike M M L Stikkelbroeck
- Department of Pediatric Endocrinology, University Medical Center Nijmegen, Nijmegen, The Netherlands
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27
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Edmonds DK. Congenital malformations of the genital tract and their management. Best Pract Res Clin Obstet Gynaecol 2003; 17:19-40. [PMID: 12758224 DOI: 10.1053/ybeog.2003.0356] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
While congenital malformations of the genital tract are not common, the sequelae of their presence can be serious. The practising gynaecologist must be aware of the range of congenital abnormalities that may occur and the symptoms that may result from them. Failure to manage these patients correctly may have long-term sequelae for their psychological, sexual and reproductive health. The involvement of a multi-disciplinary team in dealing with these patients is imperative, and preparation for surgery-particularly in congenital malformations of the vulva and the vagina-is imperative if the long-term sexual function in these patients is to be fulfilled. Surgical correction of vulval abnormalities in adolescence is related solely to sexual function as most of the reconstructive surgery is done in childhood. For the management of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, the recommendation is now that passive dilatation by Franks' technique is the treatment of first choice and only if that fails should surgical approaches be embarked upon. The results of the surgery are similar in all techniques and the particular surgical centre will have its own preference of which technique it adopts. Congenital absence of the cervix is a complex surgical problem and should be dealt with solely in centres with expertise.
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Affiliation(s)
- D Keith Edmonds
- Women's and Children's Directorate, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London, W12 0HS, UK.
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Migeon CJ, Wisniewski AB, Gearhart JP, Meyer-Bahlburg HFL, Rock JA, Brown TR, Casella SJ, Maret A, Ngai KM, Money J, Berkovitz GD. Ambiguous genitalia with perineoscrotal hypospadias in 46,XY individuals: long-term medical, surgical, and psychosexual outcome. Pediatrics 2002; 110:e31. [PMID: 12205281 DOI: 10.1542/peds.110.3.e31] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To identify and study adults (21 years or older) who have a 46,XY karyotype and presented as infants or children with genital ambiguity, including a small phallus and perineoscrotal hypospadias, reared male or female. METHODS Participants were classified according to the cause underlying their intersex condition based on review of medical and surgical records. Long-term medical and surgical outcome was assessed with a written questionnaire and physical examination. Long-term psychosexual development was assessed with a written questionnaire and semistructured interview. RESULTS Thirty-nine (72%) of 54 eligible patients participated. The cause underlying genital ambiguity of participants included partial androgen insensitivity syndrome (n = 14; 5 men and 9 women), partial gonadal dysgenesis (n = 11; 7 men and 4 women), and other intersex conditions. Men had significantly more genital surgeries (mean: 5.8) than women (mean: 2.1), and physician-rated cosmetic appearance of the genitalia was significantly worse for men than for women. The majority of participants were satisfied with their body image, and men and women did not differ on this measure. Most men (90%) and women (83%) had sexual experience with a partner. Men and women did not differ in their satisfaction with their sexual function. The majority of participants were exclusively heterosexual, and men considered themselves to be masculine and women considered themselves to be feminine. Finally, 23% of participants (5 men and 4 women) were dissatisfied with their sex of rearing determined by their parents and physicians. CONCLUSIONS Either male or female sex of rearing can lead to successful long-term outcome for the majority of cases of severe genital ambiguity in 46,XY individuals. We discuss factors that should be considered by parents and physicians when deciding on a sex of rearing for such infants.
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Affiliation(s)
- Claude J Migeon
- Department of Pediatrics, Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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29
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Abstract
Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is a common disorder, and is characterised by a defect in cortisol biosynthesis with or without a defect in aldosterone synthesis and androgen excess. The classic form, also known as the severe form, occurs in 1:15,000 births worldwide, while the nonclassic or mild form occurs in approximately 1:1,000 births worldwide and is much more common (up to 1:20) in certain ethnic groups. In classic 21-hydroxylase deficiency, glucocorticoids are given in doses sufficient to suppress adrenal androgen secretion, and mineralocorticoids are given to normalise electrolytes and plasma renin activity. The management of CAH may be complicated by iatrogenic Cushing's syndrome, inadequately treated hyperandrogenism, or both. Prenatal treatment may decrease virilisation of the affected female foetus, but the efficacy and safety of treating CAH prenatally remains to be fully defined. Close clinical monitoring of growth and development is essential to optimise treatment outcome. New treatment approaches are currently under investigation in the most severely affected patients, while nonclassic CAH does not always require treatment.
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Affiliation(s)
- D Merke
- Warren Grant Magnuson Clinical Center, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1932, USA.
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30
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Abstract
We review the controversies surrounding the management of patients born with ambiguous genitalia to determine the strengths and weaknesses of recommendations for clinical practice. Traditional practice involves paternalistic decision making by medical practitioners, including the use of deception and/or incomplete communication of facts about the infant's condition and early surgical intervention to make a "definitive" sex and gender assignment. However, modern scientific evidence about sex-role determination refutes earlier theories supporting the appropriateness and need for early decisions. Some intersex individuals have begun to speak out against their treatment, denouncing the secretive approaches and cosmetic surgery without the specific consent of the (mature) affected individuals. They argue for complete disclosure of information regarding the condition and deferral of all surgery until at least adolescence. The traditionalist practices no longer conform to modern legal or ethical standards of care. The position of some intersex activists ignores the potential for psychosocial harm to intersex children and our society's general and strong deference to parental discretion in decisions for and about their children. We argue for a middle way, involving shared decision making with parents of children with intersex and the honoring of parental preferences for or against surgery.
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Affiliation(s)
- J Daaboul
- Division of Pediatric Endocrinology, Children 's Hospital of Oakland, CA, USA
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31
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Meyer-Bahlburg HF. Gender and sexuality in classic congenital adrenal hyperplasia. Endocrinol Metab Clin North Am 2001; 30:155-71, viii. [PMID: 11344934 DOI: 10.1016/s0889-8529(08)70024-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The current debate about the psychosocial management of intersex patients has significant implications for 46,XX patients with classic congenital adrenal hyperplasia (CAH) in two respects: (1) the question of genital surgery for reasons other than purely medical ones before the patient is old enough to give informed consent, and (2) the question of gender assignment in severely masculinized patients. This article reviews the status of the empirical evidence for the development of gender and sexuality in 46,XX persons with classic CAH and its implications for clinical practice.
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Affiliation(s)
- H F Meyer-Bahlburg
- New York State Psychiatric Institute, Columbia University, New York, New York, USA.
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Abstract
Congenital adrenal hyperplasia syndromes result from deficiencies of enzymes involved in corticosteroid biosynthesis. Most commonly, they are due to mutations in 21-hydroxylase. This chapter describes the clinical diagnosis and management of congenital adrenal hyperplasias throughout life, including in the fetus, child and adult. These clinical recommendations are explained in the context of the molecular and biochemical characteristics of the diseases.
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Affiliation(s)
- P C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas, TX 75235-9063, USA
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Lo JC, Grumbach MM. Pregnancy outcomes in women with congenital virilizing adrenal hyperplasia. Endocrinol Metab Clin North Am 2001; 30:207-29. [PMID: 11344937 DOI: 10.1016/s0889-8529(08)70027-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although low fertility rates have traditionally been reported among women with classic CAH and especially among women with the salt-wasting variant, more recent data suggest that fertility rates are significantly improved, largely owing to earlier treatment of CAH, improved compliance with therapy, and surgical advances in genital reconstruction. Furthermore, ovulation induction and assisted reproductive techniques are now available to women who remain infertile despite effective adrenal androgen suppression. Although the pregnancy experience in women with classic CAH remains limited, it is apparent that, once pregnant, these women have a high probability of successful outcome. Key issues should be emphasized in the management of CAH during gestation, including the need for assessing adrenal steroid replacement and adrenal androgen suppression, particularly in light of the interplay between maternal hyperandrogenism and the protective effect of placental aromatase activity, which provides a relatively large margin of safety for the female fetus. Maternal hormone levels should be evaluated in the context of laboratory-specific reference ranges for pregnancy. The infant should be examined for ambiguous genitalia and monitored for evidence of adrenal insufficiency. Although an affected female infant with classic CAH has not been reported as a pregnancy outcome of a mother with classic virilizing CAH, these concerns should be discussed during preconception counseling. Patients should also be aware of the importance of medication compliance and careful hormonal monitoring during the entire pregnancy. In most cases, successful gestational management requires the close coordination of care between the obstetrician and endocrinologist.
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Affiliation(s)
- J C Lo
- Department of Medicine, University of California, San Francisco, USA
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34
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Abstract
More than 90% of cases of congenital adrenal hyperplasia (CAH, the inherited inability to synthesize cortisol) are caused by 21-hydroxylase deficiency. Females with severe, classic 21-hydroxylase deficiency are exposed to excess androgens prenatally and are born with virilized external genitalia. Most patients cannot synthesize sufficient aldosterone to maintain sodium balance and may develop potentially fatal "salt wasting" crises if not treated. The disease is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme. More than 90% of these mutations result from intergenic recombinations between CYP21 and the closely linked CYP21P pseudogene. Approximately 20% are gene deletions due to unequal crossing over during meiosis, whereas the remainder are gene conversions--transfers to CYP21 of deleterious mutations normally present in CYP21P. The degree to which each mutation compromises enzymatic activity is strongly correlated with the clinical severity of the disease in patients carrying it. Prenatal diagnosis by direct mutation detection permits prenatal treatment of affected females to minimize genital virilization. Neonatal screening by hormonal methods identifies affected children before salt wasting crises develop, reducing mortality from this condition. Glucocorticoid and mineralocorticoid replacement are the mainstays of treatment, but more rational dosing and additional therapies are being developed.
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Affiliation(s)
- P C White
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas 75390-9063, USA.
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Abstract
PURPOSE The present standard of practice in the management of ambiguous and traumatized genitalia was evaluated. MATERIALS AND METHODS Published cases of intersexuality and protocols for the management of traumatized genitalia were reviewed with consideration of the input of intersexual individuals. Independent research on different types of intersexuality is also presented. RESULTS The present standard pediatric recommendations and precepts for the management of ambiguous or traumatized genitalia are wanting. Followup studies on which to base treatment decisions are needed. Evidence based principles of medical management are proposed. CONCLUSIONS A moratorium on sex reassignment cosmetic surgery is recommended. Also recommended are that followup studies should be instituted on past cases, and honesty and counseling should be the core of initial and subsequent treatment.
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Affiliation(s)
- M Diamond
- Department of Anatomy and Reproductive Biology, University of Hawaii, John A. Burns School of Medicine, Honolulu, USA
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Affiliation(s)
- H F Meyer-Bahlburg
- New York State Psychiatric Institute, and Department of Psychiatry, Columbia University, New York 10032-2695, USA
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ALIZAI N, THOMAS D, LILFORD R, BATCHELOR A, JOHNSON N. FEMINIZING GENITOPLASTY FOR CONGENITAL ADRENAL HYPERPLASIA: WHAT HAPPENS AT PUBERTY? J Urol 1999. [DOI: 10.1016/s0022-5347(05)68986-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kipnis K, Diamond M. Pediatric Ethics and the Surgical Assignment of Sex. THE JOURNAL OF CLINICAL ETHICS 1998. [DOI: 10.1086/jce199809409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Bailez MM, Gearhart JP, Migeon C, Rock J. Vaginal reconstruction after initial construction of the external genitalia in girls with salt-wasting adrenal hyperplasia. J Urol 1992; 148:680-2; discussion 683-4. [PMID: 1640545 DOI: 10.1016/s0022-5347(17)36691-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A total of 28 patients with salt-wasting adrenal hyperplasia who underwent revision of the external genitalia at an early age (mean age 21.4 months) has been followed for 12 to 20 years (mean 16.3 years). The age at initial surgery ranged from 3 weeks to 5 years. Twenty-five patients had a low and 3 had a high takeoff of the vagina from the urogenital sinus. Of these children 22 (78.5%) required further vaginal reconstructive procedures to achieve a normal vaginal outlet. Of the 22 patients requiring further repair 18 have undergone vaginal reconstructive procedures with an initial success rate of 72.2%. These long-term data suggest that if vaginal reconstructive surgery is performed in infancy details, such as placement of the perineal flap well into the vagina and careful followup of the vaginal outlet, are mandatory for success. If there is evidence of outlet narrowing, periodic dilation will be needed to prevent vaginal stenosis and further vaginal surgery.
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Affiliation(s)
- M M Bailez
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Newman K, Randolph J, Anderson K. The surgical management of infants and children with ambiguous genitalia. Lessons learned from 25 years. Ann Surg 1992; 215:644-53. [PMID: 1632686 PMCID: PMC1242521 DOI: 10.1097/00000658-199206000-00011] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Over a 25-year period, 91 children with ambiguous genitalia have received surgical management. Female sex assignment was made for 79. Of these, 60 patients underwent extensive clitoral reconstruction consonant with the female assignment. Forty-two patients had vaginal reconstruction. Factors relating to success include: (1) prompt and appropriate sex assignment; (2) early and accurate diagnosis; (3) conservative reconstruction of the clitoris at an early age (less than 1 year); and (4) choice of vaginal reconstruction based on the severity of the malformation. Long-term follow-up demonstrates satisfactory anatomic and functional results when clitoral surgery alone was required. Functional results for patients with extensive vaginal reconstruction have been compromised. Physicians caring for children with congenital intersexual anomalies can expect to encounter a wide spectrum of anatomic and physiologic derangements. Cosmetic appearance alone is an inadequate measure of success because endocrinologic, social, psychological, and sexual factors must be blended into comprehensive evaluation of these patients. The management plan must be flexible and individualized, incorporating long-term follow-up to adulthood.
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Affiliation(s)
- K Newman
- Department of Surgery, Children's National Medical Center, Washington, DC 20010
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Newman K, Randolph J, Parson S. Functional results in young women having clitoral reconstruction as infants. J Pediatr Surg 1992; 27:180-3; discussion 183-4. [PMID: 1564615 DOI: 10.1016/0022-3468(92)90308-t] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nine young women who had clitoral recession for clitoromegaly as infants have been evaluated for anatomical appearance, psychosocial adjustment, and sexual function. Highly satisfactory anatomic results were obtained, although two patients required subsequent revision. The tested psychological parameters were essentially normal. Virtually all patients were sexually active and all but one have achieved regular painless orgasm. Surgical reconstruction has been accomplished by recessing the entire disfigured clitoris, thereby conserving all erectile tissue and preserving sensation. In addition to assessment of anatomical appearance, long-term follow-up of children with ambiguous genitalia requires regular evaluation of social, psychological, and sexual parameters.
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Affiliation(s)
- K Newman
- Department of Surgery, Children's National Medical Center, Washington, DC 20010
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Tummon IS. Vaginal reconstruction in congenital adrenal hyperplasia. Fertil Steril 1987; 47:1043. [PMID: 3595898 DOI: 10.1016/s0015-0282(16)59248-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Mulaikal RM, Migeon CJ, Rock JA. Fertility rates in female patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. N Engl J Med 1987; 316:178-82. [PMID: 3491959 DOI: 10.1056/nejm198701223160402] [Citation(s) in RCA: 179] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Among 80 women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency (40 with the simple virilizing form and 40 with the salt-losing form), 40 reported having an adequate introitus and being heterosexually active. In 15 of 25 patients with the simple virilizing form, 25 pregnancies resulted in 20 normal children, whereas only 1 of 15 women with the salt-losing form became pregnant; this pregnancy was electively terminated. Several factors seem to be responsible for the low fertility rates: noncompliance with therapy was probably high, as suggested by hirsutism and poor endocrine follow-up in 25 percent of patients; whereas 49 patients had regular menstrual periods, 14 had irregular periods, 10 had amenorrhea, 5 had undergone hysterectomy, and 2 had entered menopause; 87 percent of patients with salt loss and 50 percent of those with simple virilization (P less than 0.001) had remained single; the vaginal introitus was reported to be inadequate for intercourse by 35 percent of patients (53 percent of those with salt loss and 18 percent of those with simple virilization; P less than 0.002); and heterosexual activity was reported less frequently among patients with an inadequate introitus. The status of the introitus seemed to have a more important role in the sexual activity reported than did the degree of prenatal exposure to androgen (which was higher among patients with salt loss than among those with simple virilization). However, our data did not rule out an effect of androgen exposure on female fetuses. Our experience indicates that improved surgical correction of the external genitalia and better compliance with therapy will be necessary to improve fertility rates among women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.
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