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Saadat N, Pallas B, Ciarelli J, Vyas AK, Padmanabhan V. Gestational testosterone excess early to mid-pregnancy disrupts maternal lipid homeostasis and activates biosynthesis of phosphoinositides and phosphatidylethanolamines in sheep. Sci Rep 2024; 14:6230. [PMID: 38486090 PMCID: PMC10940674 DOI: 10.1038/s41598-024-56886-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
Gestational hyperandrogenism is a risk factor for adverse maternal and offspring outcomes with effects likely mediated in part via disruptions in maternal lipid homeostasis. Using a translationally relevant sheep model of gestational testosterone (T) excess that manifests maternal hyperinsulinemia, intrauterine growth restriction (IUGR), and adverse offspring cardiometabolic outcomes, we tested if gestational T excess disrupts maternal lipidome. Dimensionality reduction models following shotgun lipidomics of gestational day 127.1 ± 5.3 (term 147 days) plasma revealed clear differences between control and T-treated sheep. Lipid signatures of gestational T-treated sheep included higher phosphoinositides (PI 36:2, 39:4) and lower acylcarnitines (CAR 16:0, 18:0, 18:1), phosphatidylcholines (PC 38:4, 40:5) and fatty acids (linoleic, arachidonic, Oleic). Gestational T excess activated phosphatidylethanolamines (PE) and PI biosynthesis. The reduction in key fatty acids may underlie IUGR and activated PI for the maternal hyperinsulinemia evidenced in this model. Maternal circulatory lipids contributing to adverse cardiometabolic outcomes are modifiable by dietary interventions.
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Affiliation(s)
- Nadia Saadat
- Department of Pediatrics, 7510 MSRB, University of Michigan, 1150 W. Medical Center Dr, Ann Arbor, MI, 148019-5718, USA
| | - Brooke Pallas
- Unit Lab Animal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Joseph Ciarelli
- Department of Pediatrics, 7510 MSRB, University of Michigan, 1150 W. Medical Center Dr, Ann Arbor, MI, 148019-5718, USA
| | - Arpita Kalla Vyas
- Department of Pediatrics, Washington University St. Louis, St. Louis, MO, USA
| | - Vasantha Padmanabhan
- Department of Pediatrics, 7510 MSRB, University of Michigan, 1150 W. Medical Center Dr, Ann Arbor, MI, 148019-5718, USA.
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Yu J, Lu S, Fang L, Kakongoma N, Hu W. Pregnancy management of IVF-ET pregnancies in a patient with classical 21-hydroxylase deficiency: A case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2024; 293:50-56. [PMID: 38104394 DOI: 10.1016/j.ejogrb.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To report a rare case of a woman with classical 21-hydroxylase deficiency who twice had singleton pregnancies with live births after in vitro fertilization and embryo transfer (IVF-ET). DESIGN Case report and literature review. PATIENT A 35-year-old woman with classical 21-hydroxylase deficiency underwent external genital plastic surgery during adolescence and achieved second pregnancy after IVF-ET with long-term glucocorticoid replacement therapy. METHODS During regular antenatal testing, we focus on monitoring patients' weight gain, blood pressure, increasing trend of uterine height and abdominal circumference, and fetal growth trend. Individualized glucocorticoid therapy during pregnancy, glucocorticoid stress dose at delivery, management of systemic metabolism to prevent maternal and infant complications, and newborn screening are realized. RESULT In the second pregnancy, the glucocorticoid dosage was not increased. 17-hydroxyprogesterone and testosterone tended to increase in late pregnancy, but they were lower than in the first pregnancy. Blood pressure and blood glucose were normal, but lipids were abnormally elevated, D-dimer also showed a sharp rise under labor stress. A mature male infant was delivered by cesarean at 33+4 weeks of gestation due to placental abruption. CONCLUSION Repeated pregnancies in patients with classical 21-hydroxylase deficiency are rare, especially with Assisted Reproductive Technology. We present a case including a comparison of her two pregnancy monitoring indicators, glucocorticoid medication and delivery to achieve a successful delivery. We review the available literature to analyze pregnancies with classical 21-hydroxylase deficiency.
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Affiliation(s)
- Junxin Yu
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Sha Lu
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou, China; The Affiliated Hangzhou Women's Hospital of Hangzhou Normal University, Hangzhou, China
| | - Lingya Fang
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Nisile Kakongoma
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wensheng Hu
- Department of The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China; Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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3
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Krishnan K, Pillai S, Vaidyanathan G. Pregnancy in a woman with congenital adrenal hyperplasia with 11-beta-hydroxylase deficiency: A case report. Obstet Med 2023; 16:66-68. [PMID: 37139504 PMCID: PMC10150300 DOI: 10.1177/1753495x211042729] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Successful pregnancy with congenital adrenal hyperplasia due to 11-beta-hydroxylase deficiency is an extremely rare condition. Only two cases have been reported in the literature. Methods and results Described here is a 30-year-old woman diagnosed as a neonate with congenital adrenal hyperplasia related to 11-beta-hydroxylase deficiency classic type, who subsequently underwent clitoral resection and vaginoplasty. She was started on lifelong steroid therapy after surgery. She developed hypertension at 11 years of age and was on antihypertensive therapy from then on. In later life, she underwent division of vaginal scar tissue and perineal refashioning. She spontaneously conceived but her pregnancy was complicated by severe pre-eclampsia and delivery was required at 33 weeks of gestation by cesarean section. A healthy male infant was delivered. Conclusion Management of these women is similar to those with more common causes of congenital adrenal hyperplasia, with careful monitoring throughout pregnancy for complications such as gestational diabetes, gestational hypertension, and intrauterine growth restriction.
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Affiliation(s)
- Kavitha Krishnan
- Kavitha Krishnan, Department of Obstetrics and
Gynaecology, Sultan Qaboos University College of Medicine and Health Science, Muscat,
Oman.
| | - Silja Pillai
- Department of Obstetrics and Gynaecology, Sultan Qaboos University Hospital, Oman
| | - Gowri Vaidyanathan
- Department of Obstetrics and Gynaecology, Sultan Qaboos University Hospital, Oman
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Maher JY, Gomez-Lobo V, Merke DP. The management of congenital adrenal hyperplasia during preconception, pregnancy, and postpartum. Rev Endocr Metab Disord 2023; 24:71-83. [PMID: 36399318 PMCID: PMC9884653 DOI: 10.1007/s11154-022-09770-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/21/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders of steroidogenesis of the adrenal cortex, most commonly due to 21-hydroxylase deficiency caused by mutations in the CYP21A2 gene. Although women with CAH have decreased fecundity, they are able to conceive; thus, if pregnancy is not desired, contraception options should be offered. If fertility is desired, women with classic CAH should first optimize glucocorticoid treatment, followed by ovulation induction medications and gonadotropins if needed. Due to the possible pregnancy complications and implications on the offspring, preconception genetic testing and counseling with a high-risk obstetrics specialist is recommended. For couples trying to avoid having a child with CAH, care with a reproductive endocrinology and infertility specialist to utilize in vitro fertilization can be offered, with or without preimplantation genetic testing for monogenic disorders. Prenatal screening and diagnosis options during pregnancy include maternal serum cell free-DNA for sex of the baby, and chorionic villus sampling and amniocentesis for diagnosis of CAH. Pregnant women with classic CAH need glucocorticoids to be adjusted during the pregnancy, at the time of delivery, and postpartum, and should be monitored for adrenal crisis. Maternal and fetal risks may include chorioamnionitis, maternal hypertension, gestational diabetes, cesarean section, and small for gestational age infants. This review on CAH due to 21-hydroxylase deficiency highlights reproductive health including genetic transmission, contraception options, glucocorticoid management, fertility treatments, as well as testing, antenatal monitoring, and management during pregnancy, delivery, and postpartum.
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Affiliation(s)
- Jacqueline Yano Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Staff Clinician, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Veronica Gomez-Lobo
- Director of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 1-2740, Bethesda, MD, 20892, USA.
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5
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Ye L, Zhao Z, Ren H, Wang W, Zhou W, Zheng S, Han R, Zhang J, Li H, Wan Z, Tang C, Sun S, Wang W, Ning G. A Multiclassifier System to Identify and Subtype Congenital Adrenal Hyperplasia Based on Circulating Steroid Hormones. J Clin Endocrinol Metab 2022; 107:e3304-e3312. [PMID: 35512387 PMCID: PMC9282246 DOI: 10.1210/clinem/dgac271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Indexed: 12/04/2022]
Abstract
CONTEXT Measurement of plasma steroids is necessary for diagnosis of congenital adrenal hyperplasia (CAH). We sought to establish an efficient strategy for detection and subtyping of CAH with a machine-learning algorithm. METHODS Clinical phenotype and genetic testing were used to provide CAH diagnosis and subtype. We profiled 13 major steroid hormones by liquid chromatography-tandem mass spectrometry. A multiclassifier system was established to distinguish 11β-hydroxylase deficiency (11βOHD), 17α-hydroxylase/17,20-lyase deficiency (17OHD), and 21α-hydroxylase deficiency (21OHD) in a discovery cohort (n = 226). It was then validated in an independent cohort (n = 111) and finally applied in a perspective cohort of 256 patients. The diagnostic performance on the basis of area under receiver operating characteristic curves (AUCs) was evaluated. RESULTS A cascade logistic regression model, we named the "Steroidogenesis Score", was able to discriminate the 3 most common CAH subtypes: 11βOHD, 17OHD, and 21OHD. In the perspective application cohort, the steroidogenesis score had a high diagnostic accuracy for all 3 subtypes, 11βOHD (AUC, 0.994; 95% CI, 0.983-1.000), 17OHD (AUC, 0.993; 95% CI, 0.985-1.000), and 21OHD (AUC, 0.979; 95% CI, 0.964-0.994). For nonclassic 21OHD patients, the tool presented with significantly higher sensitivity compared with measurement of basal 17α-hydroxyprogesterone (17OHP) (0.973 vs 0.840, P = 0.005) and was not inferior to measurement of basal vs stimulated 17OHP (0.973 vs 0.947, P = 0.681). CONCLUSIONS The steroidogenesis score was biochemically interpretable and showed high accuracy in identifying CAH patients, especially for nonclassic 21OHD patients, thus offering a standardized approach to diagnose and subtype CAH.
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Affiliation(s)
| | | | | | | | | | - Sichang Zheng
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Rulai Han
- Shanghai Key Laboratory for Endocrine Tumors, Shanghai Institute of Endocrine and Metabolic Diseases, Shanghai, China
| | - Jie Zhang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Haorong Li
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Zhihan Wan
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Chao Tang
- Center for quantitative biology, Peking University, Beijing, China
| | - Shouyue Sun
- Correspondence: Shouyue Sun, MD, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, 197 Ruijin 2nd Rd, Shanghai 200025, P.R. China.
| | - Weiqing Wang
- Weiqing Wang, MD, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, 197 Ruijin 2nd Rd, Shanghai 200025, P.R. China.
| | - Guang Ning
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
- Shanghai Key Laboratory for Endocrine Tumors, Shanghai Institute of Endocrine and Metabolic Diseases, Shanghai, China
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Jha S, Turcu AF. Nonclassic Congenital Adrenal Hyperplasia: What Do Endocrinologists Need to Know? Endocrinol Metab Clin North Am 2021; 50:151-165. [PMID: 33518183 PMCID: PMC7863575 DOI: 10.1016/j.ecl.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Congenital adrenal hyperplasia encompasses a group of autosomal recessive defects in cortisol biosynthesis, and 21-hydroxylase deficiency accounts for 95% of such cases. Non-classic 21-hydroxylase deficiency is due to partial enzymatic defects, which present with normal cortisol synthesis, but excessive production of adrenal androgens, including 11-oxygenated androgens. Non-classic 21-hydroxylase deficiency is relatively common, and its phenotype resembles closely that of polycystic ovary syndrome. This review focuses primarily on non-classic 21-hydroxylase deficiency, its clinical features, diagnosis, and management.
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Affiliation(s)
- Smita Jha
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA; Metabolic Diseases Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, 9000 Rockville Pike, Room 9C432A, Bethesda, MD 20892, USA. https://twitter.com/docsmita_jha
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, 1150 West Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI 48109, USA.
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Ata A, Özen S, Onay H, Uzun S, Gökşen D, Özkınay F, Özbaran NB, Ulman İ, Darcan Ş. A large cohort of disorders of sex development and their genetic characteristics: 6 novel mutations in known genes. Eur J Med Genet 2021; 64:104154. [PMID: 33516834 DOI: 10.1016/j.ejmg.2021.104154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/03/2020] [Accepted: 01/25/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Disorders of sex development (DSD) constitutes a group of congenital conditions that affect urogenital differentiation and are associated with chromosomal, gonadal and phenotypic sex abnormalities. OBJECTIVE To evaluate the clinical and genetic features of childhood DSD cases. MATERIALS AND METHODS DSD patients followed up between the years of 2002-2018 were evaluated in terms of their complaints, demographic, clinical features and genetic diagnoses. RESULTS Out of 289 patients, 143(49.5%) were classified as 46XY DSD, 62(21.5%) as 46XX DSD and 84(29%) as sex chromosomal DSD. Genetic diagnosis was achieved in 150 patients (51.9%). The distribution of the molecular diagnosis of the 46XY DSD patients were; 12 (26.6%) SRD5A2, 10 (22.2%) AR, 7 (15.5%) HSD17B3, 3 (6.6%) WT-1, 2 (4.4%) AMHR2, 2 (4.4%) AMH, 2 (4.4%) LHCGR, 2 (4.4%) HSD3B2, 1 (2.2%) NR5A1, 1 (2.2%) CYP17A1 and 1 (2.2%) SRY mutation. Fifty (80.6%) of the 46XX DSD patients received a diagnosis with clinical and laboratory findings. Twenty-four (38.7%) of them were 21-hydroxylase deficiency, 9(14.5%) Rokitansky-Küster-Hauser Syndrome, 4 (6.5%) 11-β hydroxylase deficiency, 3 (4.8%) gonadal dysgenesis and 2 (3.2%) aromatase deficiency. In 46XX group pathogenic mutations were detected in 21(33.8%) of the patients. Eighty-four (29%) patients were diagnosed as sex chromosomal disorder. Of these 66 (78.5%) were Turner Syndrome, 6 (7.2%) Klinefelter Syndrome and 10 (11.9%) mix gonadal dysgenesis. Gender re-assignment was decided in 11 patients. Malignant and pre-invasive lesions was diagnosed in 8 (2.7%) patients. CONCLUSION Many of DSD's are clinically similar and etiology of numerous of them still cannot be established. A multi-disciplinary approach and new rapid genetic diagnostic methods are needed in the process from diagnosis to gender assignment and follow-up.
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Affiliation(s)
- Aysun Ata
- Department of Pediatric Endocrinology and Diabetes, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Samim Özen
- Department of Pediatric Endocrinology and Diabetes, Faculty of Medicine, Ege University, Izmir, Turkey.
| | - Hüseyin Onay
- Department of Medical Genetics, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Selin Uzun
- Department of Child Health and Diseases, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Damla Gökşen
- Department of Pediatric Endocrinology and Diabetes, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Ferda Özkınay
- Department of Medical Genetics, Faculty of Medicine, Ege University, Izmir, Turkey; Department of Pediatric Genetics, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Nazlı Burcu Özbaran
- Department of Pediatric and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - İbrahim Ulman
- Department of Pediatric Urology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Şükran Darcan
- Department of Pediatric Endocrinology and Diabetes, Faculty of Medicine, Ege University, Izmir, Turkey
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9
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Hirschberg AL, Gidlöf S, Falhammar H, Frisén L, Almqvist C, Nordenskjöld A, Nordenström A. Reproductive and Perinatal Outcomes in Women with Congenital Adrenal Hyperplasia: A Population-based Cohort Study. J Clin Endocrinol Metab 2021; 106:e957-e965. [PMID: 33135723 DOI: 10.1210/clinem/dgaa801] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Reduced fertility has been reported for women with congenital adrenal hyperplasia (CAH), especially for those with the salt-losing form. However, data are sparse on reproductive and perinatal outcomes in these women. OBJECTIVE To investigate reproductive and perinatal outcomes in women with CAH. DESIGN AND SETTING Population-based and nationwide study using the National CAH Register, the Total Population Register, and the Medical Birth Register of Sweden. PARTICIPANTS A total of 272 women with CAH due to 21-hydroxylase deficiency and 27 200 controls matched by sex, age, and place of birth. The median age was 31 years. MAIN OUTCOME MEASURES The proportion of CAH women that have given birth, and reproductive and perinatal outcomes. RESULTS Of the 272 women with CAH, 69 gave birth to at least 1 child (25.4%), which was a lower frequency than for the controls (45.8%) (P < .001). Furthermore, women with CAH had fewer children than controls and were slightly older at birth of their first child. More women with CAH were diagnosed with gestational diabetes than controls, 4.9% versus 1.4% (P < .05), and more women with CAH were delivered through cesarean section, 51.4% versus 12.3% (P < .05). There was no difference in Apgar score or frequency of small-for-gestational age between children born to mothers with CAH and controls. CONCLUSIONS This is, to our knowledge, the largest cohort designed to investigate reproductive and perinatal outcomes in women with CAH. We found the birth rate to be lower in women with CAH; gestational diabetes and cesarean section were more common, but perinatal outcomes were comparable with controls.
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Affiliation(s)
- Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sebastian Gidlöf
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Stockholm South General Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Lung and Allergy Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Surgery, Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
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10
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Kocova M, Anastasovska V, Falhammar H. Clinical outcomes and characteristics of P30L mutations in congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Endocrine 2020; 69:262-277. [PMID: 32367336 PMCID: PMC7392929 DOI: 10.1007/s12020-020-02323-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/18/2020] [Indexed: 01/07/2023]
Abstract
Despite numerous studies in the field of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, some clinical variability of the presentation and discrepancies in the genotype/phenotype correlation are still unexplained. Some, but not all, discordant phenotypes caused by mutations with known enzyme activity have been explained by in silico structural changes in the 21-hydroxylase protein. The incidence of P30L mutation varies in different populations and is most frequently found in several Central and Southeast European countries as well as Mexico. Patients carrying P30L mutation present predominantly as non-classical CAH; however, simple virilizing forms are found in up to 50% of patients. Taking into consideration the residual 21-hydroxulase activity present with P30L mutation this is unexpected. Different mechanisms for increased androgenization in patients carrying P30L mutation have been proposed including influence of different residues, accompanying promotor allele variability or mutations, and individual androgene sensitivity. Early diagnosis of patients who would present with SV is important in order to improve outcome. Outcome studies of CAH have confirmed the uniqueness of this mutation such as difficulties in phenotype classification, different fertility, growth, and psychologic issues in comparison with other genotypes. Additional studies of P30L mutation are warranted.
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Affiliation(s)
- Mirjana Kocova
- Medical Faculty, University"Cyril&Methodius", Skopje, Republic of North Macedonia
| | - Violeta Anastasovska
- Genetic Laboratory, University Pediatric Hospital, Skopje, Republic of North Macedonia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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11
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Abstract
Fertility rates in classic congenital adrenal hyperplasia caused by 21-hydroxylase deficiency are substantially decreased for various reasons, including hormonal, anatomic, psychosocial, and psychosexual causes. However, fecundity is comparable with the general population. Under optimal hormone replacement, the course and outcome of pregnancies is also good. This article summarizes successful gestational management, including preconceptional considerations, adjustment of hormone replacement during pregnancy, delivery and lactation, as well as the prevention of adrenal crises. In nonclassic 21-hydroxylase deficiency, preconceptional low-dose hydrocortisone replacement normalizes the otherwise increased miscarriage rate. Pregnancy reports in rarer forms of congenital adrenal hyperplasia are summarized as well.
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Affiliation(s)
- Nicole Reisch
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Ziemssenstraße 1, München 80336, Germany.
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12
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Levin G, Elchalal U, Rottenstreich A. The adrenal cortex: Physiology and diseases in human pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 240:139-143. [PMID: 31284087 DOI: 10.1016/j.ejogrb.2019.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/28/2022]
Abstract
Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.
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Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel.
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
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13
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Kocova M, Anastasovska V, Bitovska I. The impact of CYP21A2 (P30L/I172N) genotype on female fertility in one family. Eur J Med Res 2019; 24:21. [PMID: 31217034 PMCID: PMC6582564 DOI: 10.1186/s40001-019-0379-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/13/2019] [Indexed: 11/10/2022] Open
Abstract
Background The simple virilizing (SV) form of congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder usually caused by steroid 21-hydroxylase deficiency due to I172N missense mutation at the CYP21A2 gene. Clinical presentation encompasses virilization of external genitalia in newborn females and pseudoprecocious puberty in both sexes, due to reactive androgen overproduction. The aim of this study was to present two sisters with an SV form of CAH and distinctive genotype, detected and treated since childhood with a poor compliance and poor metabolic control hindering the fertility. Case presentation We retrospectively reviewed the clinical, biochemical, and molecular data of two sisters with CAH a 46,XX karyotype when they reached an age of 35 and 38 years, respectively, and were attempting conception for several years. They had been diagnosed with SV form of CAH at the age of 7 and 9 years, respectively, by the standard clinical and biochemical procedures, presenting with severe virilization due to androgen excess. Follow-up was performed through standard methods of measurement of 17-OHP, testosterone, and ACTH. Clitoroplasty with vaginoplasty was performed at the age of 18 in the older sister. Using PCR/ACRS, we performed molecular analysis of the nine most common point CYP21A2 mutations in the patients and family members. The P30L/II72N genotype was observed in both sisters. They had inadequate metabolic control due to noncompliance until decision to conceive. IVF was performed three times in the older sister without success. Sufficient follicles were harvested and fertilized; however, the embryos were lost 3–5 days after implantations. The younger sister is preparing for IVF. She underwent follicle harvesting and the embryos were frozen awaiting appropriate hormonal balance for embryo transfer. The I172N mutation in the heterozygote state was observed in their other two sisters, whose fertility was unaffected. Conclusions Despite significant improvements over the last years in achieving fertility in female patients with SV CAH, it is highly dependent upon the severity of virilization and the metabolic control. The role of P30L mutation in infertility and unsuccessfully assisted reproduction remains to be elucidated.
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Affiliation(s)
- Mirjana Kocova
- Department of Endocrinology and Genetics, University Clinic of Pediatrics, Medical Faculty, Ss. Cyril and Methodius University, Vodnjanska 17, 1000, Skopje, Republic of Macedonia.
| | - Violeta Anastasovska
- Department of Endocrinology and Genetics, University Clinic of Pediatrics, Medical Faculty, Ss. Cyril and Methodius University, Vodnjanska 17, 1000, Skopje, Republic of Macedonia
| | - Iskra Bitovska
- University Clinic for Endocrinology, Diabetes and Metabolic Disorders, Medical Faculty, Ss. Cyril and Methodius University, Vodnjanska 17, 1000, Skopje, Republic of Macedonia
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14
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Gomes LG, Bachega TA, Mendonca BB. Classic congenital adrenal hyperplasia and its impact on reproduction. Fertil Steril 2019; 111:7-12. [DOI: 10.1016/j.fertnstert.2018.11.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/25/2018] [Accepted: 11/27/2018] [Indexed: 01/30/2023]
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Teasdale S, Morton A. Changes in biochemical tests in pregnancy and their clinical significance. Obstet Med 2018; 11:160-170. [PMID: 30574177 PMCID: PMC6295771 DOI: 10.1177/1753495x18766170] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
Interpretation of laboratory investigations relies on reference intervals. Physiological changes in pregnancy may result in significant changes in normal values for many biochemical assays, and as such results may be misinterpreted as abnormal or mask a pathological state. The aims of this review are as follows: 1. To review the major physiological changes in biochemical tests in normal pregnancy. 2. To outline where these physiological changes are important in interpreting laboratory investigations in pregnancy. 3. To document the most common causes of abnormalities in biochemical tests in pregnancy, as well as important pregnancy-specific causes.
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Affiliation(s)
- Stephanie Teasdale
- Queensland Diabetes and Endocrine Centre, Mater Misericordiae Hospital, Brisbane, Australia
| | - Adam Morton
- Queensland Diabetes and Endocrine Centre, Mater Misericordiae Hospital, Brisbane, Australia
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Dörr HG, Hess J, Penger T, Marx M, Oppelt P. Miscarriages in families with an offspring that have classic congenital adrenal hyperplasia and 21-hydroxylase deficiency. BMC Pregnancy Childbirth 2018; 18:456. [PMID: 30470203 PMCID: PMC6251199 DOI: 10.1186/s12884-018-2091-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/15/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (CAH). Both men and women with classic CAH have lower fertility rates than the general population, and an increased rate of miscarriages has been reported in affected women. There are no data on the incidence rate of miscarriages in families with an offspring that have classic CAH. METHODS We studied families with a history of classic CAH. The families came from different parts of Germany and attended the annual meeting of the German CAH support group for parents and patients which was held in Hamburg in September 2014. The data was collected anonymously by a paper-based questionnaire which was completed by the families at home. The families also accepted the responsibility to address this question to their siblings. In all, the data of 50 families with at least one child with classic CAH, and the data of 164 parental siblings were available for evaluation. Miscarriage rates were calculated in relation to the reported pregnancies. RESULTS Twenty-two miscarriages were reported from 19 families. At least one miscarriage occurred in 38% of the families, three families experienced two miscarriages and 16 families had one miscarriage each. The mean miscarriage rate was 15.8%. The heterozygous mothers had a total of 90 siblings (41 m, 49 f), while 74 siblings (33 m, 41 f) were reported from the heterozygous fathers. The miscarriage rate was 10.1% in the families of the mothers` siblings, and 11.4% in the families of the fathers` siblings. The genotype was known in all parents that have an offspring with classic CAH, but not defined in 82% of the maternal siblings, and in 86% of the paternal siblings. No child with classic CAH has been diagnosed in any of the sibling's families to date. CONCLUSION Our data show that the miscarriage rate in German families with a child with classic CAH is not elevated.
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Affiliation(s)
- Helmuth G. Dörr
- Division Pediatric Endocrinology, Department Pediatrics, University Hospital of Erlangen (Friedrich Alexander-Universität Erlangen-Nürnberg), Loschgestr. 15, 91054 Erlangen, Germany
| | - Johannes Hess
- Division Pediatric Endocrinology, Department Pediatrics, University Hospital of Erlangen (Friedrich Alexander-Universität Erlangen-Nürnberg), Loschgestr. 15, 91054 Erlangen, Germany
| | - Theresa Penger
- Division Pediatric Endocrinology, Department Pediatrics, University Hospital of Erlangen (Friedrich Alexander-Universität Erlangen-Nürnberg), Loschgestr. 15, 91054 Erlangen, Germany
| | - Michaela Marx
- Division Pediatric Endocrinology, Department Pediatrics, University Hospital of Erlangen (Friedrich Alexander-Universität Erlangen-Nürnberg), Loschgestr. 15, 91054 Erlangen, Germany
| | - Patricia Oppelt
- Pediatric Gynecology, Department. Gynecology and Obstetrics, University Hospital of Erlangen, Erlangen, Germany
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17
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Choi JH, Yoo HW. Management issues of congenital adrenal hyperplasia during the transition from pediatric to adult care. KOREAN JOURNAL OF PEDIATRICS 2017; 60:31-37. [PMID: 28289431 PMCID: PMC5346506 DOI: 10.3345/kjp.2017.60.2.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/21/2016] [Accepted: 02/13/2016] [Indexed: 11/27/2022]
Abstract
Steroid 21-hydroxylase deficiency is the most prevalent form of congenital adrenal hyperplasia (CAH), accounting for approximately 95% of cases. With the advent of newborn screening and hormone replacement therapy, most children with CAH survive into adulthood. Adolescents and adults with CAH experience a number of complications, including short stature, obesity, infertility, tumor, osteoporosis, and reduced quality of life. Transition from pediatric to adult care and management of long-term complications are challenging for both patients and health-care providers. Psychosocial issues frequently affect adherence to glucocorticoid treatment. Therefore, the safe transition of adolescents to adult care requires regular follow-up of patients by a multidisciplinary team including pediatric and adult endocrinologists. The major goals for management of adults with 21-hydroxylase deficiency are to minimize the long-term complications of glucocorticoid therapy, reduce hyperandrogenism, prevent adrenal or testicular adrenal rest tumors, maintain fertility, and improve quality of life. Optimized medical or surgical treatment strategies should be developed through coordinated care, both during transition periods and throughout patients' lifetimes. This review will summarize current knowledge on the management of adults with CAH, and suggested appropriate approaches to the transition from pediatric to adult care.
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Affiliation(s)
- Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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19
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Böttcher B, Wildt L. Nichtklassisches adrenogenitales Syndrom. GYNAKOLOGISCHE ENDOKRINOLOGIE 2016. [DOI: 10.1007/s10304-016-0088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Lekarev O, Lin-Su K, Vogiatzi MG. Infertility and Reproductive Function in Patients with Congenital Adrenal Hyperplasia: Pathophysiology, Advances in Management, and Recent Outcomes. Endocrinol Metab Clin North Am 2015; 44:705-22. [PMID: 26568487 DOI: 10.1016/j.ecl.2015.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Individuals with congenital adrenal hyperplasia have reduced fertility. However, reproductive outcomes have improved over the years. This review provides an update on the multiple pathologic processes that contribute to reduced fertility in both sexes, from alterations of the hypothalamic-pituitary-gonadal axis to the direct effect on gonadal function by elevated circulating adrenal androgens. In addition, elevated serum progesterone concentrations may hinder ovulation and embryo implantation in women, whereas in men testicular adrenal rest tumors can be a major cause of infertility. Suppression of adrenal androgen secretion represents the first line of therapy toward spontaneous conception in both sexes.
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Affiliation(s)
- Oksana Lekarev
- Pediatric Endocrinology, Weill Cornell Medical College, New York, NY, USA
| | - Karen Lin-Su
- Pediatric Endocrinology, Weill Cornell Medical College, New York, NY, USA
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA.
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21
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Falhammar H, Nordenström A. Nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency: clinical presentation, diagnosis, treatment, and outcome. Endocrine 2015; 50:32-50. [PMID: 26082286 DOI: 10.1007/s12020-015-0656-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/03/2015] [Indexed: 01/14/2023]
Abstract
Nonclassic congenital adrenal hyperplasia (NCAH) is one of the most frequent autosomal recessive disorders in man with a prevalence ranging from 0.1 % in Caucasians up to a few percent in certain ethnic groups. Most cases are never diagnosed due to very mild symptoms, misdiagnosing as polycystic ovary syndrome, or ignorance. In contrast to classic CAH, patients with NCAH present with mild partial cortisol insufficiency and hyperandrogenism and will survive without any treatment. Undiagnosed NCAH may result in infertility, miscarriages, oligomenorrhea, hirsutism, acne, premature pubarche, testicular adrenal rest tumors, adrenal tumors, and voice problems among other symptoms. A baseline measurement of 17-hydroxyprogesterone can be used for diagnosis, but the ACTH stimulation test with measurement of 17-hydroxyprogesterone is regarded as the golden standard. The diagnosis can be verified by CYP21A2 mutation analysis. Treatment is symptomatic and usually with glucocorticoids alone. The lowest possible glucocorticoid dose should be used. Long-term treatment with glucocorticoids will improve the symptoms but will also result in iatrogenic cortisol insufficiency and may also lead to long-term complications such as obesity, insulin resistance, hypertension, osteoporosis, and fractures. Although the complications seen in NCAH patients have been assumed to be related to the glucocorticoid treatment, some may, in fact, be associated with prolonged hyperandrogenism. Different risk factors and negative consequences should be monitored regularly in an attempt to improve the clinical outcome. More research is needed in this relatively common disorder.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, D2:04, Karolinska University Hospital, 171 76, Stockholm, Sweden,
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22
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Abstract
Prenatal treatment of congenital adrenal hyperplasia by administering dexamethasone to a woman presumed to be carrying an at-risk fetus remains a controversial experimental treatment. Review of data from animal experimentation and human trials indicates that dexamethasone cannot be considered safe for the fetus. In animals, prenatal dexamethasone decreases birth weight, affects renal, pancreatic beta cell and brain development, increases anxiety and predisposes to adult hypertension and hyperglycemia. In human studies, prenatal dexamethasone is associated with orofacial clefts, decreased birth weight, poorer verbal working memory, and poorer self-perception of scholastic and social competence. Numerous medical societies have cautioned that prenatal treatment of adrenal hyperplasia with dexamethasone is not appropriate for routine clinical practice and should only be done in Institutional Review Board approved, prospective clinical research settings with written informed consent. The data indicate that this treatment is inconsistent with the classic medical ethical maxim to 'first do no harm'.
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Affiliation(s)
- Walter L Miller
- Department of Pediatrics and Center for Reproductive Sciences, University of California, San Francisco, San Francisco CA 94143-0556, USA.
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23
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Beckett EM, Astapova O, Steckler TL, Veiga-Lopez A, Padmanabhan V. Developmental programing: impact of testosterone on placental differentiation. Reproduction 2014; 148:199-209. [PMID: 24840528 DOI: 10.1530/rep-14-0055] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Gestational testosterone treatment causes maternal hyperinsulinemia, intrauterine growth retardation (IUGR), low birth weight, and adult reproductive and metabolic dysfunctions. Sheep models of IUGR demonstrate placental insufficiency as an underlying cause of IUGR. Placental compromise is probably the cause of fetal growth retardation in gestational testosterone-treated sheep. This study tested whether testosterone excess compromises placental differentiation by its androgenic action and/or via altered insulin sensitivity. A comparative approach of studying gestational testosterone (aromatizable androgen) against dihydrotestosterone (non-aromatizable androgen) or testosterone plus androgen antagonist, flutamide, was used to determine whether the effects of testosterone on placental differentiation were programed by its androgenic actions. Co-treatment of testosterone with the insulin sensitizer, rosiglitazone, was used to establish whether the effects of gestational testosterone on placentome differentiation involved compromised insulin sensitivity. Parallel cohorts of pregnant females were maintained for lambing and the birth weight of their offspring was recorded. Placental studies were conducted on days 65, 90, or 140 of gestation. Results indicated that i) gestational testosterone treatment advances placental differentiation, evident as early as day 65 of gestation, and culminates in low birth weight, ii) placental advancement is facilitated at least in part by androgenic actions of testosterone and is not a function of disrupted insulin homeostasis, and iii) placental advancement, while helping to increase placental efficiency, was insufficient to prevent IUGR and low-birth-weight female offspring. Findings from this study may be of relevance to women with polycystic ovary syndrome, whose reproductive and metabolic phenotype is captured by the gestational testosterone-treated offspring.
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Affiliation(s)
- E M Beckett
- Department of Pediatrics and the Reproductive Sciences ProgramUniversity of Michigan, 300 North Ingalls Building, Room 1138 SW, Ann Arbor, Michigan 48109-5404, USA
| | - O Astapova
- Department of Pediatrics and the Reproductive Sciences ProgramUniversity of Michigan, 300 North Ingalls Building, Room 1138 SW, Ann Arbor, Michigan 48109-5404, USA
| | - T L Steckler
- Department of Pediatrics and the Reproductive Sciences ProgramUniversity of Michigan, 300 North Ingalls Building, Room 1138 SW, Ann Arbor, Michigan 48109-5404, USA
| | - A Veiga-Lopez
- Department of Pediatrics and the Reproductive Sciences ProgramUniversity of Michigan, 300 North Ingalls Building, Room 1138 SW, Ann Arbor, Michigan 48109-5404, USA
| | - V Padmanabhan
- Department of Pediatrics and the Reproductive Sciences ProgramUniversity of Michigan, 300 North Ingalls Building, Room 1138 SW, Ann Arbor, Michigan 48109-5404, USA
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Abstract
: Adrenal diseases--including disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyperaldosteronism and congenital adrenal hyperplasia--are relatively rare in pregnancy, but a timely diagnosis and proper treatment are critical because these disorders can cause maternal and fetal morbidity and mortality. Making the diagnosis of adrenal disorders in pregnancy is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. In addition, pregnancy is marked by several endocrine changes, including activation of the renin-angiotensin-aldosterone system and the hypothalamic-pituitary-adrenal axis. The aim of this article was to review the pathophysiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.
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25
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Mnif MF, Kamoun M, Kacem FH, Mnif F, Charfi N, Naceur BB, Rekik N, Abid M. Reproductive outcomes of female patients with congenital adrenal hyperplasia due to 21-hydroxylase defi ciency. Indian J Endocrinol Metab 2013; 17:790-793. [PMID: 24083158 PMCID: PMC3784860 DOI: 10.4103/2230-8210.117196] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Fertility in women with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) appears to be reduced, especially in women with the classic salt-wasting type. Several factors have been suggested to contribute to this subfertility such as androgen excess, adrenal progesterone hypersecretion, consequences of genital reconstructive surgery, secondary polycystic ovaries syndrome, and psychosexual factors. In contrast to this subfertility, pregnancies are commonly normal and uneventful. Adequate glucocorticoid therapy and improvement of surgical and psychological management could contribute to optimize fertility in CAH female patients, even among women with the classic variant. This review provides current information regarding the reproductive outcomes of women with CAH due to 21-OHD and the fertility and pregnancy issues in this population.
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Affiliation(s)
- Mouna Feki Mnif
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Mahdi Kamoun
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Faten Hadj Kacem
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Fatma Mnif
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Nadia Charfi
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Basma Ben Naceur
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Nabila Rekik
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
| | - Mohamed Abid
- Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia
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26
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Keely E, Malcolm J. Congenital adrenal hyperplasia in pregnancy: approach depends on who is the 'patient'. Obstet Med 2012; 5:154-160. [PMID: 30705696 DOI: 10.1258/om.2012.120015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2012] [Indexed: 11/18/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal-recessive disorders caused by a reduced or absent enzymatic activity at one of the stages of adrenal steroid biosynthesis. Prenatal exposure to androgens leads to external genital masculinization of the affected female child. In pregnancy, the provider may be optimizing care for the woman with CAH or targeting treatment to reduce virilization in the affected unborn child. For the affected adult woman the goals of therapy in pregnancy are to prevent adrenal insufficiency, reduce fetal exposure to androgens and glucocorticoids and to avoid damage to reconstructed genitalia. For prenatal therapy for prevention of virilization of possibly affected female children, dexamethasone is used. However, questions remain about the efficacy and safety of exposing 7/8 unaffected children in the first trimester. Prenatal treatment should only be undertaken after careful discussion with the parents of the risks and benefits in an experienced centre or as part of a research protocol.
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Affiliation(s)
- Erin Keely
- Departments of Medicine and Obstetrics/Gynecology, University of Ottawa, Ottawa ON, Canada
| | - Janine Malcolm
- Departments of Medicine and Obstetrics/Gynecology, University of Ottawa, Ottawa ON, Canada
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27
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Falhammar H, Thorén M. Clinical outcomes in the management of congenital adrenal hyperplasia. Endocrine 2012; 41:355-73. [PMID: 22228497 DOI: 10.1007/s12020-011-9591-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/20/2011] [Indexed: 01/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of disorders affecting adrenal steroid synthesis. The most common form, 21-hydroxylase deficiency, leads to decreased production of cortisol and aldosterone with increased androgen secretion. In classic CAH glucocorticoid treatment can be life-saving, and provides symptom control, but must be given in an unphysiological manner with the risk of negative long-term outcomes. A late diagnosis or a severe phenotype or genotype has also a negative impact. These factors can result in impaired quality of life (QoL), increased cardiometabolic risk, short stature, osteoporosis and fractures, benign tumors, decreased fertility, and vocal problems. The prognosis has improved during the last decades, thanks to better clinical management and nowadays the most affected patients seem to have a good QoL. Very few patients above the age of 60 years have, however, been studied. Classifying patients according to genotype may give additional useful clinical information. The introduction of neonatal CAH screening may enhance long-term results. Monitoring of different risk factors and negative consequences should be done regularly in an attempt to improve clinical outcomes further.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, D2:04, 17176 Stockholm, Sweden,
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Kamata Y, Hayashi A, Ogawa A, Ichikawa R, Moriya T, Shichiri M. A woman with salt-wasting congenital adrenal hyperplasia presenting with a mucinous ovarian cystadenoma during pregnancy. Intern Med 2011; 50:1981-5. [PMID: 21921381 DOI: 10.2169/internalmedicine.50.5401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Women with congenital adrenal hyperplasia (CAH) caused by steroid 21-hydroxylase deficiency show reduced fertility, especially with the salt-wasting form. A 27-year-old pregnant woman with this disease underwent laparotomy and oophorectomy to remove a multilocular ovarian tumor at 14 weeks of pregnancy. This proved to be a mucinous cystadenoma. Toward the third trimester, she presented with marked elevations of 17α-hydroxyprogesterone and plasma renin activity. Careful management of endocrine and body fluid homeostasis allowed her to give birth to a healthy female infant with normal external genitalia. This case illustrates endocrinological parameters during pregnancy in a woman with classical salt-wasting CAH.
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Affiliation(s)
- Yuji Kamata
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Japan.
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Abstract
In the biosynthesis of steroid hormones the neutral lipid cholesterol, a normal constituent of lipid bilayers is transformed via a series of hydroxylation, oxidation, and reduction steps into a vast array of biologically active compounds: mineralocorticoids, glucocorticoids, and sex hormones. Glucocorticoids regulate many aspects of metabolism and immune function, whereas mineralocorticoids help maintain blood volume and control renal excretion of electrolytes. Sex hormones are essential for sex differentiation in male and support reproduction. They include androgens, estrogens, and progestins. A block in the pathway of steroid biosynthesis leads to the lack of hormones downstream and accumulation of the upstream compounds that can activate other members of the steroid receptor family. This review deals with the clinical consequences of these blocks.
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Affiliation(s)
- A Biason-Lauber
- University Children's Hospital, Division of Endocrinology and Diabetology, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland.
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Lee PA, Houk CP, Husmann DA. Should male gender assignment be considered in the markedly virilized patient With 46,XX and congenital adrenal hyperplasia? J Urol 2010; 184:1786-92. [PMID: 20728155 DOI: 10.1016/j.juro.2010.03.116] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 11/28/2022]
Abstract
PURPOSE We assess the outcome in 46,XX men with congenital adrenal hyperplasia who were born with Prader 4 or 5 genitalia and assigned male gender at birth. MATERIALS AND METHODS After receiving institutional review board approval and subject consent we reviewed the medical records of 12 men 35 to 69 years old with 46,XX congenital adrenal hyperplasia, of whom 6 completed social and gender issue questionnaires. RESULTS All subjects were assigned male gender at birth, were diagnosed with virilizing congenital adrenal hyperplasia at age greater than 3 years and indicated a male gender identity with sexual orientation to females. Ten of the 12 subjects had always lived as male and 2 who were reassigned to female gender in childhood subsequently self-reassigned as male. Nine of the 12 men had long-term female partners, including 7 married 12 years or more. The 3 subjects without a long-term female partner included 1 priest, 1 who was reassigned female gender, married, divorced and self-reassigned as male, and 1 with a girlfriend and sexual activity. All except the priest and the subject who was previously married when female indicated a strong libido and frequent orgasmic sexual activity. Responses to self-esteem, masculinity, body image, social adjustment and symptom questionnaires suggested adjustments related to the extent of familial and social support. CONCLUSIONS Outcome data on severely masculinized 46,XX patients with congenital adrenal hyperplasia who were assigned male gender at birth indicate male gender identity in adulthood with satisfactory male sexual function in those retaining male genitalia. In men who completed questionnaires results were poorer in those lacking familial/social support. Male gender of rearing may be a viable option for parents whose children are born with congenital adrenal hyperplasia, a 46,XX karyotype and male genitalia, although positive parental and other support, and counseling are needed for adjustment.
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Affiliation(s)
- Peter A Lee
- Section of Pediatric Endocrinology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Congenital adrenal hyperplasia: do the benefits of prenatal treatment defeat the risks? Obstet Gynecol Surv 2010; 65:196-205. [PMID: 20214835 DOI: 10.1097/ogx.0b013e3181d61046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Congenital adrenal hyperplasia (CAH) is caused by a defect in any of the 5 enzymes necessary for the synthesis of cortisol. However, in more than 90% of cases, CAH results from a defect in the enzyme 21-hydroxylase. Antenatal dexamethasone for the treatment of fetuses with CAH was introduced in 1978, and has been shown to prevent virilizaton of affected girls. Some researchers have been concerned about the possible long-term side effects of this therapy. A variety of studies have evaluated cognition and behavioral traits as well as metabolic alterations in treated children and in animals, and some investigators have reported adverse effects of antenatal treatment, but no firm conclusions about the potential risks of dexamethasone have been reached. This review summarizes the outcomes of affected children with and without antenatal dexamethasone treatment, and evaluates the benefits of prenatal treatment as well as the potential risks. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to recall the pathophysiology, broad clinical presentation, differences in prognosis with and without antenatal treatment, and face the importance of the antenatal dexamethasone treatment in congenital adrenal hyperplasia despite the potential adverse effects.
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Growth and reproductive outcomes in congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:298937. [PMID: 20148087 PMCID: PMC2817857 DOI: 10.1155/2010/298937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 12/11/2009] [Indexed: 11/21/2022]
Abstract
The treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is complex. In addition to disease control, important therapeutic goals are the maintenance of normal growth and the acquisition of normal reproductive function. Here, data regarding final adult height (FH) in patients with CAH will be reviewed. Additional difficulties associated with CAH, including risks of obesity and hypertension, will be discussed. Information about fertility and reproductive outcomes in men and women with CAH will also be summarized. Although the treatment of each child with CAH needs to be individualized, close medical followup and laboratory monitoring along with good compliance can often result in positive clinical outcomes.
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Nebesio T, Eugster E. Growth and Reproductive Outcomes in Congenital Adrenal Hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-298937] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Casteràs A, De Silva P, Rumsby G, Conway GS. Reassessing fecundity in women with classical congenital adrenal hyperplasia (CAH): normal pregnancy rate but reduced fertility rate. Clin Endocrinol (Oxf) 2009; 70:833-7. [PMID: 19250265 DOI: 10.1111/j.1365-2265.2009.03563.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Fertility in women with classical congenital adrenal hyperplasia (CAH) has been reported low; however, the true pregnancy rate for women trying to conceive with this condition is unknown. Our aim was to calculate pregnancy rate for women with CAH calculated as a proportion of those who had attempted conception. Fertility expressed as live birth rate is also calculated. PATIENTS One hundred and six women with classical CAH followed in a multidisciplinary service [81 salt-losing (SL) and 25 nonsalt-losing (NSL) form]. RESULTS Twenty-five (23.6%) women with CAH women considered motherhood, 23 had actively tried conception of whom 21 (91.3%) achieved 34 pregnancies. Pregnancy rate is no different from that in the normal population (95%). Pregnancy rates were similar in the SL (88.9%) and NSL (92.9%) subgroups but those with NSL-CAH were more likely to seek motherhood than those with SL-CAH (16/25 vs. 9/81). Optimized glucocorticoid and mineralocorticoid regimes during fertility monitoring resulted spontaneous conception in nearly all recent cases. Fertility rate was 0.25 live births per woman compared with 1.8 in the UK population (P < 0.001). CONCLUSION We report a normal pregnancy rate (91.3%) for women with classical CAH, similar in SL and NSL subgroups. Fertility rate, however, remains much lower than in general population.
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Affiliation(s)
- Anna Casteràs
- Department of Endocrinology, University College London Hospitals, London, UK
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Claahsen-van der Grinten HL, Otten BJ, Stikkelbroeck MML, Sweep FCGJ, Hermus ARMM. Testicular adrenal rest tumours in congenital adrenal hyperplasia. Best Pract Res Clin Endocrinol Metab 2009; 23:209-20. [PMID: 19500764 DOI: 10.1016/j.beem.2008.09.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In adult patients with congenital adrenal hyperplasia (CAH) the presence of testicular adrenal rest tumours (TART) is an important cause of gonadal dysfunction and infertility. In the last decade several papers have focused on the origin and pathogenesis of these tumours. In this paper we review the embryological, histological, biochemical and clinical features of TART and discuss the treatment options. Furthermore, we propose a new five-stage classification of TART, based on sonographic, clinical and biochemical parameters, that may lead to a better follow up and treatment of patients with TART.
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Hagenfeldt K, Nordenskjold A. Reply: The sex ratio of offspring of women with congenital adrenal hyperplasia. Hum Reprod 2008. [DOI: 10.1093/humrep/den371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Brassard M, AinMelk Y, Baillargeon JP. Basic infertility including polycystic ovary syndrome. Med Clin North Am 2008; 92:1163-92, xi. [PMID: 18721657 DOI: 10.1016/j.mcna.2008.04.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Infertility in women has many possible causes and must be approached systematically. The most common cause of medically treatable infertility is the polycystic ovary syndrome (PCOS). This syndrome is common in young women and is the cause of anovulatory infertility in 70% of cases. It is therefore an important condition to screen and manage in primary care medical settings. In the past 10 years, insulin sensitization with weight loss or metformin has been shown to be a safe and effective treatment for PCOS infertility that eliminates the risk of multiple pregnancy and may reduce the risk of early pregnancy loss as compared with ovulation-inductor drugs. The authors believe metformin should be considered as first-line therapy because it has the advantage to allow for normal single ovulation, for reduced early pregnancy loss, and, most importantly, lifestyle modifications and weight loss before pregnancy. Losing weight not only improves fertility but also reduces adverse pregnancy outcomes associated with obesity.
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Affiliation(s)
- Maryse Brassard
- Division of Endocrinology, Department of Medicine, Université de Sherbrooke, 3001, 12th North Avenue, Sherbrooke, QC J1H 5N4, Canada
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Kulshreshtha B, Marumudi E, Khurana ML, Kriplani A, Kinra G, Gupta DK, Kucheria K, Khadgawat R, Gupta N, Seith A, Ammini AC. Fertility among women with classical congenital adrenal hyperplasia: report of seven cases where treatment was started after 9 years of age. Gynecol Endocrinol 2008; 24:267-72. [PMID: 18569031 DOI: 10.1080/09513590801945230] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND AIM Androgen excess is believed to be one of the major factors responsible for poor fertility outcomes in females with congenital adrenal hyperplasia (CAH). Some believe that the adverse effect of androgens on fertility could have its origins as early as the antenatal years. To assess the impact of prolonged androgen exposure on fertility in CAH patients, we compiled the data of females with CAH followed in our clinic during the last 25 years who were sexually active and had not been initiated on steroids until age 9 years. STUDY DESIGN AND PATIENTS This was an observational case study on seven patients with classical CAH who fulfilled the inclusion criteria. The age at initiation of therapy in these females ranged from 9 years to 29 years. RESULTS All patients had varying degrees of genital ambiguity. The most common presenting complaints were genital ambiguity, non-development of secondary sexual characteristics, hirsutism and primary amenorrhea. Genital surgery was performed in all patients at ages ranging from 12 to 29 years, except for one patient who underwent surgery at age 5 years without a diagnosis of CAH being made. Breast development ensued within 2 to 12 months and periods started in all patients within 2-24 months of steroid initiation. There were 13 pregnancies (seven normal vaginal deliveries, two spontaneous abortions and four pregnancies were medically terminated). CONCLUSIONS Late initiation of steroid therapy did not affect fertility in our cohort of CAH women. Androgen excess in situations of subnormal cortisol may not adversely affect fertility in females with CAH.
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Affiliation(s)
- Bindu Kulshreshtha
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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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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Torresani T, Biason-Lauber A. Congenital adrenal hyperplasia: diagnostic advances. J Inherit Metab Dis 2007; 30:563-75. [PMID: 17694353 DOI: 10.1007/s10545-007-0696-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 06/20/2007] [Accepted: 06/20/2007] [Indexed: 10/23/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders resulting from the deficiency of one of the five enzymes required for the synthesis of cortisol in the adrenal cortex. The most frequent is steroid 21-hydroxylase deficiency, accounting for more than 90% of cases. Much has been learned about the genetics of the various clinical forms of 21-hydroxylase deficiency, and correlations between the genotype and the phenotype have been studied extensively. Gene-specific diagnosis is now feasible and neonatal screening and prenatal treatment have been widely implemented. This discussion will be limited to the most common form of congenital adrenal hyperplasia, with focus on the diagnostic advances in this disease.
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Affiliation(s)
- T Torresani
- Department of Endocrinology and Diabetology, University Children's Hospitals, Zurich, Switzerland.
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Abstract
Different forms of intersexuality (Disorders of Sex Development, DSD) are described (congenital adrenal hyperplasia, androgen insensitivity, disorders of androgen biosynthesis, gonadal dysgenesis). Treatment interventions for individuals with ambiguous genitalia and untypical sex development are discussed with respect to medical and psychosocial aspects considering the consensus paper on the management of subjects with intersexuality. The role of gender identity, gender role and sexual orientation are presented as well as problems of disclosure and gender change. Further research is needed to evaluate the optimal treatment procedures.
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Claahsen-van der Grinten HL, Stikkelbroeck NMML, Sweep CGJ, Hermus ARMM, Otten BJ. Fertility in patients with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2006; 19:677-85. [PMID: 16789634 DOI: 10.1515/jpem.2006.19.5.677] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is generally regarded as a paediatric endocrine disease, but nowadays nearly all patients reach adulthood as a result of improved diagnosis and treatment. It is now increasingly recognised that treatment goals shift during life: one of the major treatment goals in childhood and puberty, i.e. normal growth and development, is no longer relevant after childhood, whereas other aspects, such as fertility and side effects of long-term glucocorticoid treatment, become more important in adulthood. This paper focuses on fertility in male and female adult patients with CAH. In males with CAH the fertility rate is reduced compared with the normal population, the most frequent cause being testicular adrenal rest tumours. Development and growth of these tumours is assumed to be ACTH dependent and undertreatment may play an important role. If intensifying glucocorticoid treatment does not lead to tumour decrease, surgical intervention may be considered, but the effect on fertility is not yet known. In females with CAH the degree of fertility depends on the phenotype of the CAH. Most fertility problems are seen in the classic salt-wasting type. Age of menarche and regularity of the menstrual cycle depends on the degree of adrenal suppression. Not only adrenal androgens have to be normalised but also the levels of adrenal progestins (progesterone and 17-OH-progesterone) that interfere with normal ovulatory cycles. The regularity of menstrual cycles can be considered as an important measure of therapeutic control in adolescent females with CAH and therefore as a therapeutic goal from (peri)pubertal years on. Other factors that contribute to impaired fertility in females with CAH are ovarian hyperandrogenism (polycystic ovary syndrome), ovarian adrenal rest tumours, genital surgery and psychological factors. Subfertility in CAH can have its origin already in the peripubertal years and is therefore of interest to the paediatric endocrinologist.
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Speiser PW. Diagnosis and management of congenital adrenal hyperplasia. Expert Rev Endocrinol Metab 2006; 1:103-110. [PMID: 30743773 DOI: 10.1586/17446651.1.1.103] [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] [Indexed: 11/08/2022]
Abstract
Congenital adrenal hyperplasia is the name applied to a class of autosomal recessive disorders resulting from deficiency of one of five enzymes necessary for cortisol synthesis by the adrenal cortex. Congenital adrenal hyperplasia is most often attributable to steroid 21-hydroxylase deficiency, accounting for more than 90% of cases. This discussion will be limited to the most common form of the disease, highlighting methods of diagnostic screening and challenges in disease management.
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Affiliation(s)
- Phyllis W Speiser
- a NYU School of Medicine and Chief, Division of Pediatric Endocrinology, Schneider Children's Hospital269-01 76th AvenueNew Hyde Park, NY 11042, USA.
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Dumic M, Janjanin N, Ille J, Zunec R, Spehar A, Zlopasa G, Francetic I, New MI. Pregnancy outcomes in women with classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Pediatr Endocrinol Metab 2005; 18:887-95. [PMID: 16279367 DOI: 10.1515/jpem.2005.18.9.887] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Despite earlier detection, treatment, and surgical advances, fertility prognosis in women with classical 21-hydroxylase deficiency (21-OHD) is still low, especially in the salt-wasting (SW) form. PATIENTS AND METHODS We analysed the course and outcome of four pregnancies in two simple virilizing (SV) and one SW patient. RESULTS The evaluation of carrier status indicated that all three fathers had two normal CYP21 genes. During the pregnancy, the dose of prednisolone was increased in one of the SV patients and the SW patient. In the SW patient who developed pre-eclampsia, the dose of fludrocortisone was also increased. Three patients gave birth to a total of four healthy girls who were heterozygotes for 21-OHD with normal genitalia (one by vaginal delivery and three by Caesarean section). Family studies revealed that the mother of the SW patient has nonclassical 21-OHD. CONCLUSION Improving a low birth rate in females with SW 21-OHD remains a problem and new approaches are required. If the mother has 21-OHD (even nonclassical 21-OHD), pre-conception counselling and paternal genotyping are advisable and prenatal dexamethasone therapy should be considered.
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Affiliation(s)
- M Dumic
- Department of Paediatrics, University Hospital Centre, Zagreb, Croatia
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Abstract
Congenital adrenal hyperplasia (CAH) due to deficiency of 21-hydroxylase is a disorder of the adrenal cortex characterised by cortisol deficiency, with or without aldosterone deficiency, and androgen excess. Patients with the most severe form also have abnormalities of the adrenal medulla and epinephrine deficiency. The severe classic form occurs in one in 15,000 births worldwide, and the mild non-classic form is a common cause of hyperandrogenism. Neonatal screening for CAH and gene-specific prenatal diagnosis are now possible. Standard hormone replacement fails to achieve normal growth and development for many children with CAH, and adults can experience iatrogenic Cushing's syndrome, hyperandrogenism, infertility, or the development of the metabolic syndrome. This Seminar reviews the epidemiology, genetics, pathophysiology, diagnosis, and management of CAH, and provides an overview of clinical challenges and future therapies.
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Affiliation(s)
- Deborah P Merke
- Pediatric and Reproductive Endocrinology Branch, National Institute of Child Health and Human Development and the Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892-1932, USA.
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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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Abstract
BACKGROUND A newborn with ambiguous genitalia needs prompt evaluation to detect life-threatening conditions (e.g., salt-losing crisis in congenital adrenal hyperplasia [CAH]) and gender assignment. Sex assignment in these children continues to be a challenging diagnostic and therapeutic problem. We studied the causes and characteristics of ambiguous genitalia in children who were referred to a cytogenetic laboratory. PATIENTS AND METHODS We retrospectively reviewed a total of 120 medical records of patients with a primary indication of ambiguous genitalia that were referred to the cytogenetic lab for karyotyping during the period of 1989 to 1999. Diagnosis was based on a clinical impression from the primary physician, who was primarily a staff pediatrician, endocrinologist and/or pediatric urologist. RESULTS CAH was the underlying cause of ambiguous genitalia in 41 of 63 patients with ambiguity due to endocrine causes; 39 of these patients showed a 46,XX karyotype and 2 cases were 46,XY (both the 46,XY patients had 3 beta-hydroxylase deficiency). In 57 patients, ambiguous genitalia were due to congenital developmental defects. The most common endocrine case of ambiguous genitalia was 21-OH deficiency. Seven patients were classified as idiopathic with six showing the 46,XY and one the 46,XX karyotype. Gender was reassigned at birth or at diagnosis in 15 patients. CONCLUSION The etiology of ambiguous genitalia is variable. The physician managing these families could minimize the trauma of having a child with unidentified sex by providing appropriate genetic counseling so that the parents can make an early decision. Prenatal DNA testing in at-risk families should be considered and appropriate therapy offered to minimize or prevent genital ambiguity.
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Affiliation(s)
- Angham Al-Mutair
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M. Anwar Iqbal
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Nadia Sakati
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdullah Ashwal
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Nebesio TD, Kreher NC, Hannon TS. Infant with classic congenital adrenal hyperplasia (CAH) born to a mother with classic CAH. J Pediatr 2004; 145:250-2. [PMID: 15289778 DOI: 10.1016/j.jpeds.2004.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report a female infant with classic congenital adrenal hyperplasia (CAH), secondary to 21-hydroxylase deficiency, who was born to a mother with salt-wasting CAH.
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Affiliation(s)
- Todd D Nebesio
- Department of Pediatrics, Section of Pediatric Endocrinology/Diabetology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, 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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Abstract
Surgery for patients with genital ambiguity must be based on an accurate diagnosis, thorough understanding of the genital anatomy and realistic expectations for the patient, family and treating multi-specialty team. The goal is to create a functional and cosmetic outcome consonant with the gender assignment with the least amount of morbidity to the patient and family. An understanding of the normal genital neuroanatomy is essential for a successful surgical approach and outcome. Based on fetal human specimens, we have refined the three-dimensional relationship of the dorsal nerve of the clitoris, the female cavernosal nerve and the vaginal plexus. The surgical approach to patients with severe clitoral virilization should preserve erectile function and the neural innervation of the clitoris. When indicated, surgery should be performed in infancy to minimize psychological trauma and surgical complications from scarring. Herein, we review the neuroanatomy of the female genitalia and the implications for the rare patient who needs surgical reconstruction.
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Affiliation(s)
- Laurence S Baskin
- Pediatric Urology, UCSF Children's Medical Center, University of California, Children's Hospital, San Francisco, CA 94143, USA.
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