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Avanceña AL, Rose AM, Gardner MD, Rutter MM, Schafer-Kalkhoff T, Suorsa-Johnson KI, van Leeuwen KD, Weidler EM, Gebremariam A, Sandberg DE, Prosser LA. Preferences in Clinical Care of Individuals With Differences of Sex Development. Pediatrics 2024; 153:e2023064207. [PMID: 38699802 PMCID: PMC11153319 DOI: 10.1542/peds.2023-064207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVES To identify the most important attributes related to the process of achieving, and outcomes associated with, successful care for differences of sex development (DSD). METHODS We developed a best-worst scaling survey administered to 520 DSD stakeholders, including individuals or family members of those with DSD, health care specialists, and patient support and advocacy representatives. Fourteen process-related attributes and 16 outcome-related attributes were identified through qualitative research. We estimated relative importance scores and coefficients from regression analysis to understand the relative importance of attributes and conducted latent class analysis to explore heterogeneity in preferences. RESULTS The 3 most important process attributes were (1) good communication between care team and patient/family, (2) care team educated patient/family about condition, and (3) care team incorporates the values of patient/family. The 3 most important outcome attributes were (1) patient satisfaction, (2) patient mental health, and (3) treatment maintains physical health. Latent class analyses showed that respondents had heterogeneous preferences. For process-related attributes, we identified 3 respondent groups: "Patient autonomy and support" (46% of respondents), "Education and care transitions" (18%), and "Shared decision-making" (36%). For outcome-related attributes, we identified 2 respondent groups: "Preserving function and appearance" (59% of respondents) and "Patient health and satisfaction" (41%). CONCLUSIONS Outcomes such as patient satisfaction and health were the most important outcome attributes, and good communication and education from the care team were the most important process attributes. Respondents expressed heterogeneous preferences for selected DSD care attributes that providers should consider to improve satisfaction with and quality of DSD care.
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Affiliation(s)
- Anton L.V. Avanceña
- Health Outcomes Division, College of Pharmacy
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Texas
| | - Angela M. Rose
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - Melissa D. Gardner
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - Meilan M. Rutter
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kristina I. Suorsa-Johnson
- Division of Pediatric Psychiatry and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | | | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, Arizona
- Accord Alliance, Higley, Arizona
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Gardner M, Khorashad BS, Lee PA, Kogan BA, Sandberg DE. Recommendations for 46,XX Congenital Adrenal Hyperplasia Across Two Decades: Insights from the North American Differences of Sex Development Clinician Survey. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1695-1711. [PMID: 38684620 PMCID: PMC11106198 DOI: 10.1007/s10508-024-02853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 05/02/2024]
Abstract
Several aspects of clinical management of 46,XX congenital adrenal hyperplasia (CAH) remain unsettled and controversial. The North American Disorders/Differences of Sex Development (DSD) Clinician Survey investigated changes, over the last two decades, in clinical recommendations by specialists involved in the management of newborns with DSD. Members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology participated in a web-based survey at three timepoints: 2003-2004 (T1, n = 432), 2010-2011 (T2, n = 441), and 2020 (T3, n = 272). Participants were presented with two clinical case scenarios-newborns with 46,XX CAH and either mild-to-moderate or severe genital masculinization-and asked for clinical recommendations. Across timepoints, most participants recommended rearing the newborn as a girl, that parents (in consultation with physicians) should make surgical decisions, performing early genitoplasty, and disclosing surgical history at younger ages. Several trends were identified: a small, but significant shift toward recommending a gender other than girl; recommending that adolescent patients serve as the genital surgery decision maker; performing genital surgery at later ages; and disclosing surgical details at younger ages. This is the first study assessing physician recommendations across two decades. Despite variability in the recommendations, most experts followed CAH clinical practice guidelines. The observation that some of the emerging trends do not align with expert opinion or empirical evidence should serve as both a cautionary note and a call for prospective studies examining patient outcomes associated with these changes.
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Affiliation(s)
- Melissa Gardner
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA
| | - Behzad Sorouri Khorashad
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA
| | - Peter A Lee
- Department of Pediatrics, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Barry A Kogan
- Department of Urology, Albany Medical College and Center, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA.
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
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Neeman BB, Jaber J, Kocherov S, Levy-Khademi F, Farkas A, Chertin B. Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society. J Pediatr Urol 2024:S1477-5131(24)00189-X. [PMID: 38631940 DOI: 10.1016/j.jpurol.2024.03.033] [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] [Received: 11/02/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center. METHODS We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years. RESULTS we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9 ± 4.7 years (mean ± SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1 ± 8.2 years (mean ± SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3β-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population. CONCLUSIONS Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.
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Affiliation(s)
- Binyamin B Neeman
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel.
| | - Jawdat Jaber
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Stanislav Kocherov
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Floris Levy-Khademi
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Amicur Farkas
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Boris Chertin
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
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De Win G, De Kort L, Learner H, Noah A, Dautricourt S, Nijman R, Stein R. Long-term risks of childhood surgery. J Pediatr Urol 2024; 20:165-172. [PMID: 37487882 DOI: 10.1016/j.jpurol.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery. MATERIAL AND METHODS Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery. RESULTS Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up. CONCLUSION Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.
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Affiliation(s)
- Gunter De Win
- University Hospital Antwerp, Department of Urology, Edegem, Belgium; ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Adolescent & Congenital Lifelong Urology, University College London Hospitals, London, UK.
| | | | - Hazel Learner
- Adolescent Gynaecology, University College London Hospitals, London, UK
| | - Anthony Noah
- Adolescent & Congenital Lifelong Urology, University College London Hospitals, London, UK
| | | | - Rien Nijman
- Department of Pediatric Urology, University Medical Center Groningen, the Netherlands
| | - Raimund Stein
- Paediatric and Reconstructive Urology, University Hospital Mannheim, Germany
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Longhurst GJ, Beni R, Jeong SR, Pianta M, Soper AL, Leitch P, De Witte G, Fisher L. Beyond the tip of the iceberg: A meta-analysis of the anatomy of the clitoris. Clin Anat 2024; 37:233-252. [PMID: 37775965 DOI: 10.1002/ca.24113] [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: 07/19/2022] [Revised: 07/04/2023] [Accepted: 08/20/2023] [Indexed: 10/01/2023]
Abstract
An understanding of ranges in clitoral anatomy is important for clinicians caring for patients including those who have had female genital mutilation, women seeking genital cosmetic surgery, or trans women seeking reconstructive surgery. The aim of this meta-analysis is to investigate the ranges in clitoral measurements within the literature. A meta-analysis was performed on Ovid Medline and Embase databases following the PRISMA protocol. Measurements of clitoral structures from magnetic imaging resonance, ultrasound, cadaveric, and living women were extracted and analyzed. Twenty-one studies met the inclusion criteria. The range in addition to the average length and width of the glans (6.40 mm; 5.14 mm), body (25.46 mm; 9.00 mm), crura (52.41 mm; 8.71 mm), bulb (52.00 mm; 10.33 mm), and prepuce (23.19 mm) was calculated. Furthermore, the range and average distance from the clitoris to the external urethral meatus (22.27 mm), vagina (43.14 mm), and anus (76.30 mm) was documented. All erectile and non-erectile structures of the clitoris present with substantial range. It is imperative to expand the literature on clitoral measurements and disseminate the new results to healthcare professionals and the public to reduce the sense of inadequacy and the chances of iatrogenic damage during surgery.
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Affiliation(s)
| | - Rebecca Beni
- Department of Anatomical Sciences, St George's University of London, London, UK
| | - Su Ryeon Jeong
- Department of Anatomical Sciences, St George's University of London, London, UK
| | - Marina Pianta
- Department of Anatomical Sciences, St George's University of London, London, UK
| | - Annie Louisa Soper
- Department of Anatomical Sciences, St George's University of London, London, UK
| | - Patricia Leitch
- Department of Anatomical Sciences, St George's University of London, London, UK
| | - Gabrielle De Witte
- Department of Anatomical Sciences, St George's University of London, London, UK
| | - Lauren Fisher
- Department of Anatomical Sciences, St George's University of London, London, UK
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Kalfa N, Nordenström J, De Win G, Hoebeke P. Adult outcomes of urinary, sexual functions and fertility after pediatric management of differences in sex development: Who should be followed and how? J Pediatr Urol 2024:S1477-5131(24)00052-4. [PMID: 38423920 DOI: 10.1016/j.jpurol.2024.01.022] [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] [Received: 07/27/2023] [Revised: 12/19/2023] [Accepted: 01/21/2024] [Indexed: 03/02/2024]
Abstract
The management of Differences of Sex Development (DSD) has evolved considerably in recent years. The questioning of systematic early childhood treatment of DSD requires a better understanding of the outcomes of such treatments and long-term studies are therefore essential to better evaluate the prognosis of DSD. Unfortunately, limitations are numerous including the limited size of the series, the absence of standardized methodology, the evaluation of managements that no longer take place today and the absence of prospective and comparative studies. Despite these difficulties, the purpose of this paper is to present the current data on the long-term follow-up of patients with DSD from the urological, sexual and fertility points of view. Even if it remains difficult at present to establish precise recommendations, we recapitulate the most important points that should drive follow-up of these patients especially the constitution of a multidisciplinary team with a holistic approach, the organization of the transition between adolescence and adulthood, a particular attention to psychological care, a careful communication with the patients and his/her family and the use of standardized data collection systems.
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Affiliation(s)
- Nicolas Kalfa
- Département de Chirurgie Infantile, Service de Chirurgie Viscérale et Urologie Pédiatrique, CHU de Montpellier, Montpellier, France; Centre de Référence Maladies Rares DEVGEN Constitutif Sud, CHU de Montpellier, Montpellier, France; UMR 1302 Institute Desbrest of Epidemiology and Public Health, INSERM, Univ Montpellier, Montpellier, France.
| | - Josefin Nordenström
- Department of Pediatric Surgery/Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunter De Win
- Department of Urology, University Hospital Antwerp, Edegem, Belgium; Astarc, Faculty of Medicine and Health Science, University of Antwerp, Belgium; Adolescenty Urology, University College London Hospitals, London, UK
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium
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Suorsa-Johnson K, Delaney RK, Fagerlin A, Sandberg DE. Editorial: Shared Decision Making in Pediatric Differences/Disorders of Sex Development. FRONTIERS IN UROLOGY 2023; 3:1281181. [PMID: 37885905 PMCID: PMC10601991 DOI: 10.3389/fruro.2023.1281181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Affiliation(s)
- Kristina Suorsa-Johnson
- Division of Psychiatry and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Rebecca K. Delaney
- Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA
- Veterans Administration Health Services Research and Development Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Zwayne N, Chawla R, van Leeuwen K. Caring for Patients With Congenital Adrenal Hyperplasia Throughout the Lifespan. Obstet Gynecol 2023; 142:257-268. [PMID: 37473408 DOI: 10.1097/aog.0000000000005263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 07/22/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder affecting cortisol and aldosterone biosynthesis, which can lead to virilization in fetuses with a 46,XX karyotype. 21-hydroxylase deficiency is the most common cause of CAH, accounting for 90-99% of all patients with the condition. The management of patients with CAH should be done with a multidisciplinary team, which would address all of the complex components of their care throughout their lifespans. Many multidisciplinary teams have adopted shared decision-making approaches to genital surgery in which parents and patients can be part of the decision-making process. Continued research is needed to best serve these patients throughout their lifespans.
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Affiliation(s)
- Noor Zwayne
- Division of Pediatric and Adolescent Gynecology, Women's Health Department, University of Texas at Austin, Dell Medical School, Austin, Texas; and the Division of Pediatric Endocrinology and the Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
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Ding Y, Wang Y, Lyu Y, Xie H, Huang Y, Wu M, Chen F, Chen Z. Urogenital sinus malformation: From development to management. Intractable Rare Dis Res 2023; 12:78-87. [PMID: 37287654 PMCID: PMC10242390 DOI: 10.5582/irdr.2023.01027] [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] [Received: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023] Open
Abstract
Urogenital sinus (UGS) malformation, also known as persistent urogenital sinus (PUGS), is a rare congenital malformation of the urogenital system. It arises when the urethra and vaginal opening fail to form properly in the vulva and fuse incorrectly. PUGS can occur as an isolated abnormality or as part of a complex syndrome, and is frequently associated with congenital adrenal hyperplasia (CAH). The management of PUGS is not well-established, and there are no standardized guidelines on when to perform surgery or how to follow up with patients over the long term. In this review, we discuss the embryonic development, clinical evaluation, diagnosis, and management of PUGS. We also review case reports and research findings to explore best practices for surgery and follow-up care, in hopes of increasing awareness of PUGS and improving patient outcomes.
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Affiliation(s)
- Yu Ding
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yaping Wang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiqing Lyu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Xie
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yichen Huang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Wu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongzhong Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Urogenital Development Research Center, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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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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11
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Liao LM, Baratz A. Medicalization of intersex and resistance: a commentary on Conway. Int J Impot Res 2023; 35:51-55. [PMID: 36076030 DOI: 10.1038/s41443-022-00597-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 11/09/2022]
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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Dehneh N, Jarjour R, Idelbi S, Alibrahem A, Al Fahoum S. Syrian females with congenital adrenal hyperplasia: a case series. J Med Case Rep 2022; 16:371. [PMID: 36242011 PMCID: PMC9569117 DOI: 10.1186/s13256-022-03609-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One of the most common types of congenital adrenal hyperplasia is an autosomal recessive disorder with 21-hydroxylase deficiency. The classical form, defined by cortisol insufficiency, is accompanied by prenatal androgen excess causing variable masculinization degrees of external genitalia in babies with a 46, XX karyotype. CASES PRESENTATION These five case reports highlight the management of Syrian females aged between 0 and 32 years with congenital adrenal hyperplasia. Two of the patients have been raised as males, while two had reconstructive surgery and one had hormonal therapy. Becoming mother was achieved by two patients CONCLUSION: The integrated treatment of females with classical congenital adrenal hyperplasia CAH, which includes appropriate surgical procedures and controlled hormonal therapy, gives these females the opportunity to live as they are, and perhaps as mothers in the future.
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Affiliation(s)
- Nada Dehneh
- Dept. of Biochemistry and Microbiology, Faculty of Pharmacy, Damascus University, Damascus, Syria.
| | - Rami Jarjour
- Clinical Genetics Unit, Atomic Energy Commission of Syria (AECS), Damascus, Syria
- Faculty of Pharmacy, Arab International University (AIU), Ghabaghib, Syria
| | - Sahar Idelbi
- Unit of Pediatric Endocrinology and Metabolism, Children's Hospital, Damascus, Syria
| | - Assad Alibrahem
- Unit of Pediatric Endocrinology and Metabolism, Children's Hospital, Damascus, Syria
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Sahar Al Fahoum
- Dept. of Biochemistry and Microbiology, Faculty of Pharmacy, Damascus University, Damascus, Syria
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14
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Goodman M, Yacoub R, Getahun D, McCracken CE, Vupputuri S, Lash TL, Roblin D, Contreras R, Cromwell L, Gardner MD, Hoffman T, Hu H, Im TM, Prakash Asrani R, Robinson B, Xie F, Nash R, Zhang Q, Bhai SA, Venkatakrishnan K, Stoller B, Liu Y, Gullickson C, Ahmed M, Rink D, Voss A, Jung HL, Kim J, Lee PA, Sandberg DE. Cohort profile: pathways to care among people with disorders of sex development (DSD). BMJ Open 2022; 12:e063409. [PMID: 36130763 PMCID: PMC9494584 DOI: 10.1136/bmjopen-2022-063409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The 'DSD Pathways' study was initiated to assess health status and patterns of care among people enrolled in large integrated healthcare systems and diagnosed with conditions comprising the broad category of disorders (differences) of sex development (DSD). The objectives of this communication are to describe methods of cohort ascertainment for two specific DSD conditions-classic congenital adrenal hyperplasia with 46,XX karyotype (46,XX CAH) and complete androgen insensitivity syndrome (CAIS). PARTICIPANTS Using electronic health records we developed an algorithm that combined diagnostic codes, clinical notes, laboratory data and pharmacy records to assign each cohort candidate a 'strength-of-evidence' score supporting the diagnosis of interest. A sample of cohort candidates underwent a review of the full medical record to determine the score cutoffs for final cohort validation. FINDINGS TO DATE Among 5404 classic 46,XX CAH cohort candidates the strength-of-evidence scores ranged between 0 and 10. Based on sample validation, the eligibility cut-off for full review was set at the strength-of-evidence score of ≥7 among children under the age of 8 years and ≥8 among older cohort candidates. The final validation of all cohort candidates who met the cut-off criteria identified 115 persons with classic 46,XX CAH. The strength-of-evidence scores among 648 CAIS cohort candidates ranged from 2 to 10. There were no confirmed CAIS cases among cohort candidates with scores <6. The in-depth medical record review for candidates with scores ≥6 identified 61 confirmed cases of CAIS. FUTURE PLANS As the first cohort of this type, the DSD Pathways study is well-positioned to fill existing knowledge gaps related to management and outcomes in this heterogeneous population. Analyses will examine diagnostic and referral patterns, adherence to care recommendations and physical and mental health morbidities examined through comparisons of DSD and reference populations and analyses of health status across DSD categories.
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Affiliation(s)
- Michael Goodman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Rami Yacoub
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Darios Getahun
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, USA
| | - Courtney E McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Timothy L Lash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
- Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Richard Contreras
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lee Cromwell
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Melissa D Gardner
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Trenton Hoffman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Theresa M Im
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Brandi Robinson
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Fagen Xie
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rebecca Nash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Qi Zhang
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sadaf A Bhai
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Bethany Stoller
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Yijun Liu
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Maaz Ahmed
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - David Rink
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ava Voss
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Hye-Lee Jung
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jin Kim
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Peter A Lee
- Division of Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - David E Sandberg
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
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15
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 527] [Impact Index Per Article: 263.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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16
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Nordenström A, Lajic S, Falhammar H. Long-Term Outcomes of Congenital Adrenal Hyperplasia. Endocrinol Metab (Seoul) 2022; 37:587-598. [PMID: 35799332 PMCID: PMC9449109 DOI: 10.3803/enm.2022.1528] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022] Open
Abstract
A plethora of negative long-term outcomes have been associated with congenital adrenal hyperplasia (CAH). The causes are multiple and involve supra-physiological gluco- and mineralocorticoid replacement, excess adrenal androgens both intrauterine and postnatal, elevated steroid precursor and adrenocorticotropic hormone levels, living with a congenital condition as well as the proximity of the cytochrome P450 family 21 subfamily A member 2 (CYP21A2) gene to other genes. This review aims to discuss the different long-term outcomes of CAH.
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Affiliation(s)
- Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Corresponding author: Henrik Falhammar. Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Tel: +46-851776411, Fax: +46-851773096, E-mail:
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Techniques of Primary Vaginoplasty in Young Adults with Differences of Sex Development and Female Identification. J Clin Med 2022; 11:jcm11133688. [PMID: 35806974 PMCID: PMC9267529 DOI: 10.3390/jcm11133688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 02/01/2023] Open
Abstract
Background: The ideal timing of genital surgery in differences/disorders of sex development (DSD) is controversial and differs according to the underlying type of DSD. Increasing numbers of persisting sinus as a result of delayed feminizing genitoplasty in DSD patients require interdisciplinary collaboration of pediatric surgeons/urologists and gynecologists. This study focusses on surgical techniques other than bowel vaginoplasties and results of gender assigning surgery in young adolescents. Methods: Data of adolescent and adult patients treated between 2015 and 2022 were analyzed retrospectively: underlying type of malformation, techniques of vaginoplasty, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. Results: A total of 9 patients received a primary vaginoplasty at a median age of 16.75 years (range 10.3–29.25). The underlying anatomical conditions were persistent urogenital sinus (UGS) in 8 patients (3 patients with CAH, 2 patients with XY-DSD, 1 patient with cloacal malformation and missed UGS, 2 patients with UGS only). One patient had a MURCS association. Surgical techniques were total urogenital mobilization and perineal flap vaginoplasty in 4 patients, modified McIndoe vaginoplasty in 4 patients, and a laparoscopic vaginal pull-through in 1 patient. In a median follow-up of 45 months (2–84), all but 1 patient presented with physiological vaginal length and width. Conclusions: If possible, modern treatment concepts delay gender assigning surgery until the participation of the patient in the decision-making process is possible. Optimal treatment concepts are given by transfer of surgical techniques from pediatric urology/surgery by multidisciplinary teams. Techniques other than bowel vaginoplasties are favorable.
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Khalifeh N, Omary A, Cotter D, Kim MS, Geffner ME, Herting MM. Congenital Adrenal Hyperplasia and Brain Health: A Systematic Review of Structural, Functional, and Diffusion Magnetic Resonance Imaging (MRI) Investigations. J Child Neurol 2022; 37:758-783. [PMID: 35746874 PMCID: PMC9464669 DOI: 10.1177/08830738221100886] [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: 01/29/2023]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) is a group of genetic disorders that affects the adrenal glands and is the most common cause of primary adrenal insufficiency in children. In the past few decades, magnetic resonance imaging (MRI) has been implemented to investigate how the brain may be affected by CAH. A systematic review was conducted to evaluate and synthesize the reported evidence of brain findings related to CAH using structural, functional, and diffusion-weighted MRI. METHODS We searched bibliographical databases through July 2021 for brain MRI studies in individuals with CAH. RESULTS Twenty-eight studies were identified, including 13 case reports or series, 10 studies that recruited and studied CAH patients vs unaffected controls, and 5 studies without a matched control group. Eleven studies used structural MRI to identify structural abnormalities or quantify brain volumes, whereas 3 studies implemented functional MRI to investigate brain activity, and 3 reported diffusion MRI findings to assess white matter microstructure. Some commonly reported findings across studies included cortical atrophy and differences in gray matter volumes, as well as white matter hyperintensities, altered white matter microstructure, and distinct patterns of emotion and reward-related brain activity. CONCLUSIONS These findings suggest differences in brain structure and function in patients with CAH. Limitations of these studies highlight the need for CAH neuroimaging studies to incorporate larger sample sizes and follow best study design and MRI analytic practices, as well as clarify potential neurologic effects seen across the lifespan and in relation to clinical and behavioral CAH phenotypes.
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Affiliation(s)
- Noor Khalifeh
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Adam Omary
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Devyn Cotter
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA,Neuroscience Graduate Program, University of Southern California, Los Angeles, CA, USA
| | - Mimi S. Kim
- Center for Endocrinology, Diabetes, and Metabolism, and The Saban Research Institute at Children’s Hospital Los Angeles; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mitchell E. Geffner
- Center for Endocrinology, Diabetes, and Metabolism, and The Saban Research Institute at Children’s Hospital Los Angeles; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Megan M. Herting
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA,Division of Children, Youth, and Families, Children’s Hospital Los Angeles
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19
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Surgical experiences in adolescents and young adults with differences of sex development: A qualitative examination. J Pediatr Urol 2022; 18:353.e1-353.e10. [PMID: 35341672 PMCID: PMC9232896 DOI: 10.1016/j.jpurol.2022.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Surgical intervention in youth with differences of sex development (DSD) is a controversial topic. Historically, evidence suggests that genital surgery in DSD is associated with mixed patient satisfaction. However, less is known about surgical outcomes under therapeutic advancements in the past several decades. OBJECTIVE The purpose of the current study is to provide an updated and empirical qualitative examination of the surgical experiences and responses to care of adolescents and young adults (AYA) with DSD in order to fill this gap in the literature and inform patient care. METHODS Qualitative interviews were conducted with 37 AYA (ages 12-26) with DSD. Interviews were transcribed, coded, and analyzed thematically. RESULTS Three major themes were identified: 1) knowledge related to surgery; 2) surgical and medical experience; and 3) psychosocial factors related to surgery. Results demonstrated that most AYA were not involved in the decision to pursue surgery and were observed to have varying levels of knowledge regarding their surgeries. Most participants in the current study had received a DSD-related surgery and the majority described having positive surgical experiences and few regrets. Nonetheless, AYA described both medical and psychosocial challenges related to their surgeries and recoveries and offered feedback on ways to improve the surgical process. DISCUSSION The current study provides a qualitative examination of the surgical experiences of 37 AYA with DSD. Findings highlight the importance of regular and ongoing communication with providers to improve knowledge related to surgery during the decision-making process as well as after surgical intervention. Results underscore the benefits of multidisciplinary teams and the value of patient handouts and decision aids in assisting AYA in the decision to pursue surgical intervention. Other specific recommendations for providers include increased patient privacy during genital exams, greater emphasis on psychoeducation and pain management strategies, and the use of behavioral health services to assist with challenges and social support. CONCLUSIONS The decision to pursue surgical intervention in youth with DSD remains a complex and controversial issue, and more information regarding patients' perspectives on surgery is needed. The current study provides novel insights into patient experiences of surgical intervention and highlights the need for psychosocial support throughout the shared decision-making process.
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20
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Trachta J, Mushtaq I, Petrasova N, Hradsky O, Skaba R. Sexual function in adult females after feminizing genitoplasty for congenital adrenal hyperplasia. J Pediatr Urol 2022; 18:282-286. [PMID: 35260360 DOI: 10.1016/j.jpurol.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/06/2022] [Accepted: 02/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate sexual function and subjective attitudes towards surgery in adult women after feminizing genitoplasty (FG) for congenital adrenal hyperplasia (CAH). MATERIALS AND METHODS We retrospectively reviewed the medical files of patients who underwent FG from 1996 to 2018. Of those, patients older than 16 years of age were asked to answer non-standardized questions aiming at the awareness of genital surgery and standardized questionnaire evaluating sexual function (GRISS). The anonymized answers were compared to a control group of 50 healthy females. Student's t-test, Pearson's χ2 test, Fisher's exact test and Spearman's rank correlation coefficient were performed. A P-value less than 0.05 was considered significant. RESULTS Out of 106 patients who underwent FG, 64 were included, 55 successfully contacted and 32, aged 17-40 years (median 25.5), answered the questionnaires (58% response rate). In all, 11 patients underwent historical clitorectomy in early childhood by a pediatric gynecologist before 1996 and pull-through vaginoplasty at puberty. A total of 21 patients underwent modern one- or two-staged FG. There were statistically significant differences between the CAH group and controls as to the proportion living in committed partnerships (28% and 84%, respectively; p = 0.0000), having sexual intercourse (41% and 92%, respectively; p = 0.0000) and having their own children (13% and 36%, respectively; p = 0.0369). The median overall GRISS score was 4 (range 1-7) in the CAH group compared to 1 (range 1-9) in the control group, with infrequency and vaginismus representing the least favorable subscales (median 5). In all, 81% of the women operated on for CAH would recommend such an operation to any other individual with CAH and 66% of them suggested the surgery should be performed in early childhood. DISCUSSION By this study we have contributed to the debate over suggestions that FG may cause adverse effects on sexual life of the patients in adulthood, beside already published effects on their mental well-being and LUTS. Despite possible selection bias due to only 58% response rate the comparison with control group shows only a moderate sexual dysfunction and more significant impact on long-term partnership that might be caused by other factors related to CAH beside FG itself. CONCLUSIONS Partnership, offspring, sexual frequency and function were impaired in adult females with CAH after FG. However, the median GRISS score was below the pathological level of 5.
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Affiliation(s)
- Jan Trachta
- Pediatric Surgery Department, Motol University Hospital, Charles University in Prague, V Uvalu 84, Prague, 15600, Czech Republic.
| | - Imran Mushtaq
- Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Natalia Petrasova
- Pediatric Surgery Department, Motol University Hospital, Charles University in Prague, Czech Republic.
| | - Ondrej Hradsky
- Department of Pediatrics, Motol University Hospital, Charles University in Prague, Czech Republic.
| | - Richard Skaba
- Pediatric Surgery Department, Motol University Hospital, Charles University in Prague, Czech Republic.
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21
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Allen NG, Krishna KB, Lee PA. Differences of Sex Development: What Neonatologists Need to Know. Clin Perinatol 2022; 49:207-218. [PMID: 35210002 DOI: 10.1016/j.clp.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Differences of sex development (DSD) refer to rare conditions in which an individual's sex development is different from typical male or female development. The neonatologist is often the first health care provider to interact with parents of newborns with DSD and must be familiar with the approach to patients with DSD. In this article, we discuss definition of DSD, initial workup of the patient with DSD, terminology, and controversies in care.
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Affiliation(s)
- Natalie G Allen
- Division of Endocrinology and Diabetes, Department of Pediatrics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
| | - Kanthi Bangalore Krishna
- Division of Endocrinology and Diabetes, Department of Pediatrics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Peter A Lee
- Division of Endocrinology and Diabetes, Department of Pediatrics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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22
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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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23
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Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Congenital adrenal hyperplasia is a category of disorders characterized by impaired
adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal
hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of
CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The
clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a
diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for
Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for
Urology, and the Japan Endocrine Society, the working committee updated the guidelines for
the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on
recent evidence and knowledge related to this disorder. The recommendations in the updated
guidelines can be applied in clinical practice considering the risks and benefits to each
patient.
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Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
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Indig G, Serrano M, Dalke KB, Ejiogu NI, Grimstad F. Clinician Advocacy and Intersex Health: A History of Intersex Health Care and the Role of the Clinician Advocate Past, Present, and Future. Pediatr Ann 2021; 50:e359-e365. [PMID: 34542337 DOI: 10.3928/19382359-20210816-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Throughout the history of Western culture, sex has been reflected as a binary rule, with this binary system affecting self-expression, lifestyle choices, and health outcomes of everyone, but especially those with intersex traits. "Intersex" (or differences of sex development) is an umbrella term used to describe a wide range of natural variations in genitalia, gonads, and chromosome patterns that do not fit typical binary notions of male or female bodies. Currently, people who identify as intersex or as having intersex traits are not provided with the appropriate care needed for their wellbeing. Intersex health care has undergone a great deal of change in the last century, led by intersex leaders and advocates. Clinician advocates have also played a vital role. This article will focus on this history of intersex health care evolution, the role of clinician advocacy, and suggestions for how clinicians can become advocates for improving intersex health care. [Pediatr Ann. 2021;50(9):e359-e365.].
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Ellerkamp V, Rall KK, Schaefer J, Stefanescu D, Schoeller D, Brucker S, Fuchs J. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021; 18:1797-1806. [PMID: 37057496 DOI: 10.1016/j.jsxm.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/31/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults. AIM This study focusses on the results of the surgical treatment of these patients in our multidisciplinary transitional disorders/differences of sex development team of pediatric surgeons and gynecologists. METHODS A retrospective analysis was carried out on adult and female identified disorders/differences of sex development patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revision of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished. OUTCOMES To describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse. RESULTS Thirteen patients presented with vaginal stenosis with a median age of 19 years (range 16-31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0-233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persistent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership. CLINICAL IMPLICATIONS Perineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vaginoplasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina. STRENGTHS & LIMITATIONS The strength of this study is the detailed description of several cases while the retrospective character is a limitation. CONCLUSION In patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Ellerkamp V, Rall KK, Schaefer J, et al. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021;18:1797-1806.
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Affiliation(s)
- Verena Ellerkamp
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Tuebingen, Tuebingen, Germany.
| | - Kristin Katharina Rall
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Juergen Schaefer
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Diana Stefanescu
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Dorit Schoeller
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Sara Brucker
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Joerg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Tuebingen, Tuebingen, Germany
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Alkhzouz C, Bucerzan S, Miclaus M, Mirea AM, Miclea D. 46,XX DSD: Developmental, Clinical and Genetic Aspects. Diagnostics (Basel) 2021; 11:1379. [PMID: 34441313 PMCID: PMC8392837 DOI: 10.3390/diagnostics11081379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022] Open
Abstract
Differences in sex development (DSD) in patients with 46,XX karyotype occur by foetal or postnatal exposure to an increased amount of androgens. These disorders are usually diagnosed at birth, in newborns with abnormal genitalia, or later, due to postnatal virilization, usually at puberty. Proper diagnosis and therapy are mostly based on the knowledge of normal development and molecular etiopathogenesis of the gonadal and adrenal structures. This review aims to describe the most relevant data that are correlated with the normal and abnormal development of adrenal and gonadal structures in direct correlation with their utility in clinical practice, mainly in patients with 46,XX karyotype. We described the prenatal development of structures together with the main molecules and pathways that are involved in sex development. The second part of the review described the physical, imaging, hormonal and genetic evaluation in a patient with a disorder of sex development, insisting more on patients with 46,XX karyotype. Further, 95% of the etiology in 46,XX patients with disorders of sex development is due to congenital adrenal hyperplasia, by enzyme deficiencies that are involved in the hormonal synthesis pathway. The other cases are explained by genetic abnormalities that are involved in the development of the genital system. The phenotypic variability is very important in 46,XX disorders of sex development and the knowledge of each sign, even the most discreet, which could reveal such disorders, mainly in the neonatal period, could influence the evolution, prognosis and life quality long term.
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Affiliation(s)
- Camelia Alkhzouz
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Simona Bucerzan
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Maria Miclaus
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Andreea-Manuela Mirea
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Diana Miclea
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Molecular Science Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Bangalore Krishna K, Kogan BA, Mazur T, Hoebeke P, Bogaert G, Lee PA. Individualized care for patients with intersex (differences of sex development): part 4/5.Considering the Ifs, Whens, and Whats regarding sexual-reproductive system surgery. J Pediatr Urol 2021; 17:338-345. [PMID: 33691983 DOI: 10.1016/j.jpurol.2021.02.011] [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] [Received: 11/01/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
Issues and concerns regarding surgery of the sexual-reproductive anatomy during infancy and early childhood are discussed using four actual examples. A case of a 46, XX infant with 21 hydroxylase deficiency congenital adrenal hyperplasia (CAH) with atypical (ambiguous) genitalia is discussed regarding timing and potential harms and benefits of surgery. We present the perspective of balancing the child's rights to bodily autonomy and right to an open future versus parents' decision making authority regarding what they perceive as their child's future best interests. The second case is a newborn with complete androgen insensitivity syndrome and we discuss the harms, benefits and timing of gonadectomy. The third case examines the physical and psychological impact of penile shaft hypospadias, raising the question of whether surgery is justified to prevent what may or may not be considered a permanent disability. The fourth case involves an adult woman with classic CAH, born with a urogenital sinus and clitoromegaly, who never had genital surgery and is now requesting vaginoplasty, but not clitoral reduction. The primary message of this article, as the previous articles in this series, is to encourage patient-family centered care that individualizes treatment guided by shared decision making.
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Affiliation(s)
| | | | | | | | - Guy Bogaert
- University Hospital, UZLeuven, Leuven, Belgium
| | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA
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Erdogan G. Experience of Vaginoplasty for Enhancement of Sexual Functioning in a Center in Turkey: A Before and After Study. Cureus 2021; 13:e14767. [PMID: 34094732 PMCID: PMC8168991 DOI: 10.7759/cureus.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective The number of vaginal rejuvenation procedures for improvement of sexual function is dramatically increasing worldwide. The objective of this study was to present our experience with women who presented to our clinic with the complaint of sexual dysfunction or desire to enhance sexual function or orgasm. Methods Demographic and descriptive data of the patients were evaluated. In addition, sexual dysfunction of the patients who underwent vaginoplasty in our center were evaluated before and after vaginoplasty procedure using Golombok Rust Inventory of Sexual Satisfaction (GRISS) scale and the scores were compared before and after the procedure, which is used in the evaluation of sexual dysfunction by relationship counsellors and clinics. Results A total of 250 women who described a sensation of a wide or floppy vagina with lost or decreased ability to achieve orgasm were included in the study. The mean age of the patients was 38.51±9.126 years. Of all women, 85.2% were college graduates. A history of normal vaginal delivery was found in 77.8% of the participants. The mean GRISS scores of "Infrequency", "Non-communication", "Dissatisfaction", "Non-sensuality", "Avoidance", "Anorgasmia" and "overall GRISS" scores were statistically significantly decreased, while the mean vaginismus score was significantly increased (p<0.01). Conclusion Highly satisfying outcomes regarding patient satisfaction were obtained from vaginoplasty procedures that we have performed.
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Affiliation(s)
- Gokcen Erdogan
- Gynecology and Obstetrics, Near East University Medical Faculty, Nicosia, CYP
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Bidault V, Botto N, Paye-Jaouen A, Leger J, Josset-Raffet É, Martinerie L, Peycelon M, El-Ghoneimi A. New method for early evaluation of clitoris innervation using clitoro-perineal reflex after feminizing genitoplasty in early childhood: a pilot-study. Sci Rep 2021; 11:7087. [PMID: 33782453 PMCID: PMC8007626 DOI: 10.1038/s41598-021-86434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 03/08/2021] [Indexed: 11/20/2022] Open
Abstract
A major complication of feminizing genitoplasty in children is the loss of clitoral sensation with serious impact at adult life. We suggest a new method to evaluate the surgical results during childhood based on the bulbocavernosus or clitoro-perineal reflex (CPR). The afferent pathway of CPR implies the intact sensory receptors on the clitoral glans. Girls with congenital adrenal hyperplasia who were followed-up medically without surgery or who underwent feminizing genitoplasty with or without clitoroplasty were included (2002-2018). All clitoroplasties were standardized reduction clitoroplasty with preservation of neurovascular bundles associated with vaginoplasty and vestibuloplasty. Standardized examinations were prospectively performed including the CPR starting at one year postoperatively. The reflex was triggered by gentle touch of the glans by a cotton swab. Contraction of the perineal muscles was considered positive. Thirty-two children were operated at a median age of 8.6 months (5.8-12.1). Median follow-up (FU) was 3.9 years (1.3-6.4). Twenty-four patients had clitoroplasties: 17 were tested for CPR at one-year FU, and all had a positive test. Eight girls had genitoplasty without clitoral surgery, two of them were tested and were positive. Ten patients were managed without surgery, two of them were tested for the CPR and were positive. The reflex was always triggered easily and repeated at least twice during the FU. The clitoro-perineal reflex is a simple, non-invasive and reproducible test in early childhood and may serve as an early evaluation tool of clitoral innervation after feminizing genitoplasty. These results need to be confirmed at long term and completed at adult life.
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Affiliation(s)
- Valeska Bidault
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Nathalie Botto
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Juliane Leger
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
- Department of Pediatric Endocrinology, University Children Hospital Robert-Debré, APHP, University of Paris, Paris, France
| | - Éliane Josset-Raffet
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Laetitia Martinerie
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
- Department of Pediatric Endocrinology, University Children Hospital Robert-Debré, APHP, University of Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France.
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France.
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Babu R, Shah U. Gender identity disorder (GID) in adolescents and adults with differences of sex development (DSD): A systematic review and meta-analysis. J Pediatr Urol 2021; 17:39-47. [PMID: 33246831 DOI: 10.1016/j.jpurol.2020.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/24/2020] [Accepted: 11/08/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED Gender assignment in infants born with a difference in sexual development (DSD) remains one of the many difficult decisions faced by the multi-disciplinary treatment team as some of these children develop gender identity disorder (GID) when they become adults. In this systematic review and meta-analysis we have analyzed the prevalence of GID in adolescent and adults with DSD. The secondary outcome of this review is to help physicians in appropriate sex assignment of DSD children so that development of GID in later life can be reduced. METHODS Pubmed/Index medicus were searched for "intersex" [All fields] OR "disorders of sexual differentiation AND "gender identity disorder OR gender dysphoria" [MeSH] for articles published between 2005 and 2020. Typical diagnoses included were congenital adrenal hyperplasia (CAH); complete androgen insensitivity syndrome (CAIS); partial androgen insensitivity syndrome (PAIS); 5 alpha reductase deficiency (5ARD); 17-hydroxysteroid dehydrogenase deficiency (17HSD); mixed gonadal dysgenesis (MGD) and complete gonadal dysgenesis (CGD). GID or gender dysphoria (a strong feeling of dissatisfaction about oneself as male or female) prevalence in DSD patients older than 12 years of age was extracted. Within each condition, GID percentage was compared between female and male rearing. RESULTS The I2statistics for prevalence of GID in DSD showed high heterogeneity with I2 of 93% (95% C.I 90-95%) among the 20 articles included. The overall prevalence of GID among those with DSD was 15% (95% C.I 13-17%). CAH reared females had 4% GID while CAH reared males had significantly higher GID at 15% (p = 0.0056). All CAIS patients were raised as females and the prevalence of GID was 1.7%. GID prevalence was 12% in PAIS raised as females while 25% in those raised as males with no significant difference (p = 0.134). GID was significantly high in 5ARD (53%) and 17HSD (53%) reared as females with half of them virilizing at puberty forcing a gender change. Among sex chromosome DSD 22% of those reared as females had GID while none in those raised as male with no significant difference. CONCLUSIONS GID is low in women with CAH, CAIS and CGD favoring female sex of rearing in these conditions. GID is high in women with 5ARD/17HSD favoring male sex of rearing in these conditions. GID is variable in PAIS or MGD and no recommendations on sex of rearing could be made in these conditions. Each DSD patient is unique and they warrant multi-disciplinary care and long term psycho sexual support.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India.
| | - Utsav Shah
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India
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Dwiggins M, Brookner B, Fowler K, Veeraraghavan P, Gomez-Lobo V, Merke DP. Multidimensional Aspects of Female Sexual Function in Congenital Adrenal Hyperplasia: A Case-Control Study. J Endocr Soc 2020; 4:bvaa131. [PMID: 34485799 DOI: 10.1210/jendso/bvaa131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/28/2020] [Indexed: 11/19/2022] Open
Abstract
Context 46,XX patients with classic congenital adrenal hyperplasia (CAH) are exposed to elevated androgens in utero causing varying levels of virilization. The majority undergo feminizing genitoplasty early in life, with potential impact on sexual function and health-related quality of life (HRQoL). Objective We aimed to determine how sexual and lower urinary tract function, body image, and global HRQoL differs between patients with classic CAH and controls and to characterize how gynecologic anatomy contributes to outcomes. Methods 36 patients with classic CAH and 27 control women who were matched for age, race, and marital status underwent standardized gynecological examination and validated questionnaires. The responses were analyzed in relation to gynecological measurements, genotype, and disease status. Results Compared with controls, patients with CAH were more likely to have sexual dysfunction (P = 0.009), dyspareunia (P = 0.007), and other pelvic pain (P = 0.007); were less likely to be heterosexual (P = 0.013) or ever have been sexually active (P = 0.003); had poorer body image independent of body mass index (P < 0.001); and had worse HRQoL in the areas of general health (P = 0.03) and pain (P = 0.009). The patients with CAH had smaller vaginal calibers and perineal body lengths and larger clitoral indexes when compared with controls (P < 0.001). A larger vaginal caliber in CAH patients was associated with better overall sexual function (P = 0.024), increased sexual satisfaction (P = 0.017), less pain (P < 0.001), and greater number of sexual partners (P = 0.02). Conclusions 46,XX patients with CAH have increased rates of sexual dysfunction, poor body image, and poor HRQoL, which is mitigated by having a larger vaginal caliber. Management aimed at optimizing vaginal caliber might improve sexual function.
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Affiliation(s)
- Maggie Dwiggins
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Norton Children's Medical Group, Louisville, Kentucky
| | | | - Kylie Fowler
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Children's Minnesota, Minneapolis, Minnesota
| | | | - Veronica Gomez-Lobo
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Bangalore Krishna K, Kogan BA, Ernst MM, Romao RL, Mohsin F, Serrano-Gonzalez M, Quintos JB, Phornphutkul C, Aguiar L, Lee PA. Individualized care for patients with intersex (disorders/differences of sex development): Part 3. J Pediatr Urol 2020; 16:598-605. [PMID: 32605872 DOI: 10.1016/j.jpurol.2020.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
The focus of this article is to review the complex determinants of gender assignment in a child with a disorder of sex development using four different clinical cases. While the care of patients with DSD may be shared across several specialties and opinions regarding their management may vary, this may be further complicated by psychosocial, cultural and economic factors. In this regard, access to behavioral health specialists with experience and specialization in the treatment of patients with DSD should be a foundational component of the standard of care and can greatly assist in the complex decision-making regarding gender assignment. We recommend an individualized approach by a multidisciplinary team utilizing a range of evolving strategies, including outcome data (or lack thereof) to support families during the decision-making process.
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Affiliation(s)
| | | | - Michelle M Ernst
- University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | | | | | | | | | - Chanika Phornphutkul
- The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Liza Aguiar
- The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA
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33
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Engberg H, Möller A, Hagenfeldt K, Nordenskjöld A, Frisén L. Identity, Sexuality, and Parenthood in Women with Congenital Adrenal Hyperplasia. J Pediatr Adolesc Gynecol 2020; 33:470-476. [PMID: 32473322 DOI: 10.1016/j.jpag.2020.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To explore how women with congenital adrenal hyperplasia (CAH) describe their experiences of gender role behavior, psychosexual development, and intimate relationships. CAH results in increased androgen exposure in affected females, and is the most common reason for unclear sex at birth. Women with CAH have been studied to find answers to the role of androgens in psychosexual development. Nevertheless, factors that may account for the variability of outcomes in women with CAH are unclear. DESIGN, SETTING AND PARTICIPANTS This was a qualitative study with 13 Swedish women (aged ≥18 years) with CAH. Semi-structured interviews were analyzed using inductive content analysis. MAIN OUTCOME MEASURES Direct quotes of patients' experiences derived from interview transcripts were sorted in categories, subcategories, and according to latent theme. RESULTS The main categories were "forming identity" and "establishing relationships." Forming identity encompasses that of a girl, a tomboy, and/or a woman. Establishing relationships focuses on intimate relationships, pregnancy, and parenthood. A latent theme was interpreted as "shifting perspectives," with CAH being the main focus of some participants' lives but a side issue for others. CONCLUSION These women's experiences are varied and describe shifting perspectives on how much CAH affects their lives. Health care providers can play an important role in helping women with CAH to separate what is caused by the condition and what is not. The long-term goal is to help girls and women to feel in control of their condition across their whole life.
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Affiliation(s)
- Hedvig Engberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden; Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden.
| | - Anders Möller
- Ersta Sköndal University College, Campus Bräcke, Gothenburg, Sweden
| | - Kerstin Hagenfeldt
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Pediatric Surgery Unit and Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Child and Adolescent Psychiatry Research Centre, Stockholm, Sweden
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Affiliation(s)
- Deborah P Merke
- From the National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (D.P.M.); and the Division of Metabolism, Endocrinology, and Diabetes and the Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor (R.J.A.)
| | - Richard J Auchus
- From the National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (D.P.M.); and the Division of Metabolism, Endocrinology, and Diabetes and the Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor (R.J.A.)
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35
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Shiryaev ND, Kagantsov IM, Sizonov VV. [Disorders of sex differentiation: state of the problem 15 years after the Chicago consensus]. PROBLEMY ENDOKRINOLOGII 2020; 66:70-80. [PMID: 33351341 DOI: 10.14341/probl12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 06/12/2023]
Abstract
It is well known that the nomenclature and classification were changed in 2005 at the international consensus conference on intersex disorders, held in Chicago, where, among others, the following recommendations were proposed: (1) all children should be assigned a gender identity, and this should be done as quickly as possible, taking into account the time required for the examination. (2) all infants with congenital adrenal hyperplasia and 46,XX karyotype, including those with pronounced masculinization, must be raised as women. (3) Surgical treatment should be performed early and in cases of feminizing genitoplasty, clitoral reduction should be performed simultaneously with reconstruction of the urogenital sinus (separation of the vagina and urethra). An analysis of contemporary literature shows that all these theories, proposed 15 years ago at the Chicago meeting, failed to stand the test of time. New nomenclature and classification are constantly being revised. Currently, many groups of patients want to abolish the term «sexual maturity disorders.» Recommendations regarding gender reassignment and appropriate early surgical treatment have been completely ignored in some countries. All this was largely facilitated by the confrontational activities of a number of support groups.
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Affiliation(s)
| | - Ilya M Kagantsov
- Pitirim Sorokin Syktyvkar State University; Republican Children's Clinical Hospital
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36
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Kudela G, Gawlik A, Koszutski T. Early Feminizing Genitoplasty in Girls with Congenital Adrenal Hyperplasia (CAH)-Analysis of Unified Surgical Management. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113852. [PMID: 32485822 PMCID: PMC7312042 DOI: 10.3390/ijerph17113852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/20/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022]
Abstract
AIM To analyze a single-centre experience in feminizing genitoplasty in virilized girls with congenital adrenal hyperplasia (CAH). METHODS Review of medical records of all 46, XX CAH patients undergoing single stage feminizing genitoplasty between 2003 and 2018 was performed. RESULTS A total of 31 girls aged from 4 months to 10 years were included in the study. The majority (n = 26/31, 84%) were operated before 2 years of age (median 8 months). External virilization was rated as Prader 3 (n = 7/31), Prader 4 (n = 21/31) and Prader 5 (n = 3/31). The urethrovaginal confluence location was low in 19 and high in 12 girls with a percentage distribution similar in Prader 4 and 5 (p > 0.05) but significantly different in Prader 3 (p = 0.017). The follow-up ranged from 12 months to 15 years. All parents assessed the cosmetic result as satisfactory. Perioperative complications occurred in two patients and included rectal injury (n = 1/31) and prolonged bleeding (n = 1/31). Three patients developed late complications including labial atheromas (n = 2/31) and vaginal stricture requiring surgical dilatation (n = 1/31). Low confluence did not decrease the risk of complications. CONCLUSIONS Early feminizing genitoplasty in girls with congenital adrenal hyperplasia, irrespective of virilization severity, gives satisfactory cosmetic results and is characterized by low and acceptable surgical risk. Nevertheless, the most important determinant of the effectiveness of such management would be future patients' satisfaction.
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Affiliation(s)
- Grzegorz Kudela
- Department of Pediatric Surgery and Urology, Medical University of Silesia, 40-752 Katowice, Poland;
- Correspondence: ; Tel.: +48-501 460 285
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Tomasz Koszutski
- Department of Pediatric Surgery and Urology, Medical University of Silesia, 40-752 Katowice, Poland;
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Daae E, Feragen KB, Waehre A, Nermoen I, Falhammar H. Sexual Orientation in Individuals With Congenital Adrenal Hyperplasia: A Systematic Review. Front Behav Neurosci 2020; 14:38. [PMID: 32231525 PMCID: PMC7082355 DOI: 10.3389/fnbeh.2020.00038] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/21/2020] [Indexed: 12/12/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic condition of the steroidogenic enzymes in the adrenal cortex normally leading to variable degrees of cortisol and aldosterone deficiency as well as androgen excess. Exposure to androgens prenatally might lead to ambiguous genitalia. The fetal brain develops in traditional male direction through a direct action of androgens on the developing nerve cells, or in the traditional female direction in the absence of androgens. This may indicate that sexual development, including sexual orientation, are programmed into our brain structures prenatally. The objective of this study was to perform a systematic review of the literature, investigating sexual orientation in individuals with CAH. The study also aimed at identifying which measures are used to define sexual orientation across studies. The review is based on articles identified through a comprehensive search of the OVIDMedline, PsycINFO, CINAHL, and Web of Science databases published up to May 2019. All peer-reviewed articles investigating sexual orientation in people with CAH were included. Quantitative, qualitative, and mixed methods were considered, as well as self-, parent-, and third-party reports, and no age or language restrictions were enforced on publications. The present review included 30 studies investigating sexual orientation in patients with CAH assigned female at birth (46, XX) (n = 927) or assigned male at birth (46, XY and 46, XX) (n = 274). Results indicate that assigned females at birth (46, XX) with CAH had a greater likelihood to not have an exclusively heterosexual orientation than females from the general population, whereas no assigned males at birth (46, XY or 46, XX) with CAH identified themselves as non-heterosexual. There was a wide diversity in measures used and a preference for unvalidated and self-constructed interviews. Hence, the results need to be interpreted with caution. Methodological weaknesses might have led to non-heterosexual orientation being overestimated or underestimated. The methodological challenges identified by this review should be further investigated in future studies.
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Affiliation(s)
| | | | | | - Ingrid Nermoen
- Oslo University, Oslo, Norway
- Akershus University Hospital, Lillestrøm, Norway
| | - Henrik Falhammar
- Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Balsamo A, Baronio F, Ortolano R, Menabo S, Baldazzi L, Di Natale V, Vissani S, Cassio A. Congenital Adrenal Hyperplasias Presenting in the Newborn and Young Infant. Front Pediatr 2020; 8:593315. [PMID: 33415088 PMCID: PMC7783414 DOI: 10.3389/fped.2020.593315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/23/2020] [Indexed: 12/25/2022] Open
Abstract
Congenital adrenal hyperplasia includes autosomal recessive conditions that affect the adrenal cortex steroidogenic enzymes (cholesterol side-chain cleavage enzyme; 3β-hydroxysteroid dehydrogenase; 17α-hydroxylase/17,20 lyase; P450 oxidoreductase; 21-hydroxylase; and 11β-hydroxylase) and proteins (steroidogenic acute regulatory protein). These are located within the three major pathways of the steroidogenic apparatus involved in the production of mineralocorticoids, glucocorticoids, and androgens. Many countries have introduced newborn screening program (NSP) based on 17-OH-progesterone (17-OHP) immunoassays on dried blood spots, which enable faster diagnosis and treatment of the most severe forms of 21-hydroxylase deficiency (21-OHD). However, in several others, the use of this diagnostic tool has not yet been implemented and clinical diagnosis remains challenging, especially for males. Furthermore, less severe classic forms of 21-OHD and other rarer types of CAHs are not identified by NSP. The aim of this mini review is to highlight both the main clinical characteristics and therapeutic options of these conditions, which may be useful for a differential diagnosis in the neonatal period, while contributing to the biochemical evolution taking place in the steroidogenic field. Currently, chromatographic techniques coupled with tandem mass spectrometry are gaining attention due to an increase in the reliability of the test results of NPS for detecting 21-OHD. Furthermore, the possibility of identifying CAH patients that are not affected by 21-OHD but presenting elevated levels of 17-OHP by NSP and the opportunity to include the recently investigated 11-oxygenated androgens in the steroid profiles are promising tools for a more precise diagnosis and monitoring of some of these conditions.
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Affiliation(s)
- Antonio Balsamo
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Baronio
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Rita Ortolano
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Soara Menabo
- Genetic Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lilia Baldazzi
- Genetic Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Valeria Di Natale
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Sofia Vissani
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Alessandra Cassio
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
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Chawla R, Rutter M, Green J, Weidler EM. Care of the adolescent patient with congenital adrenal hyperplasia: Special considerations, shared decision making, and transition. Semin Pediatr Surg 2019; 28:150845. [PMID: 31668292 PMCID: PMC7199612 DOI: 10.1016/j.sempedsurg.2019.150845] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The care of infants with congenital adrenal hyperplasia has recently been examined and principles of shared decision making are being used to aid families at that crucial stage of care. Although there is no rigorous data to support delay of surgery, some families are choosing to wait until the patient can participate in choosing the course of care. Whether patients undergo reconstructive procedures or not in the newborn period, they may need or desire revision or primary surgeries as an adolescent or young adult. The first priority for one of these young, now more autonomous, patients is to help them take charge of their own care and develop an understanding of their medical needs. In the process of providing that education, providers and teams can connect to the patient, their caregivers and advocates in a way that allows further investigation into possible medical and surgical needs in a less pressurized situation.
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Affiliation(s)
- Reeti Chawla
- Division of Pediatric Endocrinology, Phoenix Children's Hospital, Phoenix, AZ, United States.
| | - Meilan Rutter
- Division of Endocrinology, Cincinnati Children’s, Cincinnati, OH
| | - Janet Green
- Accord Alliance, Former Executive Director, Patient Advocate
| | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ
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46,XX DSD due to Androgen Excess in Monogenic Disorders of Steroidogenesis: Genetic, Biochemical, and Clinical Features. Int J Mol Sci 2019; 20:ijms20184605. [PMID: 31533357 PMCID: PMC6769793 DOI: 10.3390/ijms20184605] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 12/17/2022] Open
Abstract
The term 'differences of sex development' (DSD) refers to a group of congenital conditions that are associated with atypical development of chromosomal, gonadal, or anatomical sex. Disorders of steroidogenesis comprise autosomal recessive conditions that affect adrenal and gonadal enzymes and are responsible for some conditions of 46,XX DSD where hyperandrogenism interferes with chromosomal and gonadal sex development. Congenital adrenal hyperplasias (CAHs) are disorders of steroidogenesis that mainly involve the adrenals (21-hydroxylase and 11-hydroxylase deficiencies) and sometimes the gonads (3-beta-hydroxysteroidodehydrogenase and P450-oxidoreductase); in contrast, aromatase deficiency mainly involves the steroidogenetic activity of the gonads. This review describes the main genetic, biochemical, and clinical features that apply to the abovementioned conditions. The activities of the steroidogenetic enzymes are modulated by post-translational modifications and cofactors, particularly electron-donating redox partners. The incidences of the rare forms of CAH vary with ethnicity and geography. The elucidation of the precise roles of these enzymes and cofactors has been significantly facilitated by the identification of the genetic bases of rare disorders of steroidogenesis. Understanding steroidogenesis is important to our comprehension of differences in sexual development and other processes that are related to human reproduction and fertility, particularly those that involve androgen excess as consequence of their impairment.
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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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Chawla R, Weidler EM, Hernandez J, Grimbsy G, van Leeuwen K. Utilization of a shared decision-making tool in a female infant with congenital adrenal hyperplasia and genital ambiguity. J Pediatr Endocrinol Metab 2019; 32:643-646. [PMID: 31145695 DOI: 10.1515/jpem-2018-0567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
Background Shared decision-making (SDM) is the process by which patients/families and providers make healthcare decisions together. Our team of multidisciplinary disorders of sex development (DSD) has developed an SDM tool for parents and female patients with congenital adrenal hyperplasia (CAH) and associated genital atypia. What is new Elective genital surgery is considered controversial. SDM in a patient with genital atypia will allow patient/family to make an informed decision regarding surgical intervention. Case presentation Our patient is a 2.5-year-old female with CAH and genital atypia. Initially, her parents had intended to proceed with surgery; however, after utilizing the SDM checklist, they made an informed decision to defer urogenital sinus surgery for their daughter. Conclusions We successfully utilized an SDM tool with parents of a female infant with CAH and genital atypia, which allowed them to make an informed decision regarding surgery for their daughter. Future directions include a prospective enrolling study to determine the generalizability and applicability of SDM with families of children diagnosed with CAH.
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Affiliation(s)
- Reeti Chawla
- Attending Physician, Division of Pediatric Endocrinology, Phoenix Children's Hospital, Clinical Assistant Professor - Child Health, UA College of Medicine - Phoenix, 1920 East Cambridge Ave, Suite 301, Phoenix, AZ 85016, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Janett Hernandez
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Gwen Grimbsy
- Division of Pediatric Urology, Phoenix Children's Hospital, Phoenix, AZ, USA
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Al Alawi AM, Nordenström A, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 3β-hydroxysteroid dehydrogenase type 2 deficiency. Endocrine 2019; 63:407-421. [PMID: 30719691 PMCID: PMC6420607 DOI: 10.1007/s12020-018-01835-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE 3β-hydroxysteroid dehydrogenase type 2 deficiency (3βHSD2D) is a very rare variant of congenital adrenal hyperplasia (CAH) causing less than 0.5% of all CAH. The aim was to review the literature. METHODS PubMed was searched for relevant articles. RESULTS 3βHSD2D is caused by HSD3B2 gene mutations and characterized by impaired steroid synthesis in the gonads and the adrenal glands and subsequent increased dehydroepiandrosterone (DHEA) concentrations. The main hormonal changes observed in patients with 3βHSD2D are elevated ratios of the Δ5-steroids over Δ4-steroids but molecular genetic testing is recommended to confirm the diagnosis. Several deleterious mutations in the HSD3B2 gene have been associated with salt-wasting (SW) crisis in the neonatal period, while missense mutations have been associated with a non-SW phenotype. Boys may have ambiguous genitalia, whereas girls present with mild or no virilization at birth. The existence of non-classic 3βHSD2D is controversial. In an acute SW crisis, the treatment includes prompt rehydration, correction of hypoglycemia, and parenteral hydrocortisone. Similar to other forms of CAH, glucocorticoid and mineralocorticoid replacement is needed for long-term management. In addition, sex hormone replacement therapy may be required if normal progress through puberty is failing. Little is known regarding possible negative long-term consequences of 3βHSD2D and its treatments, e.g., fertility, final height, osteoporosis and fractures, adrenal and testicular tumor risk, and mortality. CONCLUSION Knowledge is mainly based on case reports but many long-term outcomes could be presumed to be similar to other types of CAH, mainly 21-hydroxylase deficiency, although in 3βHSD2D it seems to be more difficult to suppress the androgens.
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Affiliation(s)
- Abdullah M Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Division of Medicine, 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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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 531] [Impact Index Per Article: 88.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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