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Auer MK, Birnbaum W, Hartmann MF, Holterhus PM, Kulle A, Lux A, Marshall L, Rall K, Richter-Unruh A, Werner R, Wudy SA, Hiort O. Metabolic effects of estradiol versus testosterone in complete androgen insensitivity syndrome. Endocrine 2022; 76:722-732. [PMID: 35258786 PMCID: PMC9156500 DOI: 10.1007/s12020-022-03017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/10/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE To study differences in metabolic outcomes between testosterone and estradiol replacement in probands with complete androgen insensitivity syndrome (CAIS). METHODS In this multicentre, double-blind, randomized crossover trial, 26 women with CAIS were included of whom 17 completed the study. After a two-months run in phase with estradiol, probands either received transdermal estradiol followed by crossover to transdermal testosterone or vice versa. After six months, differences in lipids, fasting glucose, insulin, hematocrit, liver parameters and blood pressure between the treatment phases were investigated. RESULTS Linear mixed models adjusted for period and sequence did not reveal major group differences according to treatment for the investigated outcomes. In each treatment group, there were however significant uniform changes in BMI and cholesterol. BMI increased significantly, following six months of estradiol ( + 2.7%; p = 0.036) as well as testosterone treatment ( + 2.8%; p = 0.036). There was also a significant increase in total ( + 10.4%; p = 0.001) and LDL-cholesterol ( + 29.2%; p = 0.049) and a decrease in HDL-cholesterol (-15.8%; p < 0.001) following six months of estradiol as well as six months of testosterone treatment (total cholesterol: + 14.6%; p = 0.008; LDL-cholesterol: + 39.1%; p = 0.005, HDL-cholesterol: -15.8%; p = 0.004). Other parameters remained unchanged. CONCLUSION Transdermal estradiol as well as testosterone treatment in women with CAIS results in worsening in lipid profiles. Given the relatively small sample size, subtle group differences in other metabolic parameters may have remained undetected.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Wiebke Birnbaum
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Michaela F Hartmann
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics in Pediatric Endocrinology, Division of Pediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Paul-Martin Holterhus
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University Hospital of Schleswig - Holstein, Campus Kiel/Christian - Albrechts University of Kiel, Kiel, Germany
| | - Alexandra Kulle
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University Hospital of Schleswig - Holstein, Campus Kiel/Christian - Albrechts University of Kiel, Kiel, Germany
| | - Anke Lux
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Luise Marshall
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Katarina Rall
- Department of Women's Health, Centre for Rare Female Genital Malformations, Women's University Hospital, Tübingen University Hospital, Tübingen, Germany
| | - Annette Richter-Unruh
- Paediatric Endocrinology, Department of Pediatrics, Universitätsklinikum Münster, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Ralf Werner
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
- Institute for Molecular Medicine, University of Lübeck, Lübeck, Germany
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics in Pediatric Endocrinology, Division of Pediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Olaf Hiort
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany.
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Tyutyusheva N, Mancini I, Baroncelli GI, D’Elios S, Peroni D, Meriggiola MC, Bertelloni S. Complete Androgen Insensitivity Syndrome: From Bench to Bed. Int J Mol Sci 2021; 22:ijms22031264. [PMID: 33514065 PMCID: PMC7865707 DOI: 10.3390/ijms22031264] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/07/2021] [Accepted: 01/22/2021] [Indexed: 12/13/2022] Open
Abstract
Complete androgen insensitivity syndrome (CAIS) is due to complete resistance to the action of androgens, determining a female phenotype in persons with a 46,XY karyotype and functioning testes. CAIS is caused by inactivating mutations in the androgen receptor gene (AR). It is organized in eight exons located on the X chromosome. Hundreds of genetic variants in the AR gene have been reported in CAIS. They are distributed throughout the gene with a preponderance located in the ligand-binding domain. CAIS mainly presents as primary amenorrhea in an adolescent female or as a bilateral inguinal/labial hernia containing testes in prepubertal children. Some issues regarding the management of females with CAIS remain poorly standardized (such as the follow-up of intact testes, the timing of gonadal removal and optimal hormone replacement therapy). Basic research will lead to the consideration of new issues to improve long-term well-being (such as bone health, immune and metabolic aspects and cardiovascular risk). An expert multidisciplinary approach is mandatory to increase the long-term quality of life of women with CAIS.
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Affiliation(s)
- Nina Tyutyusheva
- Pediatric and Adolescent Endocrinology, Division of Paediatrics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (N.T.); (G.I.B.); (S.D.); (D.P.)
| | - Ilaria Mancini
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Policlinico di Sant’Orsola, DIMEC, University of Bologna, 40138 Bologna, Italy; (I.M.); (M.C.M.)
| | - Giampiero Igli Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Paediatrics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (N.T.); (G.I.B.); (S.D.); (D.P.)
| | - Sofia D’Elios
- Pediatric and Adolescent Endocrinology, Division of Paediatrics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (N.T.); (G.I.B.); (S.D.); (D.P.)
| | - Diego Peroni
- Pediatric and Adolescent Endocrinology, Division of Paediatrics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (N.T.); (G.I.B.); (S.D.); (D.P.)
| | - Maria Cristina Meriggiola
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Policlinico di Sant’Orsola, DIMEC, University of Bologna, 40138 Bologna, Italy; (I.M.); (M.C.M.)
| | - Silvano Bertelloni
- Pediatric and Adolescent Endocrinology, Division of Paediatrics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (N.T.); (G.I.B.); (S.D.); (D.P.)
- Correspondence: ; Tel.: +39-050-992743; Fax: +39-050-992641
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Gava G, Mancini I, Orsili I, Bertelloni S, Alvisi S, Seracchioli R, Meriggiola MC. Bone mineral density, body composition and metabolic profiles in adult women with complete androgen insensitivity syndrome and removed gonads using oral or transdermal estrogens. Eur J Endocrinol 2019; 181:711-718. [PMID: 31491747 DOI: 10.1530/eje-19-0383] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/14/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To assess bone health in adult women with complete androgen insensitivity syndrome (CAIS) and removed gonads compared with age-matched healthy controls. To evaluate the effects of transdermal oestradiol 2 mg or oral estradiol valerate 2 mg on bone, biochemical and clinical characteristics. DESIGN Cohort study. METHODS Bone, body composition and anthropometric parameters were assessed in 32 adult CAIS and 32 healthy controls. In 28 cases, CAIS evaluations of metabolic, bone and body composition were performed also after a maximum of 6 years of therapy. RESULTS Lumbar, femoral and total body bone mineral density (BMD) were significantly lower in those with CAIS when compared with controls. The prevalence of vertebral osteoporosis and osteopenia was significantly higher in the CAIS group (P = 0.038, OR = 9.67, 95% CI: 1.13-82.83 and P = 0.012, OR= 3.85, 95% CI: 1.34-11.16, respectively). Prevalence of femoral osteopenia was significantly higher in the CAIS group (P = 0.0012, OR = 7.93, 95% CI: 2.26-27.9). During follow-up, lumbar BMD significantly increased suggesting a significant effect of treatment on BMD (P = 0.0016), while femoral and total body BMD did not show any significant change. Total body BMD values were positively associated to the duration and route of oestrogen administration and to serum estradiol levels. Transdermal administration of estrogens was associated with better total body BMD in comparison to oral administration. CONCLUSIONS Our results reinforce the importance of adequate hormonal treatment for women living with CAIS, suggesting a better effect from the transdermal route over the oral route.
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Affiliation(s)
- Giulia Gava
- Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Ilaria Mancini
- Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Isabella Orsili
- Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Silvano Bertelloni
- Pediatric Division, Department of Obstetrics, Gynecology and Pediatrics, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Maria Cristina Meriggiola
- Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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Lanciotti L, Cofini M, Leonardi A, Bertozzi M, Penta L, Esposito S. Different Clinical Presentations and Management in Complete Androgen Insensitivity Syndrome (CAIS). Int J Environ Res Public Health 2019; 16:ijerph16071268. [PMID: 30970592 PMCID: PMC6480640 DOI: 10.3390/ijerph16071268] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 01/08/2023]
Abstract
Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive genetic disorder resulting from maternally inherited or de novo mutations involving the androgen receptor gene, situated in the Xq11-q12 region. The diagnosis is based on the presence of female external genitalia in a 46, XY human individual, with normally developed but undescended testes and complete unresponsiveness of target tissues to androgens. Subsequently, pelvic ultrasound or magnetic resonance imaging (MRI) could be helpful in confirming the absence of Mullerian structures, revealing the presence of a blind-ending vagina and identifying testes. CAIS management still represents a unique challenge throughout childhood and adolescence, particularly regarding timing of gonadectomy, type of hormonal therapy, and psychological concerns. Indeed this condition is associated with an increased risk of testicular germ cell tumour (TGCT), although TGCT results less frequently than in other disorders of sex development (DSD). Furthermore, the majority of detected tumoral lesions are non-invasive and with a low probability of progression into aggressive forms. Therefore, histological, epidemiological, and prognostic features of testicular cancer in CAIS allow postponing of the gonadectomy until after pubertal age in order to guarantee the initial spontaneous pubertal development and avoid the necessity of hormonal replacement therapy (HRT) induction. However, HRT is necessary after gonadectomy in order to prevent symptoms of hypoestrogenism and to maintain secondary sexual features. This article presents differential clinical presentations and management in patients with CAIS to emphasize the continued importance of standardizing the clinical and surgical approach to this disorder.
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Affiliation(s)
- Lucia Lanciotti
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Marta Cofini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Alberto Leonardi
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Mirko Bertozzi
- Pediatric Surgery, Azienda Ospedaliera Santa Maria della Misericordia, 20122 Perugia, Italy.
| | - Laura Penta
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
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Birnbaum W, Marshall L, Werner R, Kulle A, Holterhus PM, Rall K, Köhler B, Richter-Unruh A, Hartmann MF, Wudy SA, Auer MK, Lux A, Kropf S, Hiort O. Oestrogen versus androgen in hormone-replacement therapy for complete androgen insensitivity syndrome: a multicentre, randomised, double-dummy, double-blind crossover trial. Lancet Diabetes Endocrinol 2018; 6:771-780. [PMID: 30075954 DOI: 10.1016/s2213-8587(18)30197-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Women with complete androgen insensitivity syndrome (CAIS) after gonadectomy have complained about reduced psychological wellbeing and sexual satisfaction. The aim of this study was to compare the effectiveness of hormone-replacement therapy with either androgen or oestrogen in women with 46,XY karyotype and CAIS after gonadectomy. METHODS This national, multicentre, double-blind, randomised crossover trial was performed at three university medical centres and three specialised treatment institutions in Germany. Eligible participants were women aged 18-54 years with 46,XY karyotype, genetically diagnosed CAIS, and removed gonads. Participants were randomly assigned (14:12) by a central computer-based minimisation method to either oestradiol 1·5 mg/day for 6 months followed by crossover to testosterone 50 mg/day for 6 months (sequence A) or to testosterone 50 mg/day for 6 months followed by crossover to oestradiol 1·5 mg/day for 6 months (sequence B). Participants also received oestradiol or testosterone dummy to avoid identification of the active substance. All participants received oestradiol 1·5 mg/day during a 2 months' run-in phase. The primary outcome was mental health-related quality of life, as measured with the standardised German version of the SF-36 questionnaire. Secondary outcomes were psychological wellbeing, as measured with the Brief Symptom Inventory (BSI), sexual function, as measured with the Female Sexual Function Index (FSFI), and somatic effects, such as signs of virilisation and effects on metabolic blood values. The primary analysis included all patients who were available at least until visit 5, even if protocol violations occurred. The safety analysis included all patients who received at least oestradiol during the run-in phase. This trial is registered with the German Clinical Trials Register, number DRKS00003136, and with the European Clinical Trials Database, number 2010-021790-37. FINDINGS We enrolled 26 patients into the study, with the first patient enrolled on Nov 7, 2011, and the last patient leaving the study on Jan 23, 2016. 14 patients were assigned to sequence A and 12 were assigned to sequence B. Ten participants were withdrawn from the study, two of whom attended at least five visits and so could be included in the primary analysis. Mental health-related quality of life did not differ between treatment groups (linear mixed model, p=0·794), nor did BSI scores for psychological wellbeing (global severity index, p=0·638; positive symptom distress index, p=0·378; positive symptom total, p=0·570). For the FSFI, testosterone was superior to oestradiol only in improving sexual desire (linear mixed model, p=0·018). No virilisation was observed, and gonadotrophin concentrations remained stable in both treatment groups. Oestradiol and testosterone concentrations changed substantially during the study in both treatment groups. 28 adverse events were reported for patients receiving oestradiol (23 grade 1 and five grade 2), and 38 adverse events were reported for patients receiving testosterone (34 grade 1, three grade 2, and one grade 3). One serious adverse event (fibrous mastopathy) and 20 adverse events (16 grade 1 and four grade 2) were reported during the run-in phase, and 12 adverse events during follow-up (nine grade 1 and three grade 2). INTERPRETATION Testosterone was well tolerated and as safe as oestrogen for hormone-replacement therapy. Testosterone can be an alternative hormone substitution in CAIS, especially for woment with reduced sexual functioning. FUNDING German Federal Ministry of Education and Research.
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Affiliation(s)
- Wiebke Birnbaum
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany
| | - Louise Marshall
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany
| | - Ralf Werner
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany
| | - Alexandra Kulle
- Department of Paediatrics, Christian-Albrechts-University, Kiel, Germany
| | | | - Katharina Rall
- Department of Women's Health, Centre for Rare Female Genital Malformations, Women's University Hospital, Tübingen University Hospital, Tübingen, Germany
| | - Birgit Köhler
- Department of Pediatric Endocrinology and Diabetology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Annette Richter-Unruh
- Paediatric Endocrinology, Department of Paediatrics, Universitätsklinikum Münster, Westfälische Wilhelms-Universität Münster, Germany
| | - Michaela F Hartmann
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Division of Paediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Division of Paediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Matthias K Auer
- Research Group Clinical Neuroendocrinology, Max Planck Institute of Psychiatry, Munich, Germany
| | - Anke Lux
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Siegfried Kropf
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany.
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Becker D, Wain LM, Chong YH, Gosai SJ, Henderson NK, Milburn J, Stott V, Wheeler BJ. Topical dihydrotestosterone to treat micropenis secondary to partial androgen insensitivity syndrome (PAIS) before, during, and after puberty - a case series. J Pediatr Endocrinol Metab 2016; 29:173-7. [PMID: 26352087 DOI: 10.1515/jpem-2015-0175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 07/20/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND X-linked partial androgen insensitivity syndrome (PAIS) causes under-virilization at all stages of development. In two thirds of males, this results in micropenis. Dihydrotestosterone (DHT) is a potent androgen that is critical for male genital development, which when applied topically, has been shown to increase penile length with micropenis of varying etiologies. We present the first case series using topical DHT gel to treat micropenis in 46,XY males with PAIS, before, during, and after puberty. METHODS Three related 46,XY males with confirmed p.L712F androgen receptor mutations exhibited varying degrees of micropenis post-surgical correction. They were of pre-pubertal, peri-pubertal and adult ages, respectively. Following baseline clinical and laboratory assessments all completed a 4-month course of daily DHT gel 2.5% (androstanolone) topically to penis (0.3 mg/kg body weight), with monitoring for adverse effects. Primary outcome was change in stretched penile length (SPL) following treatment. RESULTS Mixed results were obtained following topical DHT therapy. In the pre- and peri- pubertal patients, SPL changed from 2.5 cm to 3.5 cm (+40%), and 3.5 cm to 5.7 cm (+63%), respectively. In the adult patient with 1 year of prior high-dose weekly testosterone therapy, no additional change in SPL was seen. No adverse effects of topical DHT were reported or observed throughout the 4 months of treatment. CONCLUSIONS Topical DHT treatment appears to be a safe and well-tolerated method of virilising micropenis both prior to and during puberty in children with PAIS. Questions remain about long-term outcomes into adulthood, and efficacy in adults with prior lengthy exposure to high-dose testosterone.
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Abstract
Androgen insensitivity syndrome (AIS) results from androgen receptor dysfunction and is a common cause of disorder of sex development. The AIS phenotype largely depends on the degree of residual androgen receptor (AR) activity. This review describes the molecular action of androgens and the range of androgen receptor gene mutations, essential knowledge to understand the pathogenesis of the complete and partial forms of this syndrome. A multidisciplinary approach is recommended for clinical management from infancy through to adulthood. Hormone replacement therapy is needed following gonadectomy. Patients who choose to retain the gonads are at risk of developing germ cell tumors for which sensitive circulating tumor markers may soon become available. Whilst the contribution of AR dysfunction to complete AIS is well understood, the involvement of the AR and associated proteins as contributors to partial AIS is an area of active research. Disorders of sex development such as AIS which are related to AR dysfunction offer a breadth of manifestations for the clinician to manage and opportunities for further research on the mechanism of androgen action.
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Affiliation(s)
- Nigel P Mongan
- Cancer Biology and Translational Research, Faculty of Medicine and Health Sciences, School of Veterinary Medicine and Science, University of Nottingham, UK
| | - Rieko Tadokoro-Cuccaro
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, UK
| | - Trevor Bunch
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, UK.
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Tsimaris P, Deligeoroglou E, Athanasopoulos N, Economou E, Stamatelopoulos K, Rizos D, Papamichael C, Lambrinoudaki I, Mastorakos G, Creatsas G. The effect of hormone therapy on biochemical and ultrasound parameters associated with atherosclerosis in 46,XY DSD individuals with female phenotype. Gynecol Endocrinol 2014; 30:721-5. [PMID: 24911331 DOI: 10.3109/09513590.2014.925868] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The aim of this study was to evaluate the effect of hormone therapy (HT) in the endothelial function of 46,XY disorders of sexual development (DSD) patients with female phenotype. Biochemical and ultrasound measurements were performed in 20 patients at initiation of oral 2 mg 17β-estradiol/1 mg norethisterone acetate, and after 6 months of therapy. Lipid profile, including total cholesterol (TC), LDL, HDL, triglycerides (TG) and Atherogenic Index of Plasma (AIP), as well as levels of VE-Cadherin, E-Selectin, Thrombomodulin and vWf were determined. Ultrasonographic examinations included evaluation of flow-mediated dilatation (FMD) and measurement of Carotid and Femoral Intima Media Thickness (IMT). HT raised HDL (35.4 mg/dl versus 40.1 mg/dl, p = 0.019) while lowering TG (166 mg/dl versus 109 mg/dl, p = 0.026) and AIP (0.24 versus 0.04, p = 0.007). No changes were noted in TC and LDL (215.7 mg/dl versus 192.25 mg/dl and 87.46 mg/dl versus 76.35 mg/dl, respectively). There was significant reduction of VE-Cadherin (4.05 ng/ml versus 2.20 ng/ml, p = 0.002) and E-selectin (73.98 ng/ml versus 56.73 ng/ml, p = 0.004). No change was observed in Thrombomodulin and vWf (11.76 ng/ml versus 13.90 ng/ml and 80.75% versus 79.55%, respectively). FMD improved significantly (5.4% versus 8.15%, p = 0.003), while only carotid bulb IMT decreased significantly (0.65 mm versus 0.60 mm, p = 0.018). Overall, HT was found to improve biochemical and ultrasound markers of endothelial function in 46,XY DSD patients with female phenotype.
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Affiliation(s)
- Pantelis Tsimaris
- Division of Pediatric, Adolescent Gynecology and Reconstructive Surgery, 2nd Department of Obstetrics and Gynecology, University of Athens, Medical School , "Aretaieion" Hospital, Athens , Greece
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Hamson DK, Wainwright SR, Taylor JR, Jones BA, Watson NV, Galea LAM. Androgens increase survival of adult-born neurons in the dentate gyrus by an androgen receptor-dependent mechanism in male rats. Endocrinology 2013; 154:3294-304. [PMID: 23782943 DOI: 10.1210/en.2013-1129] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Gonadal steroids are potent regulators of adult neurogenesis. We previously reported that androgens, such as testosterone (T) and dihydrotestosterone (DHT), but not estradiol, increased the survival of new neurons in the dentate gyrus of the male rat. These results suggest androgens regulate hippocampal neurogenesis via the androgen receptor (AR). To test this supposition, we examined the role of ARs in hippocampal neurogenesis using 2 different approaches. In experiment 1, we examined neurogenesis in male rats insensitive to androgens due to a naturally occurring mutation in the gene encoding the AR (termed testicular feminization mutation) compared with wild-type males. In experiment 2, we injected the AR antagonist, flutamide, into castrated male rats and compared neurogenesis levels in the dentate gyrus of DHT and oil-treated controls. In experiment 1, chronic T increased hippocampal neurogenesis in wild-type males but not in androgen-insensitive testicular feminization mutation males. In experiment 2, DHT increased hippocampal neurogenesis via cell survival, an effect that was blocked by concurrent treatment with flutamide. DHT, however, did not affect cell proliferation. Interestingly, cells expressing doublecortin, a marker of immature neurons, did not colabel with ARs in the dentate gyrus, but ARs were robustly expressed in other regions of the hippocampus. Together these studies provide complementary evidence that androgens regulate adult neurogenesis in the hippocampus via the AR but at a site other than the dentate gyrus. Understanding where in the brain androgens act to increase the survival of new neurons in the adult brain may have implications for neurodegenerative disorders.
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Affiliation(s)
- D K Hamson
- Department of Psychology, University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
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Robinson S, Penatti CAA, Clark AS. The role of the androgen receptor in anabolic androgenic steroid-induced aggressive behavior in C57BL/6J and Tfm mice. Horm Behav 2012; 61:67-75. [PMID: 22057031 DOI: 10.1016/j.yhbeh.2011.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 10/14/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
Humans self-administer anabolic androgenic steroids (AAS) at superphysiological doses for the purpose of building muscle mass and enhancing physique whereas considerably lower doses of AAS are prescribed in the clinic to treat a variety of disorders. A number of studies have demonstrated that individual AAS influence aggressive behavior in rats and mice, but few studies have examined the aggression-enhancing effects of combinations of AAS. Using the resident-intruder paradigm, Experiment 1 determined whether a cocktail of commonly abused AAS increased aggressive behavior in gonadally-intact male C57BL/6J mice and examined whether the androgen receptor (AR) was involved. Mice given either AAS cocktail or the cocktail and the AR antagonist, flutamide, for 6 weeks were subject to three weekly tests in which the percentage of mice that fought, the latency to initiate an aggressive event and the number of aggressive events per 5-min-fight session were recorded. In C57BL/6J mice, 6 weeks of AAS administration increased the likelihood of fighting, however, within the subset of mice that engaged in aggression, AAS did not specifically modulate the latency to fight or the number of aggressive events per fight. In addition, co-administration of flutamide only slightly altered the likelihood that mice given AAS will initiate a fight. Experiment 2 examined the aggression-promoting effects of AAS in gonadally-intact adult testicular feminization mutant (Tfm) mice, which are deficient in functional ARs. Overall, fewer Tfm mice compared to C57BL/6J mice fought in both drug conditions (vehicle or AAS). Taken together, these data suggest that given the presence of AR during development, AAS enhance adult male aggression in C57BL/6J mice through AR-independent and AR-dependent pathways. In contrast, in adult Tfm mice, the likelihood of AAS-enhanced aggression in adulthood is significantly reduced.
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Affiliation(s)
- Siobhan Robinson
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH 03755, USA
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11
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Creta M, Smelzo S, Di Vito C, De Stefano G, Forchia F, Chiancone F, Imbimbo C. [Morris syndrome: description of a case characterized by partial androgen insensitivity]. Urologia 2010; 77:271-273. [PMID: 21234872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2010] [Indexed: 05/30/2023]
Abstract
The Morris syndrome is a X-linked recessive condition due to a complete or partial insensitivity to androgens, resulting in a failure of normal masculinization of the external genitalia in chromosomally male individuals. This failure of virilization can be either complete or partial depending on the amount of residual androgen receptor function. The phenotype of individuals with partial androgen insensitivity syndrome may range from mildly virilized female external genitalia to mildly undervirilized male external genitalia. We describe a case of Partial Androgen Insensitivity Syndrome in a 21-year-old patient with a 46, XY karyotype, bilateral inguinal masses, clitoral enlargement and partial posterior labial fusion. Surgical care consisted of bilateral orchiectomy and plastic surgery of external genitalia. The patient underwent estrogen replacement therapy.
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12
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Vidal I, Gorduza DB, Haraux E, Gay CL, Chatelain P, Nicolino M, Mure PY, Mouriquand P. Surgical options in disorders of sex development (dsd) with ambiguous genitalia. Best Pract Res Clin Endocrinol Metab 2010; 24:311-24. [PMID: 20541154 DOI: 10.1016/j.beem.2009.10.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Disorders of sexual development (DSD) include three main groups of patients: (1) The virilised 46,XX DSD essentially represented by congenital adrenal hyperplasia (CAH) ; (2) The undervirilised 46,XY DSD essentially represented by hypospadias; and (3) the chromosomic jigsaws essentially represented by mixed gonadal dysgenesis. It is in this last group that gender assignment remains a difficult decision involving various indicators, which can be split into four categories: (1) the inside sex (i.e., genes, hormones and target tissues); (2) the outside sex (i.e., anatomy of genitalia including size of the genital tubercle, mullerian cavity and potential adult height of the patient); (3) the functional sex (i.e., potential sexuality and fertility); and (4) and the social sex (i.e., the cultural medium in which the child is brought up). The challenge is to outline the future individual identity of the child in the postnatal period using these indicators. Current evolutions of surgical techniques of 'feminisation' and 'masculinisation' are described as well as their outcomes.
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Affiliation(s)
- Isabelle Vidal
- Department of Paediatric Urology and Surgery, Hôpital Mère-Enfants, and Claude-Bernard University, 69677 Bron, France
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13
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Affiliation(s)
- Lisa Allen
- Pediatric Gynecology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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14
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Ohba K, Hayashida Y, Hakariya H, Ichinose S, Naitou S. [Case of complete androgen insensitivity syndrome]. Hinyokika Kiyo 2009; 55:277-280. [PMID: 19507547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Androgen insensitivity syndrome, gonadectomy, estrogen supplementation a 23-year-old single female visited our gynecological clinic because of primary amenorrhea. The patient's breast development was good. However the patient had thin pubic hair and blind-ending vagina. Serum levels of estrogen E2, testosterone, luteinizing hormone (LH) and follide stimulating hormone (FSH) were 37.0, 497 pg/ml, 22.0 and 8.7 mIU/ml, respectively. Chromosomal analysis was a karyotype of 46, XY. There was no uterus and no ovaries. However, there were bilateral inguinal elastic masses which were gonads. The patient was diagnosed with complete androgen insensitivity syndrome and bilateral gonadectomy was performed. The postoperative course was good and the patient is receiving estrogen replacement therapy.
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Affiliation(s)
- Kojiro Ohba
- Department of Urology, National Hospital Organization Ureshino Medical Center
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15
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Abstract
AIM To explore whether the anti-tumor action of 17beta-estradiol is enhanced by re-expression of the homeodomain transcription factor Nkx3.1 in PC3 human prostate cancer cells. METHODS PC3 cells were stably transfected with pcDNA3.1-Nkx3.1-His vector, which carries a full-length cDNA of human Nkx3.1. The PC3 cells stably transfected with vector pcDNA3.1 were set as a control. The expression of Nkx3.1 protein in the cells was confirmed by Western blot analysis. The effect of Nkx3.1 on cell proliferation of PC3 cells was examined with MTT assay. The antiproliferative and apoptotic effects of 17beta-estradiol alone or in combination with Nkx3.1 were estimated on PC3 cells by using MTT growth tests and flow cytometric analyses. The expression of apoptosis-related proteins was analyzed using Western blotting. RESULTS The plasmid carrying Nkx3.1 gene induced high expression of Nkx3.1 protein in PC3 cells. The re-expression of exogenous Nkx3.1 did not cause a significant reduction in cellular proliferation, whereas the expression of Nkx3.1 enhanced the 17beta-estradiol anti-proliferative effect in PC3 cells. Nkx3.1 expression promoted 17beta-estradiol-induced apoptosis of PC3 cells, as shown by analysis of Bcl-2, Bax, Caspase-3 and poly (ADP-ribose) polymerase expression. CONCLUSION The present study demonstrates that re-expression of Nkx3.1 enhances 17beta-estradiol anti-tumor action in PC3 human prostate cancer cells. The in vitro study suggests that re-expression of Nkx3.1 is worthy of further consideration as an adjuvant treatment of androgen independent prostate cancer with estrogen anti-tumor therapies.
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Affiliation(s)
- Ping Wang
- Department of Urology, The First Affiliated Hospital, Medical College of Zhejiang University, Hangzhou, 310003, China
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16
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Yen JL, Chang KH, Sheu JC, Lee YJ, Tsai LP. Partial androgen insensitivity syndrome with R840H mutation in androgen receptor: report of one case. Acta Paediatr Taiwan 2005; 46:101-5. [PMID: 16302589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Androgen insensitivity syndrome (AIS) is the major cause of male pseudohermaphroditism. The severity of the disorders varies widely, ranging from the phenotypic women with female external genitalia in cases of complete AIS to the phenotype of ambiguous genitalia in partial androgen insensitivity syndrome (PAIS) and a rare group of phenotypic normal males with azoospermia. Here, we report an infant of PAIS with a missense mutation at position 2881 (G-->A) in exon 7, encoding substitution of histidine for arginine at codon 840 of the androgen receptor (AR) gene. Both the biochemical and molecular studies are presented. Establishing the diagnosis of PAIS is very important for gender assignment to an infant of ambiguous genitalia. The molecular analysis will facilitate genetic counselling to the maternal side relatives for carrier detection and prenatal diagnosis.
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Affiliation(s)
- Jui-Lung Yen
- Department of Pediatrics, Women's and Children's Hospital, Taipei City, Taiwan
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17
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Abstract
Two of the most common intersex conditions, androgen insensitivity and Klinefelter's syndrome, are described with an emphasis on aspects that are of relevance to psychiatrists. Attention is focused on commonalities and differences between these syndromes and particular attention is given to how persons who have these conditions manifest sexual and gender adjustments to their situations. Tips on counseling and medical management are offered.
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Affiliation(s)
- Milton Diamond
- Department of Anatomy and Reproductive Biology, John A. Burns School of Medicine, University of Hawaii, Manoa, 1960 East-West Road, Honolulu, HI 96822, USA.
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18
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Baratz AB. Sex determination, differentiation, and identity. N Engl J Med 2004; 350:2204-6; author reply 2204-6. [PMID: 15156588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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19
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Kearns AE, Khosla S. Potential anabolic effects of androgens on bone. Mayo Clin Proc 2004; 79:S14-8. [PMID: 15065633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Sex steroid hormones are essential to normal skeletal growth and maintenance throughout life in both men and women. The importance of estrogens to bone health in women becomes obvious at menopause when estrogen deficiency occurs and results in accelerated bone loss. After menopause, estrogen deficiency results in drastic changes in the androgen-estrogen ratio. Thus, the relative importance of androgens after menopause may increase. Androgens also appear to be important for bone health in pre-menopausal women. Evidence from human, animal, and laboratory studies is leading to a better understanding of the effects of androgens on bone in women.
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Affiliation(s)
- Ann E Kearns
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA.
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20
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Mazen I, Lumbroso S, Abdel Ghaffar S, Salah N, Sultan C. Mutation of the androgen receptor (R840S) in an Egyptian patient with partial androgen insensitivity syndrome: review of the literature on the clinical expression of different R840 substitutions. J Endocrinol Invest 2004; 27:57-60. [PMID: 15053245 DOI: 10.1007/bf03350912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The X-linked androgen insensitivity syndrome (AIS) encompasses a heterogeneous group of defects in the androgen receptor (AR) that result in varying degrees of undermasculinization. In the current study, we characterize the R840S mutation on exon 7 of the AR ligand-binding domain. The Egyptian patient, who had been reared as female, presented ambiguous genitalia at 6.5 yr. Diagnosis of partial AIS (PAIS) was based on clinical phenotype and laboratory evidence of good testosterone response and normal testosterone/dihydrotestosterone (T/DHT) ratio. The therapeutic response to testosterone depot injections justified reassignment to male sex. To our knowledge, this mutation has been reported only once in two Brazilian brothers with PAIS. Three other mutations of this residue (R840C; R840G, nonconservative; and R840H, conservative) have been reported in patients with PAIS and, when expressed in vitro, they led to subnormal transactivation of a reporter gene. Each of these mutations was associated with a very diverse spectrum of phenotypes. These data highlight the role of the AR ligand-binding pocket (LBP) in the expression of transcriptional activity during prenatal sex differentiation.
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Affiliation(s)
- I Mazen
- The National Research Center, Pediatric Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
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21
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Affiliation(s)
- Douglas A Husmann
- Division of Pediatric Urology, Mayo Clinic, Rochester, Minnesota, USA
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22
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Holterhus PM, Hiort O, Demeter J, Brown PO, Brooks JD. Differential gene-expression patterns in genital fibroblasts of normal males and 46,XY females with androgen insensitivity syndrome: evidence for early programming involving the androgen receptor. Genome Biol 2003; 4:R37. [PMID: 12801411 PMCID: PMC193616 DOI: 10.1186/gb-2003-4-6-r37] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2003] [Revised: 03/31/2003] [Accepted: 04/20/2003] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Androgen insensitivity syndrome (AIS) comprises a range of phenotypes from male infertility to complete feminization. Most individuals with AIS carry germline mutations of the androgen receptor (AR) that interfere with or ablate its function. As genital fibroblasts retain expression of the AR in vitro, we used genital skin fibroblasts from normal males and 46,XY females with complete AIS due to known AR mutations to gain insights into the role of the AR in human genital differentiation. RESULTS Using DNA microarrays representing 32,968 different genes, we identified 404 transcripts with significant differences in transcription levels between genital skin fibroblasts cultured from normal and AIS-affected individuals. Gene-cluster analyses uncovered coordinated expression of genes involved in key processes of morphogenesis. On the basis of animal studies and human genetic syndromes, several of these genes are known to have specific roles in genital differentiation. Remarkably, genital fibroblasts from both normal and AIS-affected individuals showed no transcriptional response to dihydrotestosterone treatment despite expression of the AR. CONCLUSIONS The results suggest that in addition to differences in the anatomic origin of the cells, androgen signaling during prenatal development contributes to setting long-lasting, androgen-independent transcriptional programs in genital fibroblasts. Our findings have broad implications in understanding the establishment and the stability of sexual dimorphism in human genital development.
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MESH Headings
- Androgen-Insensitivity Syndrome/drug therapy
- Androgen-Insensitivity Syndrome/genetics
- Cells, Cultured
- Chromosomes, Human, X/genetics
- Chromosomes, Human, Y/genetics
- Cluster Analysis
- Dihydrotestosterone/therapeutic use
- Diploidy
- Female
- Fibroblasts/chemistry
- Fibroblasts/cytology
- Fibroblasts/drug effects
- Fibroblasts/metabolism
- Gene Expression Profiling/methods
- Gene Expression Profiling/statistics & numerical data
- Gene Expression Regulation/drug effects
- Gene Expression Regulation/genetics
- Genes/genetics
- Genitalia, Female/cytology
- Genitalia, Male/cytology
- Humans
- Male
- Oligonucleotide Array Sequence Analysis/methods
- Oligonucleotide Array Sequence Analysis/statistics & numerical data
- Receptors, Androgen/biosynthesis
- Receptors, Androgen/genetics
- Sex Differentiation/genetics
- Skin/cytology
- Transcription, Genetic/genetics
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Affiliation(s)
- Paul-Martin Holterhus
- Department of Urology, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Pediatrics, University of Lübeck, 23538 Lübeck, Germany
| | - Olaf Hiort
- Department of Pediatrics, University of Lübeck, 23538 Lübeck, Germany
| | - Janos Demeter
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Patrick O Brown
- Department of Biochemistry and the Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - James D Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, CA, 94305, USA
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23
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Foresta C, Bettella A, Ferlin A, Garolla A, Moro E, Baldinotti F, Simi P, Dallapiccola B. Response to local dihydrotestosterone treatment in a patient with partial androgen-insensitivity syndrome due to a novel mutation in the androgen receptor gene. Am J Med Genet 2002; 107:259-60. [PMID: 11807912 DOI: 10.1002/ajmg.10146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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24
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Lambiris AG, McCormick F. Unilateral hyperkeratosis of nipple and areola associated with androgen insensitivity and oestrogen replacement therapy. J Eur Acad Dermatol Venereol 2001; 15:376-7. [PMID: 11730068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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25
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Lundberg Giwercman Y, Nikoshkov A, Lindsten K, Byström B, Pousette A, Knudtzon J, Alm J, Wedell A. Response to treatment in patients with partial androgen insensitivity due to mutations in the DNA-binding domain of the androgen receptor. Horm Res 2001; 53:83-8. [PMID: 10971094 DOI: 10.1159/000023519] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The androgen insensitivity syndrome is a disorder caused by deficient function of the androgen receptor, characterized by varying degrees of undermasculinization in karyotypic males. We have identified four mutations in the androgen receptor gene, in the region encoding the DNA-binding domain of the protein. Two mutations, R607X and R615G, were found in patients with complete insensitivity to androgens, whereas the other two, S578T and A596T, were found in patients with partial insensitivity. The functional consequences of the three missense mutations were assayed in vitro after transient expression of the receptors in COS cells. All mutants showed normal androgen binding but abnormal abilities to stimulate transcription of an androgen-responsive reporter gene. R615G abolished transactivation whereas S578T and A596T were partially malfunctional. The function of A596T, but not of S578T, was normalized at high androgen concentrations in vitro, reflecting the in vivo situation. Thus, patients with specific mutations in the DNA-binding domain of the androgen receptor may benefit from androgen treatment.
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26
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Leow MK, Loh KC. 46, XY female--a case report. Ann Acad Med Singap 2001; 30:71-5. [PMID: 11242631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
INTRODUCTION We examine a presumptive case of complete androgen insensitivity syndrome (CAIS) with certain unusual features. CLINICAL PICTURE A woman with early onset osteoporosis gave a history of primary amenorrhoea and surgery for intraabdominal gonads. She subsequently defaulted follow-up and hormone replacement therapy. Endocrinological evaluation revealed hypergonadotrophic hypogonadism associated with a 46,XY karyotype. TREATMENT Therapy included reinforcement of the female phenotype and oestrogen replacement. OUTCOME There was gradual development of her secondary sexual characteristics and improvement in her bone mineral density. CONCLUSION Patients with CAIS need proper counselling and education according to their psychosexual make-up and sociocultural factors. The importance of long-term oestrogen replacement in a young subject post-gonadectomy cannot be overemphasized as illustrated in our case.
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Affiliation(s)
- M K Leow
- Department of Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
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Marcus R, Leary D, Schneider DL, Shane E, Favus M, Quigley CA. The contribution of testosterone to skeletal development and maintenance: lessons from the androgen insensitivity syndrome. J Clin Endocrinol Metab 2000; 85:1032-7. [PMID: 10720035 DOI: 10.1210/jcem.85.3.6428] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although androgen status affects bone mass in women and men, an androgen requirement for skeletal normalcy has not been established. Women with androgen insensitivity syndrome (AIS) have 46,XY genotypes with androgen receptor abnormalities rendering them partially or completely refractory to androgen. Twenty-eight women with AIS (22 complete and 6 high grade partial), aged 11-65 yr, responded to questionnaires about health history, gonadal surgery, and exogenous estrogen use and underwent bone mineral density (BMD) assessment by dual energy x-ray absortiometry. BMD values at the lumbar spine and proximal femur were compared to age-specific female normative values and listed as z-scores. Average height for adults in this cohort, 174 cm (68.5 in.), was moderately increased compared with the average height of adult American women of 162.3 cm, with skewing toward higher values: 5 women exceeded 6 ft in height, and 30% of the 18 adult women with complete AIS exceeded 5 ft, 11 in. in height. The average lumbar spine and hip BMD z-scores of the 6 women with partial AIS did not differ from population norms. In contrast, the average lumbar spine BMD z-score of women with complete AIS was significantly reduced at -1.08 (P = 0.0003), whereas the average value for hip BMD did not differ from normal. When BMD was compared between women who reported good estrogen replacement therapy compliance and those who reported poor compliance, there was a significantly greater deficit at the spine for women with poor compliance (z = -2.15 +/- 0.15 vs. -0.75 +/- 0.28; P < .0001). Furthermore, hip BMD was also significantly reduced in the noncompliant group (z = -0.95 +/- .40). Comparison of BMD values to normative male standards gave z-score reductions (z = -1.81 +/- 0.36) greater than those observed with female standards. Because of the high prevalence of tall stature in this study sample, we calculated bone mineral apparent density, a variable that adjusts for differences in bone size. Even for the estrogen-compliant group, bone mineral apparent density z-scores were subnormal at both the spine (z = -1.3 +/- 0.43; P < 0.01) and the hip (z = -1.38 +/- 0.28; P = 0.017). Six women with complete AIS had sustained cortical bone fractures, of whom 3 reported multiple (>3) fractures. We conclude that even when compliance to exogenous estrogen use is excellent, women with complete AIS show moderate deficits in spine BMD, averaging close to 1 SD from normative means, and that with correction of BMD for bone size, skeletal deficits are magnified and include the proximal femur. The results suggest that severe osteopenia in some women with AIS probably reflects a component of inadequate estrogen replacement rather than androgen lack alone.
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Affiliation(s)
- R Marcus
- Veterans Affairs Medical Center and Department of Medicine, Stanford University, Palo Alto, California 94304, USA
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28
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Abstract
We report a 46,XY infant with an M807T mutation in his androgen receptor that abrogated cellular responses to testosterone, but not to dihydrotestosterone (DHT), resulting in ambiguous genitalia. Treatment with a topical DHT gel restored male genital development allowing the infant to be reared in accordance with his chromosomal sex.
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Weidemann W, Peters B, Romalo G, Spindler KD, Schweikert HU. Response to androgen treatment in a patient with partial androgen insensitivity and a mutation in the deoxyribonucleic acid-binding domain of the androgen receptor. J Clin Endocrinol Metab 1998; 83:1173-6. [PMID: 9543136 DOI: 10.1210/jcem.83.4.4704] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Supplemental androgen therapy has enhanced virilization in only a few patients with partial androgen insensitivity (PAIS). We herein report on virilization in a patient with PAIS and a point mutation in the DNA-binding domain of the androgen receptor. At the age of 19 yr, the patient sought medical attention because of undervirilization. Endocrine findings were typical for androgen insensitivity, but 5alpha-reductase activity and androgen binding characteristics in fibroblasts cultured from genital skin were normal. In an attempt to improve virilization, high dose testosterone enanthate treatment (250 mg by i.m. injection once a week) was begun. After 3.5 yr of this treatment, marked promotion of virilization was achieved, i.e. lowering of voice, male pattern secondary hair distribution, marked growth of beard and coarse body hair, increase in phallic size, increase in bone mineral density, and decrease in mammary gland size. In addition, serum lipid levels were not affected. To our knowledge this is the first documentation of successful treatment in a patient with PAIS and a point mutation in the DNA-binding domain of the androgen receptor.
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Affiliation(s)
- W Weidemann
- Institute of Zoophysiology, Department of Endocrinology and Developmental Biology, University of Düsseldorf, Germany
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30
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Huhtaniemi I, Aittomäki K, de la Chapelle A, Tapanainen J. [Do men need follicle-stimulating hormone?]. Duodecim 1997; 113:465-6. [PMID: 11370067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Affiliation(s)
- I Huhtaniemi
- Department of Biochemistry and Physiology, Turku University, Turku, Department of Medical Genetics Helsinki University, Helsinki and Department of Gynecology and Obsterics, Oulu University Central Hospital, Oulu, Finland
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Nedkova V, Kovacheva K, Tanchev S, Totsev N, Simeonova M. [The testicular feminization syndrome combined with disseminated hemangiomatosis]. Akush Ginekol (Sofiia) 1996; 35:35-7. [PMID: 9254567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
It is described a new born child with many hemangiomas on the liver. It is made a karyogram to exclude. The possibility of chromosome disease. We fixed male karyotype 46 XY--syndrome Morris. We found out that it is a rare combination of testicular feminization with disseminated hemangiomatosis. After the medical treatment with high doses of cortisone the hemangiomas decreased their sizes.
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32
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Slob AK, van der Werff ten Bosch JJ, van Hall EV, de Jong FH, Weijmar Schultz WC, Eikelboom FA. Psychosexual functioning in women with complete testicular feminization: is androgen replacement therapy preferable to estrogen? J Sex Marital Ther 1993; 19:201-209. [PMID: 8246276 DOI: 10.1080/00926239308404905] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Effects of oral testosterone undecanoate (Andriol) on blood hormone levels, moods, sociosexual functioning and self-image of the body were studied in four gonadectomized patients with complete testicular feminization. In a double-blind cross-over experiment, patients were treated with oral testosterone undecanoate (120 mg/day) or placebo for four weeks. Peripheral blood was taken for hormone assays at the end of each four-week period. Psychosexual functioning was reported once weekly, mood scales twice weekly. In three patients testosterone treatment resulted in adult male blood levels of testosterone and estradiol. One patient did not show increased steroid levels, possibly because of hyperthyroxinaemia. No systematic effects were found on coitus, masturbation, sexual thoughts, scores on desire for bodily contact, and on attention for physical appearance. In one patient there was a marked and sustained rise in the positive moods and a fall in negative moods during androgen treatment. These results do not demonstrate that androgen therapy is preferable to estrogen in gonadectomized women with complete testicular feminization with regard to psychosexual functioning.
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Affiliation(s)
- A K Slob
- Department of Endocrinology & Reproduction, Erasmus University Rotterdam, The Netherlands
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Bezverkhaia TP. [Androgen resistance related to receptor disorders]. Klin Med (Mosk) 1991; 69:16-21. [PMID: 1787668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
It is the review of literature data on various phenotypic anomalies consequent to the absent or reduced ability of the target tissues to response to androgens (A) due to defects in receptor A structure and function. Clinical forms of resistance to A, quantitative and qualitative abnormalities in hormone-receptor interaction detectable in relevant patients are described as well as markers of target tissue sensitivity to A action suggested for use in prognosticating the response to A treatment.
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Zachmann M, Prader A, Sobel EH, Crigler JF, Ritzén EM, Atarés M, Ferrandez A. Pubertal growth in patients with androgen insensitivity: indirect evidence for the importance of estrogens in pubertal growth of girls. J Pediatr 1986; 108:694-7. [PMID: 3701515 DOI: 10.1016/s0022-3476(86)81043-5] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Spontaneous pubertal growth was studied in eight patients with the syndrome of androgen insensitivity to obtain information on the growth-promoting action of estrogens. In one additional patient (who had a gonadectomy before puberty), the effect of exogenous estrogens was studied. Mean age at peak height velocity (12.7 years) was closer to that in normal girls than to that in normal boys. Mean peak height velocity (7.4 cm/yr) was as in normal girls (7.3 cm/yr), but was lower than in normal boys (9.3 cm/yr). Bone age corresponded better to male standards. Mean adult height (172.3 cm) was lower than in normal men (-0.6 SD), but higher than in normal women (+1.4 SD). In the patient who had a gonadectomy, estrogen replacement caused a higher peak height velocity (12 cm/yr), but lower adult height (160.5 cm) than in the patients with intact gonads who received no treatments. We conclude that in normal girls, the pubertal growth spurt also results from the action of estrogens rather than of adrenal androgens. To ensure normal pubertal growth, physiologic estrogen replacement in hypogonadal females should be started at a bone age of about 11 years, and should not be delayed in the hope of achieving a greater mature height.
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Corsello SM, De Rosa G, Liberale I, Menini E, Moneta E, Pasargiklian E. Effect of estrogens on luteinizing hormone release in testicular feminization syndrome before and after gonadectomy. Obstet Gynecol 1984; 63:312-7. [PMID: 6230548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The effect of exogenous estrogens on luteinizing hormone release was studied in three siblings with complete testicular feminization syndrome. Two subjects, 21 and 20 years old, were postpubertal. The third, 15 years old, was in the early pubertal stage. An estrogen provocation test was performed in which 20 mg of conjugated estrogens were administered intravenously and serum follicle-stimulating hormone and luteinizing hormone levels were assessed every 12 hours for 96 hours under basal conditions, on day 5 of an eight-day treatment with 0.2 mg/day ethinyl estradiol orally, and on day 5 of a subsequent eight-day treatment with 0.2 mg/day ethinyl estradiol and 120 mg/day cyproterone acetate orally. The first two tests were repeated one month after gonadectomy. During pregonadectomy treatments there was an overall luteinizing hormone fall. After gonadectomy, the two postpubertal subjects exhibited luteinizing hormone surges during ethinyl estradiol treatment -in one as a single peak and in the other as multiple peaks. A positive feedback effect was not induced in the youngest patient either before or after gonadectomy as in normal prepubertal and early pubertal females. The data suggest that testosterone or some other testicular factor inhibits estrogen induced positive feedback for luteinizing hormone. This inhibition mechanism acts independently of the testosterone cytosol receptor.
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Abstract
The clinical applicability of danazol has been postulated to depend upon its antigonadotropic and androgenic properties. However, the true mechanism of action of danazol has not been fully elucidated, and experimental evidence indicates that the major pharmacologic action of this drug may be related to the direct inhibition of multiple enzymes of gonadal steroidogenesis. In the present study, the hypothesis that danazol directly inhibits gonadal steroidogenesis was tested during the course of endocrine studies on three sisters with a complete form of testicular feminization. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and testosterone (T) levels were determined following short-term administration of varying doses of danazol. In these patients, the absence of androgen receptors and the expected inability of danazol to serve as a metabolic precursor of estrogens would minimize possible antigonadotropic effects of this drug and allow the evaluation of its direct action on the secretion of steroids by the gonads in vivo. During the experiments, there was a highly significant and dose-related suppression of serum T levels in all patients. E2 levels decreased slightly. Both LH and FSH levels showed no consistent decline and remained within the range of normal. In one patient, LH and FSH levels declined significantly during treatment, but in the other two patients serum concentrations of LH remained stable or even increased while T levels fell. In spite of the fall in steroid levels, a compensatory increase in gonadotropins did not always occur. In conclusion, danazol effectively suppresses peripheral T levels in patients with a complete form of testicular feminization. Such suppression is dose related and can occur in the absence of a decline in LH serum concentrations, possibly as a result of a direct action on gonadal steroidogenesis.l
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Saruta T, Tachibana H, Kondo K, Saito I, Takabayashi Y, Tamura S, Fukuchi S, Matsuki S. A case of 17alpha-hydroxylase deficiency with symptoms mimicking testicular feminization. Am J Med Sci 1977; 274:333-8. [PMID: 610421 DOI: 10.1097/00000441-197711000-00014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A case of 17alpha-hydroxylase deficiency mimicking testicular feminization is reported. Different from the complete form of testicular feminization in which androgens are normal or elevated and end-organ insensitivity to androgens is supposed, this case had a negligible amount of androgens and responded to the injection of testosterone propionate with a positive nitrogen and phosphate balance.
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Abstract
The effects of hormonal manipulation on gonadotropin, androgen, and estrogen concentrations in a patient with testicular feminization syndrome (TFS) were studied to clarify the feedback regulation of gonadotropins. Baseline serum LH concentrations were normal to high and FSH concentrations were normal despite markedly elevated plasma testosterone concentrations, implying the lack of a reciprocal control relationship, and fluoxymesterone administration failed to alter gonadotropin or androgenic steroid levels. Clomiphene administration resulted in a rise in both LH and androgen levels, while moderate doses of exogenous estrogens effected a diminution in testosterone but did not significantly alter the levels of gonadotropins. Following gonadectomy, these same doses of estrogens produced a dramatic fall in the very high postoperative levels of gonadotropins. These results suggest that gonadotropin regulation is mediated by estrogens and not directly by androgens in TFS.
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Epps DR, Wajntal A, de Campos EP. Comparison of weight responses to testosterone propionate in patients with male pseudohermaphroditism and controls of different age groups. Rev Hosp Clin Fac Med Sao Paulo 1975; 30:138-43. [PMID: 1135560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Leinzinger E. ["Hairless woman", the male pseudohermaphrodite with testicular feminization]. Wien Med Wochenschr 1974; 124:443-8. [PMID: 4407188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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42
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Epps DR, Tomlinson R, Forchielli E, Dorfman R. Influence of gonadectomy upon the response to testosterone in the syndrome of testicular feminization. Rev Bras Pesqui Med Biol 1974; 7:395-8. [PMID: 4431987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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43
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Besser GM, Mortimer CH. Effects of the gonadotrophin releasing hormone in patients with hypothalamic pituitary-gonadal diseases. Acta Eur Fertil 1974; 5:65-71. [PMID: 4602916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Basile F. [Testicular feminization syndrome. Clinical case report]. Minerva Ginecol 1973; 25:187-91. [PMID: 4710128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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46
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Jeune M, David L. [Male pseudohermaphroditism. Attempt at classification based upon 33 cases]. Pediatrie 1972; 27:891-912. [PMID: 4662758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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47
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Ismail AA, Davidson DW, Souka AR, Loraine JA, Foss GL. Hormonal studies in a patient with the testicular feminization syndrome. Case report. Acta Endocrinol (Copenh) 1972; 71:409-16. [PMID: 4341902 DOI: 10.1530/acta.0.0710409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
ABSTRACT
A prolonged study extending over 77 days in a patient with testicular feminization was conducted during which castration was performed and gonadal and adrenal stimulation undertaken. Prior to castration levels of urinary testosterone and epitestosterone were high and cyclic changes in oestrogens and pregnanediol output were not noted. Following operation there was a marked decrease in the excretion of androgenic steroids but no significant changes following HCG administration. The main endocrinological feature of this patient was the lack of cyclicity of gonadal steroids.
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Gower DB, Bicknell DC. Steroid excretion and biosynthesis, with special reference to 16-unsaturated C 19 steroids, in cases of testicular feminization and in a male pseudohermaphrodite. Acta Endocrinol (Copenh) 1972; 70:567-81. [PMID: 4339788 DOI: 10.1530/acta.0.0700567] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
ABSTRACT
The concentrations of the following steriods were measured in the urine of four patients with testicular feminization (TF) syndrome and of one male pseudohermaphrodite: 5α-androst-16-en-3α-ol (3α-androstenol), 5β-androst-16-en-3α-ol (aetiocholenol), 5,16-androstadien-3β-ol (androstadienol), androsterone, aetiocholanolone, dehydroepiandrosterone (DHA) and testosterone. Elevated levels of 3α-androstenol, androsterone, aetiocholanolone and DHA were found in the urine of two TF patients studied. The third TF patient and the male pseudohermaphrodite were excreting normal amounts for adult females of the three 16-unsaturated C19 steroids, although androgen output was raised. Decreases in the excretion of these steroids occurred after removal of the testes. Administration of human chorionic gonadotrophin (HCG) and corticotrophin (ACTH) to one TF patient resulted in two- to four-fold increases in urinary 16-unsaturated C19 steroids. The excretion of the three 17-oxosteroids measured, particularly androsterone and aetiocholanolone, increased after HCG and to a lesser extent after ACTH administration.
In preparations of testes removed from three TF patients androstadienol (1-8%) was formed from pregnenolone. 4,16-Androstadien-3-one (androstadienone) was obtained in greater yield (0.2–1.33%) from progesterone than from pregnenolone (0.1–0.48%) although in the histologically normal testis from the pseudohermaphrodite, pregnenolone proved to be the more efficient precursor of androstadienone. Testosterone gave rise to no 16-unsaturated C19 steroids when incubated under identical conditions. The biosynthesis of testosterone in TF testis preparations was achieved normally from both pregnenolone and progesterone, in keeping with a defect in target organ insensitivity rather than in androgen formation. The possible significance of these findings and of the formation of large amounts (19%) of DHA from pregnenolone in TF testis is discussed.
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Boczkowski K. Testicular feminization syndrome without and with sexual hair. Obstet Gynecol 1971; 38:719-23. [PMID: 5114222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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