New NR5A1 mutations and phenotypic variations of gonadal dysgenesis

Mutations in NR5A1 have been reported as a frequent cause of 46,XY disorders of sex development (DSD) associated to a broad phenotypic spectrum ranging from infertility, ambiguous genitalia, anorchia to gonadal dygenesis and female genitalia. Here we present the clinical follow up of four 46,XY DSD patients with three novel heterozygous mutations in the NR5A1 gene leading to a p.T40P missense mutation and a p.¹⁸DKVSG²²del nonframeshift deletion in the DNA-binding domain and a familiar p.Y211Tfs*83 frameshift mutation. Functional analysis of the missense and nonframeshift mutation revealed a deleterious character with loss of DNA-binding and transactivation capacity. Both, the mutations in the DNA-binding domain, as well as the familiar frameshift mutation are associated with highly variable endocrine values and phenotypic appearance. Phenotypes vary from males with spontaneous puberty, substantial testosterone production and possible fertility to females with and without Müllerian structures and primary amenorrhea. Exome sequencing of the sibling’s family revealed TBX2 as a possible modifier of gonadal development in patients with NR5A1 mutations.

Pure gonadal dysgenesis and spontaneous pregnancy: a case report

We report a case of pure gonadal dysgenesis with streak gonads in which spontaneous conception occurred 10 years after the diagnosis. Her pregnancy proceeded as normal, and she gave birth to a live baby at term by cesarean section. A lactation period lasting for 1 year and afterwards proceeded as amenorrheic. Gonadotropins measurements in post-lactational period were at the menopausal levels again. To the best of our knowledge, this is the first case of pure gonadal dysgenesis with streak gonads in which spontaneous conception occurred.

[Molecular and cytogenetic study on 5 cases with gonadal dysgenesis: clinical applications of fluorescence in situ hybridization(FISH) and BAC-FISH]

OBJECTIVE

To explore the applications of fluorescence in situ hybridization (FISH) in the diagnosis for the patients with gonadal dysgenesis.

METHODS

After routine gynecologic examination, ultrasonography and endocrine examination, 5 cases of gonadal dysgenesis and hypogonadism were analyzed by using chromosomal diagnoses including G-banding, Q-banding, multiplex FISH and BAC-FISH analyses.

RESULTS

Among the 5 cases of gonad agenesis patients, 2 were pure gonadal dysgenesis with 46, XY karyotype, 3 were mixed gonadal dysgenesis with mos 45, X/47, XXX; 45, X/46, XY or 46, X, der(Y) karyotype.

CONCLUSION

Sex chromosomal abnormalities resulted in gonadal dysgenesis symptoms. Applications of FISH and BAC-FISH analyses can correctly diagnose the sex chromosomal abnormalities for patients with gonad agenesis and provide accurate medical genetic data for clinical diagnosis and therapy.

[Quality of life in the patients with disorders of sexual development and with Y chromosome in karyotype]

New nomenclature of disorders of sexual development is provided. Contemporary the management and the quality of life in the patients with pure gonadal dysgenesis and mixed gonadal dysgenesis is assessed.

[Modern concepts in the treatment of intersexuality]

Treatment of intersexuality is demanding and requires experience and interdisciplinary cooperation. Preconditions for normal development and clear gender identification are correct (not emergency) diagnosis and gender assignment and adequate hormonal and surgical treatment. Surgery should be done early (6th to 15th month) as atraumatically as possible with cosmetically and functionally satisfying results. These preconditions are not met consistently, resulting in a 20-25% rate of mistakes in diagnosis and treatment. In experienced centers, feminizing genitoplasty, even of the severest forms, is carried out through a perineal one-stage approach. Masculinization corresponds to surgery for severe hypospadias. The high risk of malignant degeneration requires removal of all inadequate structures such as streak gonads, uterus, and tubes. In 5-alpha deficiency, early gonadectomy and feminization are not recommended since gyneophile behavior can be expected. Late or non-correction is rejected by the majority of psychiatrists. Many problems remain unclear and controversial due to lack of knowledge. In the future they can only be solved through cooperation, documentation, and observation of these individuals over their lifetime.

A case of mistaken identity. A rare presentation of gonadal dysgenesis

BACKGROUND

The incidence of gonadal dysgenesis (hermaphroditism) is recognised to be low. Rarer still is an initial late presentation in the general practice setting.

OBJECTIVE

To present a case study of a 35 year old man diagnosed as a hermaphrodite after routine investigations in general practice for lower abdominal pain. He has normal male external genitalia, a fully formed uterus and vagina, with no identifiable gonads.

DISCUSSION

This incidental finding in general practice is supported by a 46,X,i(Yp)/45,X karyotype and mosaicism for an isochromosome of the short arm of the Y. It is not unusual that with normal male genitalia, such patients are likely to survive undiagnosed or incorrectly diagnosed into adulthood.

Management of males with 45,X/46,XY gonadal dysgenesis

Males with the 45,X/46,XY karyotype and malformations of the external genitalia carry an increased risk of developing germ cell neoplasia of the gonads. We have studied gonadal tissue from 10 individuals, 0.3-17 years of age, with a male phenotype and either hypospadias and/or cryptorchidism. Four patients, 0.3-15 years of age, had carcinoma in situ, 1 boy had Sertoli-cell-only pattern and the remainder prepubertal histology. Gonadoblastoma or invasive carcinoma was not found. On the basis of our current knowledge we propose a strategy for management and follow-up of these boys in order to detect possible premalignant histological changes early and prevent development of a gonadal tumour.

A concomitant decrease in cortical and trabecular bone mass in isolated hypogonadotropic hypogonadism and gonadal dysgenesis

To assess the impact of hypogonadism on bone mineral density, we performed a cross-sectional study of 70 amenorrheic women, comprising 22 cases of gonadal dysgenesis and 48 cases of isolated hypogonadotropic hypogonadism (IHH). Bone mineral density was measured by DEXA at four sites: the femur neck, Ward's triangle, trochanter, and lumbar spine (L2-4). The results were compared to those of a control group consisting of 60 age-matched, normal-cycling women. Bone mineral densities around age 20 were already significantly lower at all four sites in patients with IHH and gonadal dysgenesis when compared with controls, suggesting that these patients failed to achieve peak bone mass during pubertal development. In patients with IHH, the initial BMD around age 18-20 were significantly lower at all four sites and the decrease in bone density continued rapidly during the early twenties up to age 25, and then it slowed markedly thereafter. Bone biochemical marker, ICTP and osteocalcin were significantly negatively correlated with age and remained increased until age 40, which was reminiscent of menopausal bone loss pattern such as high bone turn-over in the early twenties, followed by slow bone loss in the late twenties. In patients with gonadal dysgenesis, bone biochemical marker, ICTP and osteocalcin were also significantly negative correlated with age and remained increased until age 40, but no significant changes in BMD were noted as a function of age, which may be attributed to the small sample size and slow bone loss. These findings suggest that the initiation of prompt and timely therapeutic intervention as early as possible in the menarchal period and throughout the remainder of life, particularly during the period associated with rapid bone loss.

[Gonadal dysgenesis: diagnosis and therapeutic perspectives]

Ovarian dysgenesis is the endstage of a process of follicular atresia, Turner syndrome (45,X) being the most common cause, with an incidence of 1 in 2500 female births. In addition to ovarian failure, these patients have short stature and a number of primary and derived somatic anomalies. Tertiary preventive measures are considered and treatment of short stature, estrogen deficiency and of infertility is discussed.

Ambiguous genitalia--etiology, diagnosis, and therapy

Patients with ambiguous genitalia stand a far better chance of receiving a rapid diagnosis, appropriate replacement therapy, and functional surgical reconstruction than was the case even a decade ago. Although the etiologies of true hermaphroditism and mixed gonadal dysgenesis remain elusive, most gene defects in female pseudohermaphroditism or CAH have been pinpointed to the 21-hydroxylase gene. Incomplete masculinization has been found to be due to defects in the androgen receptor, 5 alpha-reductase, or enzymes in the pathway from cholesterol to testosterone. SRY point mutations have been implicated in 46XY pure gonadal dysgenesis. Retained müllerian ducts have been attributed to point mutations in the MIS gene; those with normal MIS levels should be expected to have receptor deficits. In utero diagnoses and treatment and diagnosis at the preimplantation stage may prove to be very important for the care of some of these patients, who may be potential candidates for gene replacement therapy. When necessary, surgical reconstruction can be done. If the child is to be raised as a female, clitoral recession, labioscrotal reductions and advancements, and vaginoplasties for exteriorization can be accomplished in early infancy as an extensive one-stage procedure. If patients are to be raised as males, then various types of hypospadias repair can be done, gonads can be replaced with prostheses, the prepenile scrotum can be reconstructed, and müllerian structures can be removed with the goal of preserving the vas deferens. Replacement therapy with glucocorticoids and mineralocorticoids must be precisely managed to permit proper growth, and testosterone, estrogen, and progesterone replacement must be carefully considered and managed. A most important element in the care of these patients is the psychological support that first the families and then the patient require. This must be delivered with sensitivity. The proper care of these complex patients requires that the physician be a scientist as well as a clinician and a skilled technician.

Psychological aspects in anonymous and non-anonymous oocyte donation

A study, in which 110 patients were screened by a psychoanalyst, included 69 recipients who chose non-anonymous oocyte donation, i.e. they received oocytes from a known donor, most frequently a sister or a close relative. Another 41 recipients received anonymous oocytes, but had to bring a donor. Psychological motivations for either choice are reported, and significant topics such as attitudes towards confidentiality and links to the child are compared. No specific psychopathology is reported at this stage. An additional study on children born by these techniques is ongoing.

[Clinical observations of patients with somatosexual disturbances coexisting with primary amenorrhea]

In the paper, a clinical description is presented of patients referred to the Department for primary amenorrhoea in whom somatosexual disturbances have been observed. The group of patients included three cases of Turner syndrome, four cases of pure gonadal dysgenesis, three cases of feminizing gonadal syndrome. The diagnostic-therapeutic errors are shown, paying attention to the most characteristic symptoms and proper management.

Perturbations of negative feedback sensitivity in agonadal patients undergoing estrogen replacement therapy

Urinary gonadotropin excretion was measured in 30 patients with gonadal dysgenesis, aged 2 months to 17 yr. Between bone ages 3-8 yr, mean FSH excretion (575 mIU/h) was elevated 8-fold in agonadal individuals compared to levels in intact prepubertal girls; mean urinary LH (49 mIU/h) in agonadal patients during this time period was increased nearly 2-fold over results from normal prepubertal females. Nine of 10 patients given 0.3 to 0.6 mg conjugated estrogen (Premarin) daily to initiate puberty exhibited prompt suppression of urinary gonadotropin levels from markedly elevated levels to within or very close to the normal prepubertal range. Such a response was found in only two of seven patients given 0.15 mg of the same drug. All instances of suppression were followed by escape from low levels of gonadotropin excretion as treatment was continued. Prior exposure to exogenous or endogenous estrogen markedly reduced the suppressive potential of treatment with 0.3 or 0.6 mg Premarin. A favorable advance of bone maturation in relation to chronological age was achieved by the administration of 0.15 mg Premarin daily, a dose which caused a satisfactory onset of secondary sex characteristics.

IN CONCLUSION

1) a component of gonadotropin restraint in midchildhood is supplied by the ovary; 2) adult castrate levels of gonadotropins are achieved in the agonadal patient of peripubertal age in the presence of a highly sensitive negative feedback axis between sex hormones and gonadotropins; 3) sex steroids themselves may modify the gonadotropin-gonadal negative feedback axis in patients with gonadal dysgenesis; and 4) puberty may be initiated favorably with conjugated estrogens in an oral dose of 0.15 mg daily.

Estradiol and progesterone receptor concentrations and 17 beta-hydroxysteroid-dehydrogenase activity in estrogen-progestin stimulated endometrium of women with gonadal dysgenesis

Four hypergonadotrophic women between 25 and 37 years of age with gonadal dysgenesis were treated sequentially with estrogens and a progestin. The hormonal environment induced by this therapy was similar to that of ovulating women, as demonstrated by serum levels of estradiol, endometrial histology and pituitary gonadotropin secretion before and after LH-RH double stimulation. The concentrations of estradiol and progesterone receptors (ER and PR) and the activity of the 17 beta-hydroxysteroid-dehydrogenase (17 beta-HSD) were determined in endometrial curettings obtained from the above patients at 5 different days of their 28-day artificial cycles. The results were correlated to the histology of the endometrium and the serum concentrations of estradiol at the corresponding days of the cycle. The cytoplasmic ER and PR concentrations in the endometrium were 3-6 times higher during the estrogen than progestin phase of the induced endometrial cycle. For the activity of the 17 beta-HSD, the contrary was the case, being 6-10 fold higher during the progestin phase. A 22-day administration of estrogens only did not lead to a rise in enzyme activity or decrease in receptor content as observed under progestin influence after day 14. Since ER and PR concentrations and 17 beta-HSD activities were similar to those in the endometrium of normally ovulating women, these results confirm experimentally the present concept concerning the dependence of the cytoplasmic ER and PR content and 17 beta-HSD activity on female sex hormone action.

Micropenis. III. Primary hypogonadism, partial androgen insensitivity syndrome, and idiopathic disorders

This paper, the third in a series, presents data from 28 patients with micropenis categorized as primary hypogonadism (11 subjects), partial androgen insensitivity (1 subject), idiopathic (6 subjects), and etiology undetermined (10 subjects). Among the 11 patients with primary hypogonadism, 8 presented with various degrees of gonadal dysgenesis, 1 was a true hermaphrodite and 2 had the Robinow syndrome. Nine of the 28 patients were raised as females: 5 with primary hypogonadism and 4 with undetermined etiology. Eleven of the 19 patients raised as males received androgen stimulation during prepubertal years and responded with penile growth. However, this growth response was temporary and did not appear to be predictive of eventual adult size of the penis. Generally, the prestimulation size of this group of patients is more predictive of adult penile size. Only 7 of the patients raised as males have attained adult somatic growth. Three out of the three with primary hypogonadism, the subject with partial androgen insensitivity, and one of three with idiopathic micropenis have below-normal adult penile length. These limited data suggest that growth potential of the micropenis may be greater among the patients with an idiopathic state than among those with primary hypogonadism and partial androgen insensitivity.