Disorders of sexual differentiation

Disorders of sexual differentiation; introduction, assessment and management guidelines

1. Dr. Faheem Fellow Pediatric Urology IGICH Banglore Prof. Narendrababu Prof Pediatric Urology IGICH Banglore

2. Before the 7 th week both XX and XY foetuses have an identical reproductive anatomy. At 7 weeks testis and ovaries form foetuses with a Y chromosome------ testes foetuses with no Y chromosome …… ovaries Disorders of sexual differentiation Embrology

3. Disorders of sexual differentiation The sex-determining region on the Y chromosome (SRY) initiates the molecular events of testis formation

4. The SOX9 results in sex reversal in XY individuals, Steroidogenic factor 1 (SF-1) DAX- 1 on the X chromosome The Wilms tumour ( WT-1) gene is involved in both gonadal and renal development WT1 WAGR DDS Fraisers Syndrome (46,XY DSD) gonadal dysgenesis , and renal failure Disorders of sexual differentiation Genes

5. Disorders of sexual differentiation Algorithm of differentiation

6. fusion of labioscrotal folds LSF Formation of the scrotum , Urethral plate tubularization , and development of the genital tubercle into a penis Disorders of sexual differentiation Virilisation DHT

7. GT will become the clitoris and the Labioscrotal folds will form the labia majora and minora . Disorders of sexual differentiation Feminisation

8. When the external genitalia do not have the typical anatomic appearance of normal male or female genitalia Most of the cases present in the newborn period Disorders of sexual differentiation Definition

9. Disorders of sexual differentiation When to suspect

10. Disorders of sexual differentiation Classification

11. Disorders of sexual differentiation Classification

12. Disorders of sexual differentiation Classification

13. Disorders of sexual differentiation Congenital adrenal hyperplasia ( inc ; 1:10,000 to 1:20,000) 21-OH 95%

14. Disorders of sexual differentiation Congenital adrenal hyperplasia ( inc ; 1:10,000 to 1:20,000)

15. Congenital adrenal hyperplasia 46XX DSD (Incidence 1:10,000 to 1:20,000)

16. Salt-wasting CAH (75%): Inadequate aldosterone salt-losing adrenal crisis in the first or second week of life severe hyponatremic dehydration secondary hypotension CAH Clinical forms

17. Simple virilizing form (25%): residual enzymatic activity is enough for MCD production Excess production of androgens masculinization in females -"ambiguous genitalia” males are usually normal at birth. Linear growth is accelerated, but epiphyses fuse early  short stature. CAH Clinical forms

18. Non-classical form : Produce normal amounts of cortisol and aldosterone at the expense of mild-to-moderate overproduction of sex hormone precursors Mild , usually manifest as androgen excess later in life . Hirsutism (most common) Oligomenorrhea (54 %) ◦ Acne (33 %). ◦ Decreased fertility CAH Clinical forms

19. In both males and females with SLV of CAH Dehydration progressive weight loss Hypotension Vomiting ( mimicks Pyloric stenosis ) Without therapy , death may rapidly ensue from hyperkalemia, dehydration, and shock. CAH Clinical features Addisonian crisis

20. In females Variable degree of masculinization at birth. Enlargement of the clitoris and Sometimes clitoris appears as hypospadiatic penis rarely, a fully masculinized urethra to the tip of glans Varying degrees of labial fusion Vagina and urethra open into a common urogenital sinus. CAH Clinical features

21. Males isosexual precocity. normal at birth, signs of sexual and somatic precocity appear within the first 2 to 3 years of life. enlargement of the penis, scrotum, and prostate The musculature is well developed (“ little Hercules”), bone age > chronologic age. CAH Clinical features

22. CAH Clinical features

23. CAH Clinical features

24. Disorders of sexual differentiation Embrology

25. ABG S electrolytes Cortisol ACTH 17-OHP Pelvic USG Karyotyping CAH Investigations

26. CAH Embrology

27. Raised Urinary levels of 17-ketosteroids enlarged or “ cerebriform ”-appearing adrenal glands on neonatal ultrasonography, Prenatal Diagnosis amniotic fluid for 17-hydroxyprogesterone at 16 to 17 weeks’ gestation HLA genotyping or by DNA analysis ( chorionic villus sampling at 9 to 11 weeks’ gestation) CAH Diagnosis

28. 5% cases Hypertension is a common finding (secondary to increased serum levels of deoxycorticosterone (DOC )). Some are normotensive and others experience only intermittent hypertension. CF are same as 21-hydroxylase deficiency. Diagnosis: ncreased plasma levels of 11-deoxycortisol and 11-DOC . Urinary levels of 17-ketosteroids CAH 1 1 β- hydroxylase

29. The least common enzyme deficiency affects the early steps in steroid biosynthesis in both adrenals and gonads Virilisation is accompanied symptoms of aldosterone and cortisol deficiency. CAH 3β- hydroxysteroid dehydrogenase The diagnosis is based increased serum levels of 17-hydroxypregnenolone and dehydroepiandrosterone (DHEA).

30. CAH 21-hydroxylase deficiency, 1 1 β- hydroxylase 3β- hydroxysteroid dehydrogenase Ambiguous genitalia 46 XX DSD Raised precursor metabolite Normal Mullarian structures on Pelvic USG

31. The karyotype varies 46,XX (60%), Mosaic 46,XX/XY (30 %) 46,XY (10%). Very rare comprises (3-10 % of the DSD pool) Rare as hens’ teeth The gonads are asymmetrical, ovary on one side, (usually the left) And an ovotestis on the other side , (usually the right) Ovotesticular Sydrome

32. OT is located anywhere from the abdomen to the scrotum . Amb G with both Wolffian and Mullerian duct derivatives are seen Risk of neoplasia is 2.5- 5 % Phenotype is variable Gonadal biopsy is required for confirming diagnosis Ovotesticular Sydrome

33. Ovotestes are usually compartmentalized However, on rare occasions, an i ntermixture of these elements may occur . Testicular (presence of immature seminiferous tubules) ovarian tissue (presence of numerous primordial and/or maturing follicles ) Ovotestis

34. Disorders of sexual differentiation 46 XX DSD 21-hydroxylase deficiency, CAH Assymetrical Symmetrical OTS 1 1 β- hydroxylase 3β- hydroxysteroid dehydrogenase

35. CAIS PAIS FARD PMDS MGD Disorders of sexual differentiation 46 XY DSD

36. 46,XY bilateral testes absence of mullerian derivatives . female-appearing external genitalia Normal appearing breasts Scanty pubic and axillary hair Primary amenorrhea Short and blind vagina CAIS Hanne Gaby Vogue Supermodel AIS CAIS doesn’t present with ambiguous gentalia

37. Diagnosis Newborn female with previous amniocentesis 46XY 1-2% present as B/L inguinal hernia Primary amenorrha with small pit vagina without cervix Normal Gonadotropins (LH and FSH) USG- No mullarian structures PCR characterisation of androgen receptor gene in venous blood CAIS Chance of malignancy in CAIS 1-2%

38. 46 XY DSD Male to female genotype (usually male) Perineoscrotal hypospadias , cryptorchidism , rudimentary wolffian duct structures, gynecomastia , and azoospermis PAIS

39. Diagnosis PSH to small pit vagina without cervix Normal Gonadotropins (LH and FSH) USG- No mullarian structures PCR characterisation of androgen receptor gene in venous blood P AIS

40. CAIS Vs PAIS CAIS PAIS 46 XY 46 XY Normal female genitalia Ambiguous gentalia Normal Gonadotropins Normal Gonadotropins PCR ARG ARG Become models Don’t become models

41. Disorders of sexual differentiation 5a-Reductase Deficiency

42. Neonates with a 46,XY karyotype normal female to markedly ambiguous genitalia (more common) penoscrotal hypospadias Typically the phallus is quite small urogenital sinus is present, Testes and epididymis are present in labia Disorders of sexual differentiation 5a-Reductase Deficiency

43. FARD is also called “Penis at 12” partial masculinization occurs at puberty with an increase in muscle mass, development of male body habitus , increase in phallic size Disorders of sexual differentiation 5a-Reductase Deficiency

44. they have elevated mean plasma testosterone but low DHT levels. After hCG stimulation, the testosterone-to-DHT ratio increases to greater than 20 : 1 . Genital skin fibroblast cultures demonstrate diminished to absent 5a- reductase activity Disorders of sexual differentiation 5a-Reductase Deficiency

45. 46,XY karyotype Normal male external genitalia but internal müllerian duct structures. Typically, these phenotypic males have unilateral or bilateral UDT bilateral fallopian tubes, a uterus, and an upper vagina draining into a prostatic utricle. Persistent Müllerian Duct Syndrome

46. The condition is commonly diagnosed after müllerian tissue is encountered during inguinal herniotomy or orchidopexy . PMDS is etiological factor in transverse testicular ectopia ( 30 % to 50% of cases) Some subjects have a defect in the gene for MIS Persistent Müllerian Duct Syndrome

47. 46,XY/45X0 . MGD is the second most common cause of ambiguous genitalia in a newborn The gonads are also asymmetrical, with a dysgenetic testis on one side streak gonad on the other side Mixed gonadal dysgenesis (MGD)

48. Mixed gonadal dysgenesis (MGD)

49. Dysgenetic testis : disordered tubules ,& abundant stroma streak gonad composed of ovarian stroma but with no oocytes Mixed gonadal dysgenesis (MGD)

50. The phenotype is usually ambiguous. These patients have a tendency to a male phenotype with hypospadias . The internal ducts vary according to the associated gonads. Fertility has not been reported in patients with MGD. The sex assignment varies , Mixed gonadal dysgenesis (MGD)

51. 46XY Complete gonadal dysgenesis (CGD ) is characterized by bilateral streak gonads , normally developed Mullerian ducts , and hypergonadotropic hypogonadism ( elevated gonadotropin and decreased E levels ) Disorders of sexual differentiation Complete gonadal dysgenesis

52. Such individuals usually present with primary amenorrhea and absence of secondary sexual characteristics. CDG resembles Turner syndrome, (But 46,XX or 46,XY) Disorders of sexual differentiation Complete gonadal dysgenesis

53. Disorders of sexual differentiation 3ß – Hydroxysteroid Dehydrogenase Deficiency

54. Disorders of sexual differentiation 3ß – Hydroxysteroid Dehydrogenase Deficiency Ambiguous genetalia with various degrees of incomplete Virilisation resulting from a block in testosterone biosynthesis, salt-wasting adrenal insufficiency resulting from impaired synthesis of aldosterone and cortisol 46 XY male, Amb G and adrenal insufficiency increased levels of ß- hydroxysteroids is confirmative

55. A 2 year-old boy presented with severe penoscrotal hypospadias .Physical examination revealed right UDT with left gonad palpable in left hemi scrotum and normal in size. No other physical abnormality was noted. Ultrasound examination showed a heterogenous ovoid structure present in the right inguinal region . Left gonad had homogenous echotexture . Pelvic ultrasound examination showed no evidence of a uterus or ovaries . The testosterone levels were measured both were in the normal range (3-10ng/ml). Cytogenetic analysis performed on peripheral blood lymphocytes revealed a 45,XX/46,XY karyotype . Case Study No 1 OTS. Gonadectomy with biopsy

56. Three month old girl child presented to IGICH OPD with history of bilateral inguinal hernia. Was planned for B/L herniotomy On Inguinal exploration B/L testes with vas were present Case Study No :2 Karyotype 46XY CAIS

57. A 14 year old patient presented to IGICH OPD with severe penoscrotal hypospadias with PST, SPL 3 cm Patient was initially rared as female child Rt testis in Scrotum, Lt testis Inguinal Canal Testosterone <200 ng /ml Testosterone : DHT <20 17OHP normal Patient has male voice but Gynecomastia is present Case Study Case No: 3 PAIS (ARG)

58. A 16-year-old person, reared as female presented with complaints of genital ambiguity and primary amenorrhoea along with lack of secondary sexual characters , Karyotype analysis revealed 46XY karyotype. There was no evidence of hypocortisolemia (cortisol 9.08 μ g/dl, adrenocorticotropic hormone [ACTH] 82.5 pg /ml) or elevated level of 17-OH-progesterone (0.16 ng /ml). Pooled luteinizing hormone (LH) was 11.79 mIU /ml and follicle-stimulating hormone (FSH) was 66.37 mIU /ml. Serum estradiol level was 25 pg /ml (21-251). Basal and 72 h post beta-human chorionic gonadotropin ( hCG ) levels of androstenedione and testosterone levels were done (basal testosterone of 652 ng /dl and basal androstenedione of 1.17 ng /ml; 72 h post hCG testosterone of 896 ng /dl and androstenedione of 1.34 ng /ml). Magnetic resonance imaging (MRI) pelvis (with ultrasonogrphy [USG] correlation) revealed uterus didelphys and bilateral ovarian-like structures . Right sided gonads and adjacent tubal structures were visualized laparoscopically and removed . Left sided gonads were not visualized and Mullerian remnants were adhered to sigmoid colon.  Case study Case No;4 MGD

59. 7 m female presented a new episode of gastroenteritis. Laboratory data at this time showed severe hyponatremia (Na 110  mEq /L), hypochloraemia ( Cl 74  mEq /L) and hyperkalemia (K 6.3  mEq /L). Mild skin hyper-pigmentation was evident on the face, hands, elbows and knees. Blood glucose levels was moderately low ( 61  mg/dl).   KT 46XX Case Study Case No; 5

60. Case Study Lipoid congenital adrenal Hyperplasia ( STAR) gene mutation

61. Proximal hypospadias with cryptorchidism and micropenis Distal Hypospadias with cryptorchidism Female genitalia with inguinal or labial mass FG with clitoromegaly (>9mm) and posterior labial fusion Evaluation Suspect

62. Personal history • Parental consanguinity. Potential prenatal exposure to androgens , androgen antagonists or other drugs Maternal virilization during pregnancy. Family history Family history of hypospadias, infertility, amenorrhoea or early menopause, salt-losing or unexplained infant deaths. Evaluation History

63. • Palpation of the gonads along the inguinal canal (from the labioscrotal fold to the abdomen). • Assessment of hydration and blood pressure persistent jaundice accompanied by recurrent episodes of hypoglycaemia (hypopituitarism with growth hormone and cortisol deficiency) Evaluation Physical Examination

64. • Overall assessment Hyper pigmentation of the skin due ↑↑ ACTH Abdominal masses In adolescent evidence of hirsutism / virilization Tanner staging Evaluation Physical Examination

65. Evaluation Physical Examination

66. Evaluation Physical Examination AAP2008

67. Prader Scale In Females Evaluation Physical examination

68. EMS <11 should be investigated for DSD Evaluation EMS Scale In males

69. There are three fundamental tests Karyotype analysis (peripheral blood ) Hormone evaluation from 48 h post birth Abdominal ultrasound Evaluation First-line diagnostic tests

70. Hormonal Evaluation

71. Hormonal Evaluation (46XY) Disorder Hormonal status 21-hydroxylase def Decreased cortisol and/or mineralocorticoids Increased 17-hydroxyprogesterone 11β- hydroxylase def Increased 11-deoxycortisol, 11-deoxycorticosterone, androstenedione, testosterone 3β- hydroxysteroid dehydrogenase II def Increased concentrations of Δ 5  C 21 - and C 19 - steroids, 17 hydroxypregnenolone and DHEA suppressible by dexamethasone P450 aromatase def. High androgens in cord blood, androgens may stay elevated or normalize soon after birth UK guidance on the initial evaluation of an infant or an adolescent with a suspected disorder of sex development 2015

72. Hormonal Evaluation (46XY) Disorder Hormonal status Leydig cell hypoplasia Low T and DHT , elevated LH and FSH Lipoid CAH Usually deficient of glucocorticoids, mineralocorticoids and sex steroids 3β- HSD Increased concentrations of Δ 5  C 21 - and C 19 - steroids, 17 hydroxypregnenolone and DHEA suppressible by dexamethasone 5 α- reductase-2 def increased T/DHT ratio before and after hCG stim , modest increase in LH CAIS Increased LH and T, increased oestradiol , FSH levels normal or slightly increased PAIS Increased LH and T, increased oestradiol , FSH levels may be normal or slightly increased UK guidance on the initial evaluation of an infant or an adolescent with a suspected disorder of sex development 2015

73. Indicator of testis ( Sertoli Cells) Undetectable 46 XX CAH CGD PMDS due to AMH gene mutation Raised above male Related Ref. Range CAIS PAIS FARD Leydig Cell Hypoplasia Testosterone biosynthesis defect Hormonal Evaluation AMH

74. genitogram , RGU or cystoscopy/ vaginoscopy . MRI (when the gonads are not detected by ultrasound) Laparoscopic examination with gonadal biopsy may be needed Molecular studies : analyse the candidate gene Evaluation Additional imaging tests

75. Evaluation

76. It is at times very difficult to assign gender Haste should not be made in assigning gender Gender to be decided by team of doctors in consultation with the parents Gender Assigment

77. Neonatologist or General Paediatrician Paediatric Endocrinologist Paediatric Radiologist Paediatric Urologist * Paediatric Specialist Nurse Clinical Psychologist Clinical Endocrine Biochemist Clinical Geneticist Gynaecologist Team UK guidance on the initial evaluation of an infant or an adolescent with a suspected disorder of sex development

78. Explanation of the anatomy and results of imaging Explanation of pros and cons of reconstructive surgery Develop a plan for complex imaging (other than pelvic ultrasound) and further assessment of the anatomy Perform procedures such as laparoscopy, biopsy, reconstructive surgery and gonadectomy Organize timely and appropriate involvement of other members of MDT Paediatric Urologist*

79. Recent guideline Female sex should be assigned to all 46XX Male sex should be assigned to all 46 XY Gender Assigment But this is not applicable universally

80. Sex assignment is influenced by factors like etiological causes (CAH) Time at presentation external genital features (chances of reconstruction) internal reproductive anatomy possibility of spontaneous pubertal development , (FARD) the capacity for sexual activity and fertility potential, the ethnic or cultural & religious background of the parents Gender Assigment

81. Sex of rearing doesn’t only depend on diagnosis each patient should be evaluated and managed individually There is a recent trend towards preferable male sex assignment Gender Assigment

82. Gender Assigment

83. Gender Assigment in recent years elective surgery has been deferred to allow the patient to participate in decision-making in regard to both gender assignment and surgical intervention.

84. There are some major guiding principles Girls with CAH are fertile & must always be assigned a female sex all patients with complete androgen insensitivity syndrome (CAIS) and CGD are raised as female 17β-HSD3 or 5ARD deficiencies during the neonatal period could virilise during puberty , (hence should be assigned male sex ) PAIS and partial gonadal dysgenesis , gender identity corresponds with the sex of rearing (gender dysphoria is seen in approx. 25%of individuals whether raised male or female) Gender Assigment AAP 2008

85. ovotesticular DSD GOR should consider the potential for fertility on the basis of gonadal differentiation and genital development and assuming that the genitalia are , or can be made, consistent with the chosen sex . ( usually reared as females) Gender Assigment AAP 2008

86. mixed gonadal dysgenesis (MGD), factors to consider include prenatal androgen exposure, Testicular function at and after puberty, phallic development , and gonadal location Gender Assigment AAP 2008

87. In cases which can not be fertile, gender assignment will depend on The appearance of the external genitalia The potential for unambiguous appearance The potential for normal sexual functioning Gender Assigment AAP 2008

88. Gender Assigment ( consider chances of malignancy)

89. Gender Assigment ( coran )

90. CAH Monitor electrolytes & glucose Hypoglycemia can appear in the first hours Serum electrolytes will become abnormal D 6-14 Hydrocortisone 10-20 mg/m2/D PO Fludrocortisone acetate 0.1 mg/D Prenatal RX CAH Mothers with family Hx (Dexamethasone is started at earliest) If confirmed Dx of CAH in Female fetus ( by CVS/amniocentesis ) then continue Rx till term Medical Management

91. Sex steroid replacement therapy at puberty Testosterone enanthate 200-300 mg im / Month: Male Pt with steroid enzyme def Male Pt with partial gonadal dysgenesis , low leydig cell Number Estrogen premarin 0.625 mg PO/D For one year . Then cyclic estrogen progesterone or OCP (if there is uterus) Female Pt with enzyme def , 3 β- OH –steroid dehydrogenase & 17-hydroxylase Female 46 XY ,partial gonadal dysgenesis , OTS Medical Management

92. For suspected CAH (salt-losing variety), D5 NS (dextrose in normal saline) and Hydocortisone (100 mg/m 2/day), with treatment modified after 24 hours, based on electrolyte correction; fludrocortisone (0.1mg po qd ) is added, with a switch to table salt (2.5 grams po qd /given in 24-hr worth of formula ). Medical Management (Emergency)

93. Medical Management Coran

94. Genital surgery for Female Timing of surgery …..controversial Clitroplasty is done usually at 3-6 M of age for F with CAH Vaginoplasty is delayed until the individual is ready to start sexual life Genital surgery for M individualised Surgical management

95. Decision of Sx should be taken after consulting MDT and Family Where possible, the patient should be involved in the decision-making process In cases where surgery is performed at early ages, mutilating and irreversible procedures should be avoided. Surgical management

96. Surgery should only be considered in cases of severe virilization ( Prader III–V) and be performed in conjunction , when appropriate, with repair of the common urogenital sinus. Emphasis is on functional outcome rather than a strictly cosmetic appearance UGS should be operated early the beneficial effects of estrogen on tissue in early infancy, and the avoidance of potential complications from the connection between the urinary tract and peritoneum via the Fallopian tubes Surgical management AAP2008

97. An absent or inadequate vagina requires a vaginoplasty performed in adolescence when the patient is psychologically motivated and a full partner in the procedure . The testes in patients with CAIS (and those with PAIS , raised female) should be removed at diagnosis to prevent malignancy psychological problems availability of estrogen-replacement therapy allows for the option of early removal Surgical management

98. The streak gonad in a patient with MGD raised male should be removed laparoscopically Bilateral gonadectomy is performed in early childhood in females (bilateral streak gonads ) A scrotal testis in patients with gonadal dysgenesis is at risk for malignancy. Current recommendations are testicular biopsy at puberty If Biopsy positive then sperm banking and gonadectomy Surgical management AAP2008

99. Surgical management

100. Keeping the genital tubercle intact is recommended if it is not too big (<2cm) delayed surgery is therefore favored by some because the patient herself is involved in the decision process, although there is not yet any published support for this option Surgical management

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