DSD (disorders of sex development) M. Šnajderová Pediatrická klinika, 2. LF UK a FN Motol, Praha Photos of patients and other documents which are subject to copyright were removed

Sex development Genes related to gonadal development Gonadal differentiation Internal and external genitalia Phenotype and pubertal development Sexual identity

Disorders of sex development (DSD)

Male development Y chromosome (SRY) Genes Hormones(T, DHT, AMH) Androgen sensitivity T testosterone DHT dihydrotestosterone AMH Antimüllerian hormon

DSD: „disorders of sex development“ Prevalence Genital anomalies 1: 4 500 births (Thyen, U. et al.,Horm.Res., 2006) DSD: „disorders of sex development“ congenital conditions in which development of chromosomal, gonadal or anatomical sex is atypical

DSD Most cases recognised in neonatal period Later presentation: Previously unrecognised genital ambiguity Inguinal hernia with gonads in „girl“ Delayed or incomplete puberty Virilisation in girls Primary amenorrhea Breast development in boy Occassionally cyclical haematuria in a boy

Revised nomenclature (DSD) LWPES and ESPE 20061 Previous Proposed Intersex Male pseudohermaphroditism Undervirilisation of XY male Undermasculinisation of XY male DSD (disorders of sex development) 46, XY DSD

Revised nomenclature 2 Previous Proposed Female pseudohermaphrodite Overvirilisation of XX female Overmasculinisation of 46 XX female True hermaphrodite XX male nebo XX sex reversal XY sex reversal 46, XX DSD Ovotesticular DSD 46, XX testicular DSD 46, XY complete gonadal dysgenesis

DSD Life threatening If not Urgent Time for diagnostics

Approach to the problem 1 History (family history of ambiguous genitalia, maternal health including virilisation), drugs during pregnancy, previous stilbirths or neonatal deaths Examination (dysmorphic features of midline defects, hydration, blood pressure)

Approach to the problem 2 Genitalia Palpable gonads? (if yes: likely to be testes – normal or dysgenetic or ovotestes) Degree of virilization (Prader) Measure the length of the phallus stretched length from pubic tubercle to tip of penis). (Normal: about 3 cm, micropenis 2-2.5 cm (ethnic origin) Position of the urethral opening, vaginal opening, urogenital sinus?

Approach to the problem 3 Appearance of labioscrotal folds, rugosity Note the pigmentation of genital skin (excessive ACTH and opiomelanocortin in CAH) Determine the baby´s gestation (preterm girls: clitoris and labia minora are relatively prominent, in boys usually testes undescended until 34 weeks)

Investigations 1 FISH or PCR for Y and X chromosomes Blood karyotype Blood electrolytes Blood sugar If male/mosaic karyotype is confirmed: investigation directed at determining anatomy of internal genitalia and establishing whether testes are capable of producing androgens

Investigations 2 T and hCG test LH, FSH and GnRH test ACTH test (17-OHP,DHEAS, A-dion, T, DOC…) Determining of internal anatomy (Prader stages I-V) Ultrasound scan (anatomy of urogenital sinus/vagina/uterus/renal anomalies) Urogenital sinogram

Investigations 3 Cystography, laparoscopy with or without biopsies of gonads and skin MRI scan of the pelvis

BIOSYNTHETIC DEFECT Testosterone biosynthetis defect StAR defect, Smith-Lemli-Opitz syndrome, 3&-HSD deficiency, 17α-OHD Karyotype 46 XY ↓basal and ↓ hCG stimulated T ↑ T precursors (A-dion, DHEAS) on hCG test in lipoid CAH: adrenal failure confirmed on ACTH test, electrolytes and urinary steroids

BIOSYNTHETIC DEFECT 5α – reductase deficiency Karyotype 46 XY = / ↑ basal and peak T on hCG test ↑ T/DHT ratio Screening for mutations in the 5α – reductase type II gene (5RD5A2) in blood

BIOSYNTHETIC DEFECT Leydig cell hypoplasia (inactivating mutation of LH receptor) Karyotype 46 XY ↓ basal and hCG stimulated T ↑ LH level

END-ORGAN UNRESPONSIVENESS PAIS (mutation in the androgen receptor) Karyotype 46 XY = / ↑ basal and peak T in hCG test Normal T:DHT ratio Abnormality in genital skin fibroblasts or a mutation in the androgen receptor CAIS does not present in the neonatal period (normal female phenotype)

SYNDROMES Smith-Lemli-Opitz Denys-Drash syndrome Genital ambiguity, congenital nefropathy and Wilms´tumour Mutations in the Wilms´tumour suppressor (WT1) gene Proteinuria and renal impairment and determinind WT1 mutation

Intersex criteria for sex determining Anatomical defect and function aspects Psychosocial aspects Future sexual function and fertility

Therapeutic options and strategies CAH: prenatal diagnostics, recent approaches to the treatment of girls in utero Hormonally active tumors - oncologist Gonadal dysgenesis (45X/46XY and other mosaics) Disorders of biosynthesis and metabolism of androgens Androgen insensitivity partial complete

Hormone replacement (HRT) defects of steroidogenesis after removal of the gonads, afunction, gonadal agenesis induction of puberty feminization, virilization and maintain the state sexual function induction of spermatogenesis (when, how?) induction of ovulation reproduction

 risk (<5%): biopsie and gonadectomy? Risk of gonadal tumors 1    risk: gonadectomy ± + TSPY (testis-specific proteinY encoded) u GD: (gonadal dysgenesis) : risk 15-40% PAIS intra-abdominal gonads : risk 50% Frasier syndrome : risk 60%  risk (<5%): biopsie and gonadectomy? ovotestis DSD : risk 2.6-3% CAIS : risk 0.8-2% 24

Risk of gonadal tumors 2 Moderate risk: No risk (?): Turner syndrome (-Y) : gonadectomy ±, risk 12% 17 beta-HSD : monitoring risk 17-28% GD (gonads in scrotum) : biopsy and irradiaton? risk ? PAIS (gonads in scrotum) : biopsy and irradiation? risk 15% No risk (?): 5aR risk 0 ??? Leydig cells hypoplasia risk 0 ??? 25

B C A E D F Fig. 3. Gonad histology and immunohistochemical analysis. A Branching seminiferous tubule. B Region settled with germ cells (stained for TSPY, red) neighboring with an area of Sertoli-cell only tubules. C FOXL2-positive (granulosa) cells (orange) within seminiferous tubules settled by Sertoli cells positive for SOX9 (blue). D Multiple calcifications. E Double-staining for OCT3/4 (orange) and TSPY (blue) with double-positive cells attached to the basal lamina (arrows). F Same area with KITLG expression (red). 45,X/46,X,psu dic(Y) Gonadal Dysgenesis: Influence of the Two Cell Lines on the Clinical Phenotype, Including Gonadal Histology J. Kaprova-Pleskacova, M. Snajderova, J. Stoop, M. Koudova, E. Kocarek, D. Novotna, S.L.S. Drop, B Obermannova, J. Lebl, J.W. Oosterhuis, L.H.J. Looijenga Sex Dev DOI: 10.1159/000356173

Surgical management Prader III – V virilisation in girls Preservation of erectile function and innervation of clitoris Timing of separation of the vagina and urethra not before puberty (beneficial effects of estrogen on tissue) Vaginoplasty in some cases DSD with hypospadias: urethral reconstruction, phalloplasty, penile reconstruction

CAIS and PAIS raised as female: testes should be removed to prevent malignancy in adulthood (E2-HST) Mixed gonadal dysgenesis (MGD): streak gonad to remove (laparo) in males in early childhood bilateral gonadectomy in females (bilateral streak gonads) and Y chromosome