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Sexual Disorders. Classification of Anomalous Sexual Development A.Seminiferous tubule dysgenesis (Klinefelter’s syndrome) B.Syndrome of gonadal dysgenesis.

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Presentation on theme: "Sexual Disorders. Classification of Anomalous Sexual Development A.Seminiferous tubule dysgenesis (Klinefelter’s syndrome) B.Syndrome of gonadal dysgenesis."— Presentation transcript:

1 Sexual Disorders

2 Classification of Anomalous Sexual Development A.Seminiferous tubule dysgenesis (Klinefelter’s syndrome) B.Syndrome of gonadal dysgenesis & its variants (Turner’s syndrome) C.Complete & incomplete forms of XX & XY gonadal dysgenesis D.True hemaphroditism Disorders of Gonadal differentiation:

3 Classification of Anomalous Sexual Development A.Congenital virilizing adrenal hyperplasia B.Androgens & synthetic progestins transferred from maternal circulation C.Malformations of intestine & urinary tract (nonadrenal femalepseudohermaphroditism.) D.Other tetralogic factors Female Pseudohermaphroditism:

4 Cholesterol PregnelononeProgesteroneDOCCorticosterone 180H Corticosterone Aldosterone 170H Pregnenolone 170H Progesterone 11 DeoxycortisolCortisol DHEAAndrostenedioneTestosteroneEstradiol P450scc P450c21 3(B)HSD P450c11 P450c17 3(B)HSD P450c21 P450c113(B)HSD 17(B)HSD P450aro

5 Classification of Anomalous Sexual Development A.Testicular unresponsiveness to hCG & LH (Leydig cell agensis or hypoplasia). B.Inborn errors of testosterone biosynthesis: 1.Enzyme defects affecting synthesis of both corticosteroids & testosterone (variants of congenital adrenal hyperplasia i.P-450 scc (Cholesterol side-chain cleavage) deficiency (Congenital lipoid adrenal hyperplasia) ii.3(B)-hydrooxysteroid dehydrogenase 5 isomerase deficiency iii.P-450c17 (17(a)-hydroxylase) deficiency. Male Pseudohermaphroditism:

6 Classification of Anomalous Sexual Development C.Defects in androgen-dependent target tissue: 1.End-organ resistance to androgenic hormones (androgens receptor & postreceptor defects). A.Syndrome of complete androgens resistance & its variants (testicular feminization & its variant forms) B.Syndrome of incomplete androgen resistance & its variants (Reifenstein’s syndrome) C.Androgen resistance in phenotypically normal males 2.Defects in testosterone metabolism by peripheral tissues; 5(a)-reductance deficiency (pseudovaginal perineoscrotal hypospadias). Male Pseudohermaphroditism:

7 Classification of Anomalous Sexual Development D.Dysgenetic male pseudohermaphroditism: 1.X chromatin-negative variants of the syndrome of gonadal dysgenesis (eg. XO/XY,XYp-). 2.Incomplete form of XY gonadal dysgenesis. 3.Associated with degenerative renal disease (Wilms’ tumor- aniridia-gonadoblastoma-mental retardation syndrome). 4.“Vanishing testes” (embryonic testicular regression XY agonadism XY gonadal agenesis rudimentary testesanorchia). E.Defects in synthesis, secretion, or response to mulleran duct inhibitory factor: female genital ducts in otherwise normal men – “ uteri herniae inguinale”; persistent mullerian duct syndrome. Male Pseudohermaphroditism:

8 Unclassified Forms of Abnormal Sexual Development A.In males 1.Hypospadias 2.Ambiguous external genitalia in XY males with multiple congenital anomalies. B.In Females: 1.Absence or anomalous development of the vagina, uterus, & uterine tubes (Rokitansky- Kuster syndrome). Disorders of Gonadal differentiation:

9 Sexual Disorders The adrenal androgens serve no essential physiological role but mediate some secondary sexual characters in females and their overproduction may result in virilism. These steroids are synthesized from cholesterol by a complex series of enzymatic conversions. Congenital Adrenal Hyperplasia

10 Cholesterol PregnelononeProgesteroneDOCCorticosterone 180H Corticosterone Aldosterone 170H Pregnenolone 170H Progesterone 11 DeoxycortisolCortisol DHEAAndrostenedioneTestosteroneEstradiol P450scc P450c21 3(B)HSD P450c11 P450c17 3(B)HSD P450c21 P450c113(B)HSD 17(B)HSD P450aro

11 Sexual Disorders Congenital adrenal hyperplasia can be caused by a disorder in any of the steps in steroid hormone synthesis. There are 6 major types of congenital adrenal hyperplasia (CAH) all transmitted as autosomal recessive disorders. The common denominator in all the 6 types is a defect in the synthesis of cortisol that result in an increase in ACTH production and then in adrenal hyperplasia. Congenital Adrenal Hyperplasia

12 Sexual Disorders Type IP-450c21 hydroxylase deficiency with virilization. Type IIP-450c21 hydroxylase deficiency with virilization & salt loss. Type IIIP-450c21 hydroxylase deficiency with virilization & hypertenstion. Types of Congenital Adrenal Hyperplasia

13 Sexual Disorders Type IV3B hydroxy steorid dehydrogenase deficiency with adrenal insufficiency Type VP-450c17 deficiency with sexual infantilism, hypertension & hypokalaemic alkalosis. Type VIP-450cc side-chain cleavage deficiency with sexual infantilism & adrenal insufficiency. Types of Congenital Adrenal Hyperplasia

14 Sexual Disorders The most common type of congenital adrenal hyperplasia is the P-450c21 hydroxylase deficiency. Prevalence is 1:14,000 live birth in caucasions. The defect in the enzyme activity results in impaired cortisol synthesis, increased ACTH levels & increased adrenal androgen & androgen precursors production. Congenital Adrenal Hyperplasia

15 Sexual Disorders Prior to 12 weeks of gestation high fetal androgen level lead to varying degree of labioscrotal fusion & clitorial enlargement in the female fetus, exposure to androgens after 12 weeks induces clitorimegaly only. In the male fetus no structural abnormalities in the external genitalia are evident at birth but the phallus may be enlarged. These patients produce sufficient amount of aldosternone to prevent the signs & symptoms of mineralocorticoid deficiency, virilization continues after birth in the untreated patients. Congenital Adrenal Hyperplasia

16 Sexual Disorders This results in rapid growth & bone maturation as well as physical signs of excess androgen secretion (e.g. Acne, seborrhoea, premature development of pubic & axillary hair & phallic enlargement). Mild defect in the P-450c21 enzyme activity can occur & patients: A.Can be symptomatic (late onset or acquired form). B.Asymptomatic (cryptic form). These forms are more common that the classical form of the disease. Congenital Adrenal Hyperplasia

17 Sexual Disorders It has been postulated that the “non- classical” P-450c21 hydroxylase deficiency is the most common autosomal recessive disorder affecting 1:100 persons of all the ethnic groups but having an incidence 2-3 times higher in Congenital Adrenal Hyperplasia

18 Sexual Disorders Males have normal external genitalia at birth but later in childhood they may exhibit premature pubic & axillary hair, early puberty & short stature due to early bone maturation & epiphyseal fusion. Asymptomatic patients can be detected by hormonal testing in families in which there is at least one member with symptoms. Congenital Adrenal Hyperplasia

19 Diagnosis In patients with this enzymatic defects the 17- hydroxy progesterone values are usually very high depending on the age of the patient & the severity of the enzymatic defect. In the late onset form the basal 17-hydroxy- progesterone may be borderline but can be augmented by ACTH stimulation test. Urinary 17-ketosteroids & pregnanetriol are still valid test in the diagnostic procedure but have been replaced by the ACTH stimulation test.

20 Diagnosis The diagnosis of P-450c21 hydroxylase deficiency should always be considered in the following: 1.Patients with ambiguous genitalia who have 45XX Karyotype i.e. Female pseudo- hemophrodite. 2.Apparent cryptochid males. 3.In any infant who presents with shock, hypoglycemia & chemical findings compatible with adrenal insufficiency. 4.Males & females with sign of virilization prior to puberty, including premature adrenarche.

21 Treatment Replacement therapy with glucocorticoids provides the body with that which it cannot produce. The choice of the specific formulation of the glucocorticoids & the dose varies depending on the age & the therauptic goals in each patient. It is necessary to increase the physiological requirement (3-10 times) during period of stress e.g. surgery, illness.

22 Turner’s Syndrome & its Variants One in 10,000 new born females has a 45, X or XO sex chromosome constitutions & the cardinal feature of 45, X gonadal dysgenesis are : –A variety of somatic anomalies –Sexual infantilism at puberty –Short stature

23 Turner’s Syndrome & its Variants Lymphedema of the extremetiesLymphedema of the extremeties Loose skin folds over the nape of the neckLoose skin folds over the nape of the neck Typical faces include:Typical faces include: –Micrognathia –Epicanthal folds –Prominent low-set ears –Fish like mouth –Ptosis Sheild like chestSheild like chest Short neck which is broad & webbed (40%)Short neck which is broad & webbed (40%)

24 Additional Anomalies Associated with Turner’s Syndrome Coarctation of the aorta10%Coarctation of the aorta10% Renal abnormalities50%Renal abnormalities50% HypertensionHypertension Pigmented naeviPigmented naevi Cabitus valgusCabitus valgus Tendency to keloid formationTendency to keloid formation Puffiness of dorsum of hand & feetPuffiness of dorsum of hand & feet Short fourth metacarpalShort fourth metacarpal Recurrent otitis mediaRecurrent otitis media

25 Additional Anomalies Associated with Turner’s Syndrome Coarctation of the aorta10%Coarctation of the aorta10% Renal abnormalities50%Renal abnormalities50% HypertensionHypertension Pigmented naeviPigmented naevi Cabitus valgusCabitus valgus Tendency to keloid formationTendency to keloid formation Puffiness of dorsum of hand & feetPuffiness of dorsum of hand & feet Short fourth metacorpalShort fourth metacorpal Recurrent otitis mediaRecurrent otitis media

26 Associated Disorders ObesityObesity OsteoporosisOsteoporosis Diabetes MellitusDiabetes Mellitus Hashimoto thyroiditisHashimoto thyroiditis Rheumatoid arthritisRheumatoid arthritis Inflammatory bowel diseaseInflammatory bowel disease Biscupid aortic valve & aortic dilatation with aneurysm formation.Biscupid aortic valve & aortic dilatation with aneurysm formation.

27 Diagnosis Turner’s syndrome should be suspected in any female with : –Short stature (>2.5 SD below the mean value per age). –Somatic anomalies associated with the syndrome of gonadal dysgenesis. –Delayed adolescence & increased plasma level of gonadotrophins Although a buccal smear of sex chromatin is useful, karotype should be performed for definitive diagnosis, 45, XO

28 Treatment Treatment should be directed towards: –Maximizing final height –Inducing secondary sexual characters at menarche. Clinical trials showed that patients treated with growth hormone plus oxandrolone had an increase in growth rate which resulted in an increase in the predicted final height after 3 years of therapy.

29 Klinefelter’s Syndrome & its Variants Klinefelter’s sydnrome is one of the most common form of primary hypogonadism & infertility. Affected patients usually have an XXY sex chromosome constitution & an X chromatin- positive buccal smear although patients with a variety of sex chromosome constitutions including mosaicism, have been described. Virtually all of these variants have in the common the presence of at least two X chromosomes & a Y chromosome. The incidence is about 1/1000 in new born males.

30 Klinefelter’s Syndrome & its Variants Clinical Feature Include: –Male phenotype –Samll firm testes less than 3 cm in length & azospermia (invariable) –Pre pubertally thereare: Disproportionately long legsDisproportionately long legs Low verbal I.Q. scoreLow verbal I.Q. score Small testesSmall testes

31 Klinefelter’s Syndrome & its Variants Clinical Feature Include: –Delay in the onset of adolescence –Signs of androgen deficiency such as: GynacomastiaGynacomastia Diminished facial & body hairDiminished facial & body hair Small phallusSmall phallus Poor muscular developmentPoor muscular development Eunuchoid body habitus post pubertallyEunuchoid body habitus post pubertally Psycho-social abnornalitiesPsycho-social abnornalities Impotence & infertilityImpotence & infertility

32 Klinefelter’s Syndrome & its Variants Associated disorders: –Primary hypothyroidism –Mild diatetes mellitus –Varicose veins –Chronic pulmonary disease –Carcinoma of breast (20% more then normal men). –They are at greater risk of developing malignant extragonadal germ cell tumors including CNS germinoma

33 Klinefelter’s Syndrome & its Variants Associated disorders: The testicular lesion appear to be progressive & gonadotrophin dependent. It is characterized in the adults by extensive seminiferous tubular hyalinization & fibrosis, absent or severely deficient spermatogenesis, & pseudoadenomatous dumping of the leyding cells. Spermatogenesis is rarely found except in the XY/XXY mosaics & therefore they are infertile.

34 Diagnosis It is suggested by the classical phenotype & hormonal changes & is confirmed by the findings of X chromatin-positive buccal smear & demonstration of XXY karotype in blood. After puberty levels of serum gonadotrophin especially FSH are raised. The testosterone production rate, the total & free levels of testosterone & metabolic clearance rate of testosterone & estradiol tend to be low while plasma estradiol levels are normal or high & relatively high estradiol:testosterone ratio is responsible for the variable degrees of feminization & gynaecomastia. Testicular biopsy reveals the classical findings.

35 Differential Diagnosis Kilnefelter’s syndrome should be distinguished from other causes of hypogonadism. Small firm tested should suggests the diagnosis. Hypothalamic-pituitary hypogonadism may be associated with rubbery testes if puberty has not occurred & atrophic testes if normal puberty has occurred & the gonadotrophin levels are usually low. The consistency of the testes in the klinefelter’s syndrome is also different from that noted in acquired forms of adult seminiferous tubular damage.

36 Treatment Treatment is directed towards androgen replacement especially patients with delayed puberty or failure of progression in those with subnormal testosterone levels for age & development. Testosterone therapy also may enhance secondary sexual characteristics & sexual performance prevent osteoporosis & improve general well being in most patients. Personally defects do not improve & most patients require long term psychiatric counselling.

37 History Physical Examination Bone age Serum FSH, LH: GNRH test testosterone, oestradiol FSH LH Karyotype + gonad biopsy Detailed steroid analysis Sense of smell Obesity Skull radiograph & coronal CT Scan Pituitary function tests Follow up 6-monthly intervals Gonadotrophin stimulation History Physical Examination Bone age Serum FSH, LH: GNRH test testosterone, oestradiol Klinefelter’s syndrome Gonadal dysgenesis Male pseudohermaphroditism Mixed gonadal dysgenesis True hermaphroditism Congenital anorchia Resistant ovary syndrome Gonadal damage Inborn error of sex steroid synthesis Kallmann’s syndrome Pradder-Willi syndrome Laurence-Moon-Beidl syndrome CNS tumor Hypopituitarism Constituional delay Hypogonadotrophic hypogonadism


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