INTERSEX

1. INTERSEX Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.

2. Defining Sex and Gender Gender identity (Psychological sex) Inner sense of owns maleness / femaleness. • Sex of rearing • Gender role Sexual identity (Organic sex) The biologic sexual differentiation • Chromosomal sex • Gonadal sex • Internal genital sex • External genital sex • Hormonal sex

3. Human sexual differentiation Chromosomal sex Gonadal sex Internal genital sex External genital sex SEX ASSIGNMENT Sex of rearing Gender identity and role

4. Gonadal development SRY-gene (TDF) Short arm of Y chromosome Present Absent Bipotential Gonad 2 X chromosomes Receptors For H -Y antigen TESTES OVARY

5. Male development TESTIS Leydig cells Sertoli cells Mullerian inhibiting factor Testosterone Wollfian duct 5a-reductase DHT Regrsession of Muuleian ducts Urogenital sinus Male internal Genital organs Male external genitalia

6. Female development Neutral Development OVARY Urogenital sinus Mullerian ducts Female external genitalia . Lower part of vagina Female internal genital Organs . Most of upper vagina . Cervix and uterus . Fallopian tubes Absence of androgen exposure

7. Summary of Normal Sex Differentiation • genetic sex is determined at fertilization. • testes develop in XY fetus, ovaries develop in XX fetus. • XY fetus produces MIS and androgens and XX fetus does not. • XY fetus develops Wolffian ducts and XX fetus develops Mullerian ducts. • XY fetus masculinizes the female genitalia to make it male and the XX fetus retains female genitalia.

8. INTERSEX An individual in whom there is discordance between chromosomal, gonadal, internal genital, and phenotypic sex or the sex of rearing • INTERSEXUALITY: Discordance between any two of the organic sex criteria • TRANSSEXUALITY: Discordance between organic sex and psychological sex components

9. CLASSIFICATIONOFINTERSEXUALITY Disorders of fetal Endocrinology

10. CLASSIFICATIONOFINTERSEXUALITY Primary gonadal defect – Swyer syndrome

11. How many children are born with intersex conditions? • A conservative estimate is that 1 in 2000 children born will be affected by an intersex condition • 98 % of affected babies are due to congenital adrenal hyperplasia

12. EXCESS FETAL ANDROGENS Congenital adrenal hyperplasia  21 -hydrxylase deficiency  11-hydroxylase deficiency  3ß-hydroxysteroid dehydrogenase deficiency EXCESS MATERNAL ANDROGENS Maternal androgen secreting tumors (ovary, adrenal)  Maternal ingestion of androgenic drugs FEMALE PSEUDOHERMAPHRODITISM

13. Congenital Adrenal Hyperplasia • It is a familial disorder of adrenal steroid biosynthesis with autosomal recessive mode of inheritance. • The defect is expressed as adrenal enzyme deficiency. • 5 major Enzymes deficiency are clinically important • 21-Hydroxylase • 11-b-Hydroxylase • 17-a-Hydroxylase • 3-b-Hsteroid hydrogenese • 20,22 Desmolase deficiency

14. CAH • The most frequent is steroid 21-hydroxylase deficiency, accounting for more than 90 percent of cases. • The enzyme deficiency causes reduction in end-products, accumulation of hormone precursors & increased ACTH production. • The clinical picture reflects the effects of inadequate production of cortisol & aldosterone and the increased production of androgens & steroid metabolites.

15. Biochemistry Steroid 21-hydroxylase (CYP21, also termed CYP21A2 and P450c21) is a cytochrome P-450 enzyme located in the endoplasmic reticulum. It catalyzes the conversion of 17-hydroxyprogesterone to 11-deoxycortisol, a precursor of cortisol, and the conversion of progesterone to deoxycorticosterone, a precursor of aldosterone. Owing to this loss of enzyme function, patients with 21-hydroxylase deficiency cannot synthesize cortisol efficiently, and as a result, the adrenal cortex is stimulated by corticotropin and overproduces cortisol precursors.

17. Contd… Cortisol is an adrenal steroid hormone that is required for normal endocrine function. Production begins in the second month of fetal life. Poor cortisol production is a hallmark of most forms of CAH. Inefficient cortisol production results in rising levels of ACTH, which in turn induces overgrowth (hyperplasia) and overactivity of the steroid-producing cells of the adrenal cortex. The defects causing adrenal hyperplasia are congenital (i.e., present at birth)

18. Contd… Some of these precursors are diverted to the biosynthesis of sex hormones, which may cause signs of androgen excess, including ambiguous genitalia in newborn girls and rapid postnatal growth in both sexes. Concomitant aldosterone deficiency may lead to salt wasting with consequent failure to thrive, hypovolemia, and shock.

19. 21-hydrxylase deficiencycongenital adrenal hyperplasia Cholesterol Pituitary Pregnenolone Progesterone ACTH 17-OH progesterone Adrenal cortex 21-hydroxylase  Androgens Cortisol Cortisol Androgens

20. 21-hydrxylase deficiencycongenital adrenal hyperplasia • Most common type, accounts for >80% of cases. • Incidence is 1:5000 to 1:15000 live birth. • Gene is located on the short arm of chromosome 6 near the C4 locus in close association with HLA genes. • Heterozygous carriers can be detected by ACTH stimulation test.

21. Contd.. • It is characterized by reduced production of cortisol and aldosterone and increased production of progesterone; 17-OH-progesterone, and sex steroids. • The urinary steroid metabolites (17-ketosteroids and pregnanetriol) are elevated above normal levels.

22. Contd.. • Decreased secretion of aldosterone results in salt loss with hyponatremia and hyperkalemia; plasma renin activity is therefore elevated. • In partial enzyme deficiencies, the aldosterone deficiency is not expressed, and patients remain normonatremic and normokalemic. • The excess androgens causes virilization of girls & ambiguous genitalia & dark scrotum in boys.

23. Contd… • There are 3 forms: 1. classic early virilization type with or without salt-losing crisis(typically identified at birth because of genital ambiguity) 2.Salt wasting (in which there is impairment of mineralocorticoid as well as glucocorticoid secretion), 3. non-classic type with late-onset virilization(in which heterosexual development occurs at the expected age of puberty).

24. Contd… • Male babies with non salt-losing non-classic type remains asymptomatic till late childhood when they may show signs of sexual precocity. • Because members of the same family may have classic, non-classic & asymptomatic forms, the disorder may be due to allelic variations of the same enzyme. • Mass neonatal screening using filter paper blood sample for 17-OH-Progesterone is used in the USA.

25. CLINICAL MANIFESTATIONS 1. In classic form(girls are born with ambiguous genitalia) having • enlarged clitoris • fusion of the labioscrotal folds and the urogenital sinus. • The internal female organs (including the uterus, fallopian tubes, and ovaries) develop normally because they are not affected by the increased androgen levels. • early pubic hair and rapid growth in childhood precocious puberty or failure of puberty to occur (sexual infantilism: absent or delayed puberty) • excessive facial hair • Virilization • menstrual irregularity in adolescence • infertility due to anovulation • shallow vagina

26. clitoromegaly Marked virilization with hypospadiac-appearing phallus labioscrotal fusion

27. 2. In salt wasting 21hydroxylase deficiency hyponatremia hyperkalemia hypotension CLASSICAL CAH

28. Contd… • During childhood, untreated girls with either the classic or salt wasting form grow rapidly but have advanced bone ages, enter puberty early, experience early closure of their epiphyses, and ultimately are short in stature as adults. CAH, with appropriate therapy, is the only inherited disorder of sexual differentiation in which normal pregnancy and childbearing are possible. • Boys : -no overt signs of the disease except variable and subtle hyperpigmentation and penile en-largement

29. BOYS WITH CAH • Are unrecognized at birth because their genitalia are normal. • They are not diagnosed until later, often with a salt wasting crisis resulting in dehydration, hypotension, hyponatremia and hyperkalemia or later in childhood with early pubic hair & phallic enlargement accompanied by accelerated linear growth and advancement of skeletal maturation. • High blood pressure & hypokalemia may occur in those with 11-b-hydroxylase deficiency and 17-a-hydroxylase deficiency due to the accumulation of the mineralocorticoid desoxycorticosterone

30. (Williams Textbook of Endocrinology, 10th ed, 2003)

31. 11-hydroxylase (P450c11) deficiency • Accounts for 5-10% of cases of CAH. • Gene is located on the long arm of chromosome 8. • caused by mutations in the CYP11B1 gene. • It is characterized by low plasma renin activity & elevation of serum 11-Deoxycortisol and 11-deoxycorticosterone. • Because of the strong mineralocorticoid activity of deoxycorticosterone, the condition is characterized by salt retention, hypertension & hypokalemic alkalosis. • The elevated plasma androgens may cause virilization of the female fetus.

32. 3ß-hydroxysteroid dehydrogenase deficiency • This is a very rare disorder that results in accumulation of DHEA, which is converted to testosterone in peripheral tissues. • Enzyme defects in adrenal and ovary in autosomal –recessive fashion • Caused by mutations in the HSD3B2 gene encoding the 3ß-HSDII enzyme affects the synthesis of glucocorticoids, mineralocorticoids, and sex steroids. • Cortisol↓ & aldosterone ↓ • Dehydroepiandrosterone ↑↑  the external genitalia ambiguity • It can cause virilization of female fetus and leads to ambiguous genitalia in the newborn. • A diagnosis based on baseline and ACTH-stimulated changes in steroid levels is not accurate ; indeed, in adult women, an apparent late-onset 3ß-hydroxysteroid dehydrogenase deficiency is almost always, if not always, a secondary response to anovulation and polycystic ovaries, accompanied by hyperinsulinemia

33. 17-hydroxylase deficiency • Genetic defect is on chromosome 10. • Corticosterone, 11-deoxycorticosterone ↑ • Presents with similar features of those of 11-Hydroxylase deficiency except that Androgens are low, so no virilization in girls & genitalia is ambiguous in boys. • Hypertension (due to hypernatremia and hypervolemia), hypokalemia • Infantile female external genitalia & primary amenorrhea

34. ESSENTIALS OF DIAGNOSIS • Increased linear growth with advanced bone age and eventual short stature • Pseudohermaphorditism in girls due to androgen virilizing effect • Isosexual precocity in boys with small infantile testes. • Adrenal crisis with salt-loss & metabolic acidosis or Hypertension & hypokalemic alkalosis. • Low cortisol with high androgens, ACTH and steroid precursors e.g. 17-OH-Progest. or 11-Deoxycortisol. • Diagnosis is confirmed by measurement of ACTH, Cortisol, Aldosterone, 17-OH-progesterone, Testosterone & urinary 17-ketosteroids. • Needs alertness for the possibility in all babies with Diarrhea & Vomiting, hypoglycemia or  BP.

35. Diagnosis Classic 21-hydroxylase deficiency is characterized by markedly elevated serum levels of 17-hydroxyprogesterone, the main substrate for the enzyme. The gold standard for differentiating 21-hydroxylase deficiency from other steroidogenic enzyme defects is the corticotropin (cosyntropin) stimulation test,measuring base-line and stimulated levels of 17-hydroxyprogesterone. corticotropin (cosyntropin) stimulation test : The most commonly used stimulatory test involves measurement of 17-hydroxyprogesterone 30 minutes after administration of a bolus of 250 mg of synthetic cosyntropin (Cortrosyn).

36. Contd… In normal women - this value seldom exceeds 400 ng/dL. Patients with classic 21-hydroxylase deficiency - achieve peak levels of 3,000 ng/dL or higher. Patients with nonclassic 21-hydroxylase deficiency-achieve levels of 1,500 ng/dL or more. Heterozygous carriers - achieve peak levels up to about 1,000 ng/dL. In hirsute women with hypertension, 11-deoxycortisol levels can be determined during the test. If both 11-deoxycortisol and 17-hydroxyprogesterone levels are increased, the rare 11-hydroxylase deficiency is present. Only measurements of several steroid precursors after corticotropin stimulation can identify individuals with nonclassic forms of 3-HSD deficiency. The elevated levels of 17-hydroxyprogesterone present in all forms of 21-hydroxylase deficiency are rapidly suppressed by administration of exogenous corticoids. Even a single dose of a glucocorticoid such as dexamethasone will suppress 17-hydroxyprogesterone in CAH but not in virilizing ovarian and adrenal neoplasms.

38. CONGENITAL ADRENAL HYPERPLASIA - Diagnosis • Normal infant :100ng/dl (17 -hydroxyprogesterone) • Affected infants : 3,000 - 40,000ng/dl ↑ • The severity of hormonal abnormalities : depends on the type of 21-hydroxylase def • Salt wasting : 17-hydroxyprogesterone: 100000ng/dl • In adult , random 17-hydroxyprogesterone (17-OHP) : baseline - 200ng/dl ↓ • Levels greater 200ng/dl, but less than 800 ng/dl -> Corticotropin stimulation test

39. Lab Findings • Demonstration of inadequate production of cortisol and/or aldosterone in the presence of accumulation of excess concentrations of precursor hormones is diagnostic. • In 21-hydroxylase deficiency, very high serum 17-hydroxyprogesterone is characteristic together with very high urinary pregnanetriol (metabolite of 17-hydroxyprogesterone). • Both are accompanied by elevated 24-hour urinary 17-ketosteroids, the urinary metabolites of adrenal androgens.

40. Other tests • Salt wasting forms of adrenal hyperplasia are accompanied by low serum aldosterone, hyponatremia, hyperkalemia and elevated plasma renin activity indicating hypovolemia. • In contrast hypertensive forms of adrenal hyperplasia (11-b-hydroxylase deficiency and 17-a-hydroxylase deficiency) are associated with suppressed plasma renin activity and hypokalemia • A karyotype is essential in the evaluation of the infant with ambiguous genitalia in order to establish the chromosomal sex. • Prenatal diagnosis of adrenal hyperplasia is possible through biochemical and genetic tests.

41. Imaging Studies A pelvic ultrasound: in the infant with ambiguous genitalia to demonstrate the presence or absence of a uterus or associated renal anomalies A urogenitogram is often helpful to define the anatomy of the internal genitalia. A CT scan of the adrenal gland to R/O bilateral adrenal hemorrhage in the patient with signs of acute adrenal failure A bone age study is useful in the evaluation of the child who develops precocious pubic hair, clitoromegaly, or accelerated linear growth.

42. CONGENITAL ADRENAL HYPERPLASIA – Management GOALS • According to the clinical course & hormonal level • Purpose : Normal growth, B.Wt, pubertal development, optimal adult height • Growth velocity, body Wt velocity, bone age maturation • Classic 21-OH def -> glucocorticoid : adrenal androgen secretion ↓ -> mineralocorticoid : electrolytes & plasma renin activity

43. MODE OF TREATMENT • Steroid replacement • Supportive therapy when needed • Treatment is life-long • Plastic surgery for ambiguous genitalia at early age • Genetic counseling • Psychological support

44. Treatment(1)-Glucocorticoids • Patients with classic 21-hydroxylase deficiency require long-term glucocorticoid treatment to inhibit excessive secretion of corticotropin-releasing hormone and corticotropin by the hypothalamus and pituitary, respectively, and to reduce elevated levels of adrenal sex steroids. • In children, the preferred drug is hydrocortisone (i.e., cortisol itself ) in maintenance doses of 10 to 20 mg per square meter of body-surface area per day in three divided doses.

45. Treatment(2)-Glucocorticoids • Doses of up to 100 mg per square meter per day are given during adrenal crises and life-threatening situations. • Even these maintenance doses exceed physiologic cortisol secretion (7 to 9 mg per square meter per day in neonatesand 6 to 8 mg per square meter per day in children and adolescents). • The efficacy of treatment is best monitored by measuring 17-hydroxyprogesterone and androstenedione levels at a consistent time in relation to the administration of medication.

46. Treatment(3)-Glucocorticoids • The therapeutic goal is to use the lowest dose of glucocorticoid that adequately suppresses adrenal androgens and maintains normal growth and weight gain. • Children should also undergo radiography annually to determine bone age, and their linear growth should be carefully monitored. • Older adolescents and adults may be treated with prednisone (e.g., 5 to 7.5 mg daily in two divided doses) or dexamethasone (total, 0.25 to 0.5 mg given in one or two doses per day).

47. Treatment(1)-Mineralocorticois • Infants with the salt-wasting form of 21-hydroxylase deficiency require supplemental mineralocorticoid (usually 0.1 to 0.2 mg of fludrocortisone daily) and sodium chloride (1 to 2 g or 17 to 34 mmol of sodium chloride chloride daily in addition to glucocorticoid treatment). • Older infants and children usually do not require sodium chloride supplements, and they often have reduced requirements for fludrocortisone.

48. Treatment(2)-Mineralocorticoids • Plasma renin activity levels or direct renin immunoassays may be used to monitor the adequacy of mineralocorticoid and sodium replacement, taking into account the age-specific reference ranges for each laboratory. • Hypotension, hyperkalemia, and elevated renin levels suggest the need for an increase in the dose, whereas hypertension, edema, tachycardia, and suppressed plasma renin activity signify overtreatment with mineralocorticoids.

49. NEW TRENDS OF T/T • A New approach therapy is the combined use of 4 drugs: • glucocorticoid (to suppress ACTH and adrenal androgen production), • mineralocorticoid (to reduce angiotensin II concentrations), • aromatase inhibitor (to slow skeletal maturation), • flutamide (an androgen blocker to reduce virilization)

50. Management of Ambiguous Genitalia • Improvements in the surgical correction of genital anomalies over the past two decades have led to earlier use of single-stage surgery — between two and six months of life in girls with 21-hydroxylase deficiency, a time when the tissues are maximally pliable and psychological trauma to the child is minimized. • The long-term outcomes of the newer surgical procedures have yet to be evaluated.