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Reifenstein Syndrome

PAIS

Reifenstein syndrome is a type of androgen insufficiency. Reifenstein syndrome occurs in men when their body is unable to appropriately respond to androgens and testosterone. It is characterized by ambiguous external genitalia, gynecomastia, and infertility due to sclerosis of the seminal tubules.


Presentation

Males with Reifenstein syndrome have partial androgen insensitivity; they are born with external male sex features. Affected men often present for clinical workup at the time of puberty, with the following physical characteristics and/or complaints [1] [2]:

It is important to note a contrast of presenting symptoms between men with Reifenstein syndrome (partial androgen insensitivity) to those with complete androgen insensitivity. Men with complete androgen insensitivity often present with external female sex characteristics (without a uterus), internal male sex characteristics (e.g., undescended testes), and absent or very little pubic or axillary hair.

Pediatric Disorder
  • Pediatric disorders of sex development. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 13th ed. Philadelphia, PA: Elsevier; 2016:chap 23. Shnorhavorian M, Fechner PY.[medlineplus.gov]
  • Pediatric disorders of sex development. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 23. Lin-Su, K, New MI. Ambiguous genitalia in the newborn.[stelizabeth.com]
Pediatric Disorder
  • Pediatric disorders of sex development. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 13th ed. Philadelphia, PA: Elsevier; 2016:chap 23. Shnorhavorian M, Fechner PY.[medlineplus.gov]
  • Pediatric disorders of sex development. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology . 13th ed. Philadelphia, PA: Elsevier; 2016:chap 23. Lin-Su, K, New MI. Ambiguous genitalia in the newborn.[stelizabeth.com]
Deepening of Voice
  • They may also receive androgens to help facial hair grow and deepen the voice. For those assigned as females, surgery may be done to remove the testicles and reshape the genitals. The female hormone estrogen is then given during puberty.[account.allinahealth.org]
Failure to Thrive
  • Fred Ferri’s popular "5 books in 1" format provides quick guidance on menorrhagia, Failure to Thrive (FTT), Cogan’s syndrome, and much more.[books.google.de]
Small Scrotum
  • ., small penis, small scrotum, incompletely closed or undescended testicles) Gynecomastia Sparse facial hair and difficulty growing a beard (normal amount of pubic and axillary hair) Complaints of sexual dysfunction Inability to impregnate female partner[symptoma.com]
  • Symptoms Abnormal male genitals Hypospadias Small penis Small scrotum, with a line down the middle (bifid) or incompletely closed Undescended testicles Breast development in males at time of puberty Decreased body hair and beard, but normal pubic and[coordinatedhealth.com]
  • These may include: Abnormal male genitals, such as the urethra being on the underside of the penis, small penis, small scrotum (with a line down the middle or incompletely closed), or undescended testicles .[account.allinahealth.org]
  • Symptoms Abnormal male genitals, including undescended testes; a small scrotum, with a line down the middle (bifid) or incompletely closed; a small penis; and hypospadias (the urethra exits the body on the side of the penis, not the tip) Breast development[medical-dictionary-search-engines.com]

Workup

Diagnosis of Reifenstein syndrome consists of a history, physical findings, blood tests, genetic tests, sperm count, and less often a testicular biopsy. Physical findings include varying degrees of ambiguous external genitalia, small penis and scrotum, undescended testes, space facial hair, and gynecomastia. Affected individuals may also have partially developed female sex organs, a small or missing vas deferens.

Blood tests for various sex hormones (testosterone and its derivatives, anti-müllerian hormone, sex hormone-binding globulin, luteinizing hormone) are often performed. Prior to puberty, laboratory tests will reflect normal levels of testosterone, dihydrotestosterone, and luteinizing hormone. Following puberty, there may be normal or elevated testosterone with elevated levels of luteinizing hormone. Additionally, either during the first year of life or the following puberty, men will often have elevated levels of anti-müllerian hormone [4].

An abdomen/pelvic ultrasound is the most useful radiological test. Findings commonly demonstrate the absence of a uterus, impaired development of prostate and Wolffian duct derivatives, and undescended testes [5] [6] [7]. In rare instances where there is a palpable mass or otherwise clinically indicated, a magnetic resonance imaging may be used to visualize the pelvic anatomy.

Genetic analysis will show a normal 46 XY chromosomal pattern. Genetic defects in the androgen receptor (AR) gene cause androgen insensitivity syndrome by preventing the androgen receptors from functioning correctly. A mutation of the AR gene causes cells to be less responsive or refractory to androgens. Androgens and androgen receptors also play a role in hair growth and libido. Depending on the degree of mutation of the AR gene, an affected individual's sex characteristics can vary from mostly female to mostly male [8] [9] [10] [11]. A DNA analysis of the androgen receptor gene will detect any mutations in the AR gene. The number of CAG repeats in exon 1 of the AR gene have been shown to be inversely proportional to the transcriptional activity of the androgen target gene; in other words, the greater the number of trinucleotide CAG repeats, the greater the degree of androgen insensitivity.

Abnormal Thyroid Function Test
  • THYROID FUNCTION TEST 47 THYROID DISORDERS OF INFANCY 462 P A RT IV CALCIUM AND BONE METABOLISM 473 MORPHOLOGY OF THE PARATHYROID 51 PARATHYROID HORMONE 497 PHYSIOLOGY OF CALCIUM 52 PARATHYROID HORMONERELATED 512 CLINICAL APPLICATION OF BONE MINERAL[books.google.de]

Treatment

  • Treatment with testosterone suppressed serum luteinizing hormone levels and promoted mild virilizing effects.[ncbi.nlm.nih.gov]
  • The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions.[pacificschoolserver.org]
  • CLOSE Medical Disclaimer The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes.[crm.diseaseinfosearch.org]
  • Testosterone treatment that is started early may prevent some infertility.[coordinatedhealth.com]
  • After puberty: normal or elevated testosterone , elevated LH. 46,XY karyotype DNA analysis of the androgen receptor gene Treatment of Androgen Insensitivity Syndromes Treatment of the Mild Androgen Insensitivity Syndrome (MAIS) Causal treatment of MAIS[urology-textbook.com]

Prognosis

  • Support Groups Androgen Insensitivity Syndrome Support Group (AISSG) — www.aissg.org Intersex Society of North America (ISNA) — www.isna.org Expectations (prognosis) Androgens are most important during early development in the womb.[coordinatedhealth.com]
  • Tests may include: Blood tests to check levels of male and female hormones Genetic tests such as karyotyping to check chromosomes Sperm count Testicular biopsy Pelvic ultrasound to check if female reproductive organs are present Outlook (Prognosis) Androgens[account.allinahealth.org]
  • Support Groups Androgen Insensitivity Syndrome Support Group (AISSG) -- www.aissg.org Intersex Society of North America (ISNA) -- www.isna.org Expectations (prognosis) Androgens are most important during early development in the womb.[indiatoday.in]
  • Expectations (prognosis) Androgens are most important during early development in the womb.[medical-dictionary-search-engines.com]
  • Support Groups Return to top Androgen Insensitivity Syndrome Support Group (AISSG) -- www.medhelp.org/www/ais/ Intersex Society of North America (ISNA) -- www.isna.org Outlook (Prognosis) Return to top Androgens are most important during early development[pacificschoolserver.org]

Etiology

  • Reifenstein syndrome has been shown to have a heterogenous etiology, with some patients demonstrating a decreased number of normal receptors and others having receptors that are defective, as evidenced by their decreased affinity for dihydroterststerone[medigoo.com]
  • Etiology (Causes) of the Androgen Insensitivity Syndrome Different mutations of the androgen receptor gene, located on the X chromosome, lead to a reduced (partial) androgen response or complete lack of androgen response (PAIS or CAIS).[urology-textbook.com]

Epidemiology

  • Endocrine epidemiology of male breast cancer. Anticancer Res. 8 , 845–850 (1988). 3 Thomas, D.B. et al . Breast cancer in men: risk factors with hormonal implications. Am. J. Epidemiol. 135 , 734–748 (1992). 4 Rosenblatt, K.A. et al .[nature.com]
  • Epidemiology Incidence 1:20000 to 1:60000 Mild Androgen Insensitivity Syndrome (MAIS) Patients with a minimal androgen insensitivity syndrome (MAIS) are phenotypically male; the most common symptom is infertility.[urology-textbook.com]
Sex distribution
Age distribution

Pathophysiology

  • Morris suggested the term testicular feminization , and by 1963 most of the essential pathophysiology of complete AIS was suspected.[t-vox.org]

Prevention

  • In addition, the defective androgen receptor might have prevented suppressive effects of androgens on the Leydig cells.[ncbi.nlm.nih.gov]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.de]
  • Prevention Prenatal testing is available. People with a family history of these conditions should consider genetic counseling. Testosterone treatment that is started early may prevent some infertility.[coordinatedhealth.com]
  • Genetic defects in the androgen receptor (AR) gene cause androgen insensitivity syndrome by preventing the androgen receptors from functioning correctly. A mutation of the AR gene causes cells to be less responsive or refractory to androgens.[symptoma.com]
  • Prevention Prenatal testing is available. People with a family history of these conditions should consider genetic counseling. Testosterone treatment that is started early may prevent some infertility. References Donohoue P.[indiatoday.in]

References

Article

  1. Hannema SE, Scott IS, Rajpert-De Meyts E, Skakkebaek NE, Coleman N, Hughes IA. Testicular development in the complete androgen insensitivity syndrome. J Pathol. 2006;208:518–27.
  2. Gottlieb B, Pinsky L, Beitel LK, Trifiro M. Androgen insensitivity. Am J Med Genet. 1999;89:210-7.
  3. Van Batavia JP, Kolon TF. Fertility in disorders of sex development: A review.J Pediatr Urol. 2016 Nov 3. [Epub ahead of print] Review
  4. Sinnecker GH, Hiort O, Nitsche EM, Holterhus PM, Kruse K. Functional assessment and clinical classification of androgen sensitivity in patients with mutations of the androgen receptor gene. German Collaborative Intersex Study Group. Eur J Pediatr. 1997;156:7–14.
  5. Galani, A, Kitsiou-Tzeli S, Sofokleous C, Kanavakis E, Kalpini-Mavrou A. Androgen insensitivity syndrome: clinical features and molecular defects. Hormones (Athens). 2008; 7:217-29.
  6. Quigley CA, Bellis AD, Marschke KB, el-Awady MK, Wilson EM, French FS. Androgen receptor defects: historical, clinical, and molecular perspectives. Endocr Rev.1995;16:271-321.
  7. Turan V, Yeniel O, Ergenoğlu M, Terek C, Ulukuş M. Incomplete androgen insensitivity (Reifenstein syndrome) - a case report.J Turk Ger Gynecol Assoc. 2010;11:110-2.
  8. Griffin JE. Androgen resistance--the clinical and molecular spectrum.N Engl J Med. 1992;326:611.
  9. Chen MJ, Vu BM, Axelrad M, et al. Androgen Insensitivity Syndrome: Management Considerations from Infancy to Adulthood. Pediatr Endocrinol Rev. 2015;12:373-87.
  10. Gottlieb B, Pinsky L, Beitel LK, Trifiro M. Androgen insensitivity. Am J Med Genet. 1999;89:210-7.
  11. Hiort O. Clinical and molecular aspects of androgen insensitivity. Endocr Dev. 2013;24:33-40.

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Last updated: 2019-06-28 11:00