To systematically review the current literature on gynecologic function and dysfunction in transmasculine and gender-diverse individuals in the context of testosterone therapy, with a focus on menstrual suppression, contraceptive needs, pelvic pain, vulvovaginal changes, and sexual health. PubMed, Embase, and Web of Science databases were searched through September 2025 using search terms related to transmasculine individuals, assigned female at birth, reproductive organs, and testosterone and gender-affirming hormone therapy. No restrictions on publication year were applied. Studies were included if they reported on the impact of exogenous testosterone on gynecologic or sexual (dys)function and contraceptive use and choices, in transmasculine and gender-diverse individuals. Only original human research studies were eligible. Studies focusing on fertility, reproductive outcomes, malignancy, histology, animal models, or individuals with differences of sex development were excluded. All included studies were critically appraised using Joanna Briggs Institute quality assessment tools, and findings were synthesized narratively. Fifty-seven studies were included. Testosterone was generally effective in achieving menstrual suppression, although breakthrough bleeding and ovulatory activity occurred in a substantial proportion of individuals. Contraceptive needs were frequently unmet, partly due to misinformation and provider-related barriers. Pelvic pain was commonly reported, with varied etiologies. While testosterone often increased sexual desire, dyspareunia and genital discomfort were frequently described. Vaginal microbiome alterations and epithelial changes were observed, although their clinical implications remain unclear. Testosterone-based gender-affirming hormone therapy has diverse effects on gynecologic function in transmasculine and gender-diverse individuals, including both physiologically expected as well as underexplored effects. Clinicians should adopt an individualized and affirming approach to care, while further research is needed to understand long-term outcomes, improve assessment tools, and close gaps in inclusive gynecologic healthcare.

Detection of androgen doping relies on mass spectrometry-based methods to detect natural endogenous and exogenous androgens in urine and serum. To distinguish exogenous administration from natural variation in endogenous serum androgens requires a robust quantitative basis in the variability of serum androgen measurements. The present study therefore aimed to use extensive data from serial antidoping testing of elite male and female athletes to define the reproducibility of serum androgen profiles in male and female athletes. The present study analyzed 5516 samples from 1689 athletes for serum T, DHT, and A4 concentrations and calculated the T/DHT and A4/T ratios from 889 male and 778 female athletes, excluding samples from pregnant, doped, or XY Disorders of Sexual Development (DSD) individuals. As well as the median and interquartile range, the coefficient of variation (CV) and its 95% confidence limits were calculated from three, six, or nine replicate within-person serum samples (309, 146, and 83 for females and 276, 122, and 65 for males, respectively). Variability was greater for females than males for serum T, DHT, and T/DHT ratio (p < 10-6) but not significantly different for serum A4 and for A4/T ratio. These data may provide a basis for enhanced detection of T doping and for diagnosis of XY DSD disorders, 5α reductase 2, and 17β hydroxysteroid dehydrogenase 3 deficiencies.

Differences in sex development (DSD) with 46,XY karyotype are a group of rare congenital conditions affecting the structure and function of the urogenital system. Published data indicate, that despite the increasingly widespread use of genetic testing, the etiology remains unclear in approximately half of cases. To clarify the molecular causes of 46,XY DSD by performing whole-exome sequencing (WES) in a precisely phenotyped and clinically comprehensively evaluated group of patients. WES was performed in a consecutive cohort of 39 children diagnosed in our center as 46,XY DSD (aged 0.2-17.9 years). 32 were assigned male, 6 female, and 1 was a transgender boy. All patients underwent detailed clinical, hormonal and biochemical evaluation prior to genetic testing. A genetic cause explaining DSD phenotype was identified in 8 children. Pathogenic variants were detected in 3 patients, including variants in the AR and DHX37 genes. Likely pathogenic variants were found in 5 patients, affecting the AR and HSD17B3 genes. Variants of uncertain significance (VUSs) were identified in 7 patients, involving genes with well-established relevance to DSD- NR5A1, DHX37, AR, MAMLD1, SOS2andFAM111A. Although classified as VUSs these variants represent plausible contributors to the patients' phenotypes. In the remaining children, no variants currently known or suspected to be associated with 46,XY DSD were identified. The most common confirmed etiology in the cohort was androgen insensitivity syndrome (AIS). In addition, pathogenic variants in genes not linked to DSD were identified in 7 patients, demonstrating the broader clinical utility of WES. Our findings confirm that even a broad, high-throughput method such as WES fails to establish the molecular cause of 46,XY DSD in a substantial proportion of well-phenotyped patients, while at the same time enabling the identification of pathogenic variants in genes unrelated to DSD. We observed frequent genotype-phenotype discordance: similar clinical phenotypes could be associated with different genotypes, whereas the same gene variant could present with variable clinical expression. Re-analysis of WES data after 12-24 months should be considered in patients without a definitive diagnosis or in those who develop additional clinical features.

This study evaluates an educational intervention using a constructivist guidebook developed by the authors to teach human development and sex diversity within physiology education. Despite scientific advances, tertiary curricula often maintain binary, pathologizing views that overlook biological complexity. We implemented the BioQueer guidebook in a one-group pretest-posttest study with 44 undergraduate students from bachelor's and teacher-education tracks (Licenciate) degree. The intervention focused on the hormonal signaling, and differences of sex development (DSD) as natural physiological variations. Statistical analysis using Wilcoxon signed-rank tests revealed significant perceived learning across all five dimensions (P < 0.0001), with large effect sizes (r ≥ 0.64). Cumulative link models indicated that the material reduced disparities in physiological knowledge regardless of baseline levels, while cumulative learning patterns emerged regarding gender binarism. Bachelor's students showed higher odds of attaining top-tier post-test categories in specific domains. This approach fosters gender literacy without compromising scientific rigor, situating physiological processes within the broader context of natural variability. Promoting such inclusive frameworks is essential for training future professionals to interpret human biology with greater precision and social responsibility. Future longitudinal research is needed to assess the durability of these conceptual shifts in reproductive physiology education.

Noonan syndrome occurs in approximately 1/1,000-1/2,500 live births and is caused by defects in the Ras/mitogen-activated protein kinase pathway. Pubertal development includes syndrome-specific differences which may manifest as delayed puberty in both sexes, as well as cryptorchidism and impaired gonadal function, especially in the males. However gonadal dysgenesis and disorders of sex development have not been previously reported in the literature before. Our patient presented with ambiguous genitalia at two days of age. There was no consanguinity between the parents. On physical examination, the external masculinisation score was 4. Laboratory tests were compatible with gonadal dysgenesis. Echocardiography revealed pulmonary stenosis and a secundum atrial septal defect. Karyotype was 46 XY, SRY (+) and no pathogenic variant was detected in the targeted gene sequencing panel for disorders of sex development. A targeted next-generation seqeuencing (NGS) panel for Noonan syndrome was performed in the patient due to pulmonary stenosis and suggestive facial appearance, identifying a pathogenic c.136 T>G variant in the RIT1 gene. Noonan syndrome may cause gonadal dysfunction leading to delayed puberty and infertility; however, gonadal dysgenesis and ambiguous genitalia have not been previously reported. Noonan syndrome should be investigated in every patient with suggested clinical findings and affected gonadal functions.

Androgen receptor (AR) gene mutations are a common cause of 46, XY disorders of sex development (DSD), resulting in varying degrees of androgen insensitivity. This study aims to comprehensively evaluate the clinical features, hormone profiles, and AR gene variants of patients diagnosed with Androgen Insensitivity Syndrome (AIS), and to analyze the distribution of these variants across different functional domains. This retrospective, single-center study analyzed 16 cases of 46, XY DSD, all of whom were found to have AR variants from a single tertiary center in Turkey. Patients were evaluated based on their complaints, hormonal measurements, clinical features, and genetic diagnoses. Patients were classified as having Complete, Partial, or Mild AIS. The variants were categorized based on their location within the functional domains: The Ligand Binding Domain (LBD) and the N-terminal Domain (NTD). Patients were classified as having CAIS (8/16), PAIS (6/16), MAIS (1/16), and suspected diagnosis (1/16). The most common clinical finding was cryptorchidism (11/16). Ten different AR variants were detected: eight missense (p.Pro392Ser, p.Ala749Val, p.Val890Met, p.Asp733Asn, p.Arg856His, p.Arg856Cys, p.Glu494Ala, and p.Glu710Lys), one nonsense (p.Lys659Ter), and with p.Lys659Ter, p.Glu494Ala and being novel. A CAIS associated with p.Pro392Ser has been reported, and intrafamily variability has been documented in variants such as p.Arg856His and p.Pro392Ser. Most variants (10/16 patients) localized to the LBD. Individuals harboring LBD variants demonstrated lower external genital scores and shorter phallus lengths compared to those with NTD variants. T/DHT ratio was available in 11 patients and did not yield false-positive AIS diagnoses. Marked intrafamilial phenotypic variability was observed. This study expands the AR variant spectrum in AIS and represents one of the more comprehensively characterized cohorts from our country. While LBD variants were more often associated with severe phenotypes and NTD variants with milder presentations, marked phenotypic variability was observed. Nevertheless, considerable phenotypic variability, including marked intrafamilial heterogeneity, was evident. The T/DHT ratio provided supportive biochemical information but did not replace the need for molecular confirmation. Molecular confirmation remains essential, and multidisciplinary, patient-centered management is warranted.

Neuroendocrine basis of affective behavior: what we can learn from differences in sex development (DSD).

NR5A1 encodes a transcription factor essential for adrenal and gonadal development. Gene variants are a known cause of heterogeneous 46,XY disorders of sex development (DSD), but the mechanisms underlying the phenotypic variability remain unclear. We investigated how different NR5A1 variants affect downstream gene regulation and contribute to DSD pathogenesis. We analyzed four naturally occurring NR5A1 variants identified in patients with 46,XY DSD-two novel (p.Cys65Ser, p.His310Arg) and two previously reported (p.Cys30Ser, p.Gln329*). We performed protein and transcriptomic analyses to characterize variant effects and identify dysregulated and candidate target genes, validated by qPCR and luciferase assays. Transcriptomic and CUT&Tag analyses focused on the p.Gln329* truncating variant. All four variants occurred at conserved residues and resulted in reduced NR5A1 protein expression and impaired nuclear localization upon transfection in HEK293T cells. Transcriptomic analysis using the p.Gln329* variant revealed broad downregulation of genes involved in steroidogenesis, including CYP11A1, STAR, and CYP17A1. Notably, AMHR2 and STARD8 were significantly downregulated and showed reduced CUT&Tag signal in variant-transfected cells. Promoter assays confirmed that all variants diminished CYP11A1 and AMHR2 promoter activity. Only the p.Gln329* variant affected STARD8 promoter activity. These findings indicate that NR5A1 variants impair protein expression and localization, leading to transcriptional dysregulation of genes involved in steroid hormone biosynthesis and sexual development. Based on analysis of the p.Gln329* truncating variant, AMHR2 and STARD8 are strong candidate novel downstream targets of NR5A1, offering further insight into the mechanisms driving 46,XY DSD.

Genital surgery in children with differences of sex development (DSD): Strengths and concerns across diverging regulations in four European countries.

To develop and validate Disorders of Sexual Development (DSD) Interpreter, a point-of-care mobile application, to guide the management of infants with atypical genitalia. The DSD interpreter offers clinical guidance based on key clinical and diagnostic inputs. The retrospective validation involved comparing its guidance with that of two pediatric endocrinologists, a neonatologist, a pediatrician, and a pediatric trainee, against the final clinical diagnosis in 55 children with atypical genitalia (XX DSD in 21, XY DSD in 27, ovotesticular DSD in one, and DSD mimics in six). The concordance score (maximum score 153) for DSD interpreter (145; 94.8%) and pediatric endocrinologists (141; 92.2% and 135; 88.2%) were higher than that for the neonatologist (106; 69.3%), the pediatrician (98; 64.1%), and the trainee (59; 38.6%). Agreement analysis showed highest agreement for DSD interpreter (Cohen's κ 0.913, 95% confidence interval 0.825-0.978) and lowest for the trainee (Cohen's κ 0.131, 95% confidence interval 0.048-0.220). Discordance in the final diagnosis was noted in four cases for the DSD interpreter (7.3%). The diagnosis of CAH variants requiring urgent management was erroneous in four subjects for the neonatologist and the pediatrician and nine for the trainee. The DSD interpreter guidance could have prevented 92.7% of the discordance observed in the non-experts. These findings suggest the role of the DSD interpreter in the point-of-care evaluation of children with atypical genitalia across resource settings.

In May 2021, a German law was implemented to protect children with differences of sex development (DSD) from non-consensual genital surgery. In children and persons incapable of giving consent, exceptions can occur in emergencies or with the approval of the family court. To this end, a favourable opinion from an interdisciplinary DSD committee can be submitted to initiate file-based court proceedings. This study analysed the frequency of referrals post-legislation, alongside diagnoses and demographic information. A survey by the German Society for Paediatric and Adolescent Endocrinology and Diabetology identified centres with interdisciplinary committees. Data from these centres were analysed descriptively. Ten centres established interdisciplinary committees, evaluating 78 patients. The common karyotypes were 46,XX (36%) and 46,XY (55%), with other variations at 9%. The median age at initial presentation was 0.91 years, with most evaluations happening in surgical departments (80.8%). In 46,XX individuals, CAH due to 21-hydroxylase deficiency (21OHD) was predominant (93%), with a median Prader score of 4. In 46,XY individuals, phenotypic assessments mostly identified various levels of undervirilisation, mainly proximal hypospadias. This study highlights the significant impact of this legislation on clinical practice for DSD in Germany. Our results show that the majority of patients with DSD assessed by the interdisciplinary committee had a diagnosis of CAH or hypospadias. The composition of the interdisciplinary committee is prescribed by law, but the approach to counselling may vary depending on the discussions within the DSD committee. Open questions include reimbursement and evaluation criteria. In 2021, Germany introduced a law to protect children with a difference of sex development who are not yet able to give their own consent. We investigated how often specialist teams were asked by families to provide an opinion to facilitate surgery, and the changes in care that have resulted from the law. Most of the children had CAH or hypospadias.

ObjectiveTo describe individuals with differences in sex development presenting with a female phenotype and an absent uterus and identify specific diagnostic characteristics that improve diagnostic accuracy and optimize patient care.Materials and MethodsThis descriptive comparative study included retrospective and prospective clinical data collected between 2023 and 2025 at the Reproductive Medicine Center "Universe," Tbilisi, Georgia. Among 233 individuals evaluated for primary amenorrhea, 26% with a female phenotype and an absent uterus who were evaluated for Complete Androgen Insensitivity Syndrome, Mayer-Rokitansky-Küster-Hauser syndrome, and ovotesticular disorder of sex development were included in the final sample. All participants underwent clinical, hormonal, genetic, and imaging assessment. Laparoscopy and histomorphological examination were performed when indicated.ResultsMayer-Rokitansky-Küster-Hauser syndrome accounted for 57.4%, Complete Androgen Insensitivity Syndrome for 37.7%, and ovotesticular disorder of sex development for 4.9% of the cases. Complete Androgen Insensitivity Syndrome patients exhibited preserved breast development with absent or sparse pubic hair, whereas Mayer-Rokitansky-Küster-Hauser syndrome and ovotesticular disorder of sex development patients exhibited normal pubic hair and breast development. Vaginal length was shortest in patients with Mayer-Rokitansky-Küster-Hauser, intermediate in those with complete androgen insensitivity syndrome, and variable in patients with ovotesticular disorder of sex development. Complete Androgen Insensitivity syndrome patients demonstrated male-range testosterone levels; Mayer-Rokitansky-Küster-Hauser patients exhibited female-range hormone profiles, and ovotesticular disorder of sex development patients were observed to have nonspecific endocrine patterns. Ovotesticular disorder of sex development was confirmed histomorphologically.ConclusionAn integrated diagnostic approach combining specific clinical features, hormonal profiles, imaging, karyotyping, and histomorphology enables accurate differentiation of Mayer-Rokitansky-Küster-Hauser, complete androgen insensitivity syndrome, and ovotesticular disorder of sex development.

WWOX Exon 4 Copy Number Gain in Dogs With Testicular or Ovotesticular XX (SRY-Negative) Disorder of Sex Development.

Middle Childhood Morbidity in Children Born Preterm: A Canadian Cohort Study.

Growth patterns and optimal methods for predicting finale height in individuals with 45,X/46,XY mosaicism remain insufficiently characterized. To assess growth patterns and bone maturations in children with 45,X/46,XY mosaicism and to optimize final height prediction. Multicenter retrospective registry-based cohort study. Twenty-six participating centers contributing data. Ninety-five cases of 45,X/46,XY mosaicism were include. Longitudinal growth data were available for 54 participants and stratified by external genitalia score (EGS): group 1 (EGS 0-4) and group 2 (EGS 4.5-12). Growth and bone maturation were evaluated based on male and female references. Growth hormone (GH) treatment outcomes were analyzed. Mean height SD score (SDS), bone age assessed centrally using the Greulich and Pyle, predicted adult height (PAH), target height (TH) and near-final height (nFH). Mean nFH was 157.5 cm in Group 1 and 160.3 cm in Group 2 (n.s.). Growth aligned more closely with female reference curves, with nFH at -0.7 SDS (Group 1) and -0.3 SDS (Group 2) on female charts, and -2.0 and -1.6 SDS on male charts. Bone age was delayed using female standards and advanced using male standards. Female-based PAH slightly underestimated nFH, whereas male-based PAH slightly overestimated it. PAH approximated nFH more accurately than TH. nFH was similar in those who did and did not receive GH treatment, although interpretation was limited by small sample size and treatment bias. Female growth charts and bone age readings best reflect longitudinal growth and maturation in individuals with 45,X/46,XY DSD and provide the most accurate prediction of nFH. Larger prospective studies are needed to guide evidence-based treatment decisions.

A Familial X-Linked Disorder of Sexual Development in Thoroughbred Horses Associated With a Novel Androgen Receptor Splice-Site Variant.

Penile anthropometry of healthy boys in Qatar.

Quality of life and gender identity in females with congenital adrenal hyperplasia after genital restoration surgery: A single-center experience.

This study characterizes disorders of sex development (DSD) in 60 Sudanese patients recruited from Khartoum (2021 - 2022), revealing a high rate of late presentation (63.3% post-puberty), consanguinity, and female genital mutilation (FGM) in 75% of cases with genotype - phenotype discordance. Karyotyping showed 61.7% had a 46,XY karyotype and 31.7% a 46,XX karyotype, with 33.3% exhibiting discordance between chromosomal sex and sex of rearing. SRY gene analysis by PCR was negative in 10% of patients, and Sanger sequencing in a subset of 46,XY individuals identified five novel SRY mutations in seven patients. The findings underscore the influence of sociocultural practices such as female genital mutilation, and consanguinity on the expression and management of disorders of sex development in Sudan. The study offers critical insights from an underrepresented African population and addressing a gap in global literature on disorders of sex development.

Ovotesticular disorders of sex development (DSD) are variations in sex development characterized by the presence of both ovarian and testicular parenchyma in the same individual, with histopathologic confirmation being mandatory for accurate diagnosis. FOXL2, a transcription factor involved in ovarian differentiation and maintenance, has emerged as a potential immunohistochemical marker for ovarian tissue. However, its diagnostic utility in pediatric DSD patients, particularly in identifying ovotesticular cords (OVTCs), remains underexplored. This study aims to evaluate the immunohistochemical expression of FOXL2 in gonadal tissues of patients with ovotesticular DSD and gonadal dysgenesis to determine its value in identifying ovotesticular cords (OVTCs) and support the diagnosis of ovotestis. A retrospective histopathological analysis was conducted on 19 gonadal specimens from 14 pediatric patients diagnosed with ovotesticular DSD or gonadal dysgenesis. Cases were retrieved from the surgical pathology archives of the University of Pittsburgh Medical Center - Children's Hospital of Pittsburgh and the consultation files of Miguel Reyes-Múgica. Formalin-fixed, paraffin-embedded tissue sections underwent hematoxylin and eosin staining and immunohistochemical analysis for FOXL2 and additional gonadal markers. FOXL2 expression was assessed for nuclear localization, and distribution within stromal and cordal compartments, with staining intensity semi-quantitatively scored as 0 (no positive cells), 1+ (few-to-moderate, < 50%), or 2+ (numerous, ≥ 50%). Among the 19 gonads examined, histologic diagnoses included 4 ovaries, 11 ovotestes (among which 3 were classified as bipolar ovotestis, 2 as streak-type ovotestis), and 4 dysgenetic testes, and streak gonads. FOXL2 showed strong and diffuse nuclear expression in ovarian stroma and was consistently positive in ovotestes, including focal intracordal staining within OVTCs, even in gonads with predominantly testicular histology. Of the 12 gonads with ovotesticular DSD (including 11 ovotestes and 1 ovary with OVTCs), 11 (92%) demonstrated FOXL2 expression in testicular components. All gonads classified as ovaries were FOXL2-positive, while dysgenetic testes lacking histologic evidence of ovarian differentiation were either negative or showed only rare positive stromal cells without intracordal expression. FOXL2 staining correlated with histologic and clinical findings, confirming its value in identifying ovarian differentiation and supporting the diagnosis of ovotesticular DSD. FOXL2 immunohistochemistry is a reliable marker of ovarian differentiation and can aid in the diagnosis of ovotesticular DSD. Its expression in ovarian stroma and OVTCs enhances the histological evaluation of ambiguous gonads and supports its routine use in the diagnostic workup of pediatric DSD patients.