Signs Of Virilization Research Articles

SUN-005 Hirsutism Due to Bilateral Leydig Cell Tumors

Severe hyperandrogenism in post-menopausal women is rare. It may be caused by either benign or malignant neoplasms of the adrenal or ovary. We report a rare case of a post-menopausal woman with hirsutism associated with virilization due to Leydig cell tumors (LCT) of both ovaries. Case report 61 yo female presented for evaluation of hirsutism. She had also been experiencing increased facial hair growth, deepening of voice, clitoromegaly, alopecia, and acne. Physical examination: normal vital signs. Patient had signs of virilization, including coarse hair along her upper lip, chin, lower abdomen and inner thigh with Ferriman-Gallwey score of 8, acne, and clitoromegaly. She had no signs of acanthosis nigricans or Cushing syndrome. Base line labs: Hemoglobin 16.2 gm/dL (ref 12.0 to 15.5), total testosterone 803 ng/dL (ref 3–41), free testosterone 20.2 pg/mL (ref 0.0–4.2), estradiol 77 pg/mL (<6.0−54.7), estrone 148 pg/mL (ref 7–40), FSH 11.5 mIU/mL (ref 25.8 - 134.8), LH 6.90 mIU/mL (ref 7.7 - 58.5), androstenedione 28 ng/dL (ref 17–99), DHEAS 99.9 mcg/dL (ref 19–205), dehydroepiandrosterone 512 ng/dL (ref 31–701), inhibin A 2.3 pg/mL (ref <5), inhibin B <7.0 pg/mL (ref 00-16.9), 17-alpha hydroxyprogesterone 187 ng/dl (ref <51). Her other serum markers such as anti -Mullerian hormone, alpha-fetoprotein, and hCG were normal. A CT scan of adrenals: normal. Similarly a transvaginal US did not show any ovarian pathology, however MRI of the pelvis showed homogeneous ovarian enhancement bilaterally and based on this information a diagnosis of ovarian hyperthecosis was considered and patient underwent laparoscopic bilateral oophorectomy. Pathology confirmed: LCT in both ovaries. Laboratory values performed 3 months later showed the following values: hemoglobin 14.2 gm/dL, total testosterone 13 ng/dL, free testosterone 1.4 pg/mL, LH 124 mIU/mL, FSH 99mIU/mL, estradiol <5.0 pg/mL. In 6 months she had significant improvement in hirsutism and virilization. Discussion Hyperandrogenism, especially serum testosterone in the male range with rapidly progressive hirsutism or virilization signs in a female indicates tumor etiology. Androgen-secreting ovarian tumors are usually small and often embedded in the ovary. Transvaginal US is useful in the diagnosis of ovarian tumors. However, in our case, transvaginal US failed while MRI scan showed bilaterally enlarged ovaries and with this information patient underwent bilateral oophorectomy. Although 5 cases of bilateral LCT are reported in the literature, LCT is unilateral 95% of the time, the pathogenesis of Leydig cell proliferation and LCT is unclear. In conclusion, androgen secreting tumors should be considered in women (especially in post-menopausal state) with hyperandrogenism and hirsutism. In fact, diffuse stromal Leydig cell hyperplasia and small Leydig cell tumors may be missed on imaging and in some cases only pathology can confirm the result.

MON-004 Ovarian Steroid Cell Tumor, Not Otherwise Specified (NOS): A Case Report and Clinical Review

Background: Ovarian tumors are divided into non functioning and functioning, within the last group, we can find those with endocrine activity that produce androgenization. Ovarian cell tumors, not otherwise specified (SCT-NOS) is a rare type of ovarian sex cordomal tumor and represents the 60% of this tumors, which compromise less than 0.1% of the ovarian tumors. (1) Clinical Case: We here present a 28 year old woman who was referred to the Endocrine Clinic due to secondary amenorrhea and virilization signs. At the age of twelve a diagnosis of polycystic ovarian syndrome (POS) was made and treated with combined oral anticonceptive (COA). Menses became regular only with medication. Six months after she stopped medication, amenorrhea and virilization signs worsened. Biochemically she had levels of serum total testosterone 6.8 ng/mL (0.02-0.45) and free testosterone 42 pg/mL (0.1-6.4) since only pelvic ultrasonography has been made by physician, a transvaginal ultrasound and abdomen – pelvic CT scan showed a anexial tumor. After analysis of biochemical and imaging results a multidisciplinary team performed a surgical extirpation of the primary lesion, which was diagnosed by histopathology as a tumor of lipoidic cells NOS. A month after the surgery, menses became regular. Conclusion: The purpose of this article is to present the available information about this kind of tumors and the treatment recommended. It is mandatory to follow a correct approach among a multidisciplinary team, in order to get the correct diagnosis at the proper time.(1) Zang L, Ye M, Yang G, Li J, Liu M, Du J et al. Accessory ovarian steroid cell tumor producing testosterone and cortisol. Medicine. 2017;96(37):e7998.

Review of Topical Therapies for Beard Enhancement

Beards and facial hair are part of males. It may be a sign of masculinity and attraction. Topical therapy for beard enhancement may be desired by some men to improve beard growth and density. A review of all reports on topical treatment options for beard enhancement is presented here. Reports on topical treatment for beard enhancement were searched using The United States National Library of Medicine PubMed, exploring all titles containing beard, facial hair or mustache as of July 22 2020. A total of 445 articles resulted from the search after reviewing the publications for potential relation to beard enhancement. Three studies match the aim of the review regarding topical therapy for beard enhancement in men. Two of which were double-blind clinical trials and one was a case report. Topical 3 % minoxidil, as studied by Ingprasert et al., showed a significant increase in hair count, photographic scoring and patient self-assessment. Saeedi et al. studied the use of 2.5 % testosterone gel for men with thalassemia major with an increase in terminal hair. Vestita et al. published a case report demonstrating unexpected improvement of beard density for a patient using tretinoin 0.05 % cream. Only limited evidence could be presented on topical treatments for beard enhancement. Topical minoxidil is an off-label treatment to enhance the beard. Other topical options such as testosterone, tretinoin, bimatoprost could constitute potential treatment options. Further studies needed to recommend the best topical options for men who desire to enhance their beards.

Central Precocious Puberty in two Boys with Prader-Willi Syndrome on Growth Hormone Treatment

Prader-Willi syndrome (PWS) is a rare genetic neuroendocrine disorder characterized by hypotonia, obesity, short stature, and mental retardation. Incomplete or delayed pubertal development as well as premature adrenarche are usually found in PWS, whereas central precocious puberty is rarely seen. This study reports the clinical, biochemical, and histologic findings in 2 boys with PWS who developed central precocious puberty. Both boys were started on growth hormone therapy during the first years of life according to the PWS indication. They had both bilateral cryptorchidism at birth and had orchidopexy in early childhood. Retrospective histologic analysis of testicular biopsies demonstrated largely normal tissue architecture and germ cell maturation, but severely decreased number of prespermatogonia in one of the patients. Both boys had premature adrenarche around the age of 6. Precocious puberty was diagnosed in both boys with enlargement of testicular volume (>3 mL), signs of virilization and a pubertal response to a gonadotropin-releasing hormone (GnRH) test and they were both treated with GnRH analog. The cases described here displayed typical characteristics for PWS, a considerable heterogeneity of the hypothalamic-pituitary function, as well as testicular histology. Central precocious puberty is extremely rare in PWS boys, but growth hormone treatment may play a role in the pubertal timing.

Oxandrolone for growth hormone-treated girls aged up to 18 years with Turner syndrome.

The final adult height of untreated girls aged up to 18 years with Turner syndrome (TS) is approximately 20 cm shorter compared with healthy females. Treatment with growth hormone (GH) increases the adult height of people with TS. The effects of adding the androgen, oxandrolone, in addition to GH are unclear. Therefore, we conducted this systematic review to investigate the benefits and harms of oxandrolone as an adjuvant therapy for people with TS treated with GH. To assess the effects of oxandrolone on growth hormone-treated girls aged up to 18 years with Turner syndrome. We searched CENTRAL, MEDLINE, Embase, the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was October 2018. We applied no language restrictions. We included randomised controlled clinical trials (RCTs) that enrolled girls aged up to 18 years with TS who were treated with GH and oxandrolone compared with GH only treatment. Three review authors independently screened titles and abstracts for relevance, selected trials, extracted data and assessed risk of bias. We resolved disagreements by consensus, or by consultation with a fourth review author. We assessed trials for overall certainty of the evidence using the GRADE instrument. We included six trials with 498 participants with TS, 267 participants were randomised to oxandrolone plus GH treatment and 231 participants were randomised to GH only treatment. The individual trial sample size ranged between 22 and 133 participants. The included trials were conducted in 65 different paediatric endocrinology healthcare facilities including clinics, centres, hospitals and academia in the USA and Europe. The duration of interventions ranged between 3 and 7.6 years. The mean age of participants at start of therapy ranged from 9 to 12 years. Overall, we judged only one trial at low risk of bias in all domains and another trial at high risk of bias in most domains. We downgraded the level of evidence mainly because of imprecision (low number of trials, low number of participants or both). Comparing oxandrolone plus GH with GH only for final adult height showed a mean difference (MD) of 2.7 cm in favour of oxandrolone plus GH treatment (95% confidence interval (CI) 1.3 to 4.1; P < 0.001; 5 trials, 270 participants; moderate-quality evidence). The 95% prediction interval ranged between 0.3 cm and 5.1 cm. For adverse events, we based our main analysis on reliable date from two trials with overall low risk of bias. There was no evidence of a difference between oxandrolone plus GH and GH for adverse events (RR 1.81, 95% CI 0.83 to 3.96; P = 0.14; 2 trials, 170 participants; low-quality evidence). Six out of 86 (18.6%) participants receiving oxandrolone plus GH compared with 8/84 (9.5%) participants receiving GH only reported adverse events, mainly signs of virilisation (e.g. deepening of the voice). One trial each investigated the effects of treatments on speech (voice frequency; 88 participants), cognition (51 participants) and psychological status (106 participants). The overall results for these comparisons were inconclusive (very low-quality evidence). No trial reported on health-related quality of life or all-cause mortality. Addition of oxandrolone to the GH therapy led to a modest increase in the final adult height of girls aged up to 18 years with TS. Adverse effects identified included virilising effects such as deepening of the voice, but reporting was inadequate in some trials.

Oestrogen versus androgen in hormone-replacement therapy for complete androgen insensitivity syndrome: a multicentre, randomised, double-dummy, double-blind crossover trial

Summary Background Women with complete androgen insensitivity syndrome (CAIS) after gonadectomy have complained about reduced psychological wellbeing and sexual satisfaction. The aim of this study was to compare the effectiveness of hormone-replacement therapy with either androgen or oestrogen in women with 46,XY karyotype and CAIS after gonadectomy. Methods This national, multicentre, double-blind, randomised crossover trial was performed at three university medical centres and three specialised treatment institutions in Germany. Eligible participants were women aged 18–54 years with 46,XY karyotype, genetically diagnosed CAIS, and removed gonads. Participants were randomly assigned (14:12) by a central computer-based minimisation method to either oestradiol 1·5 mg/day for 6 months followed by crossover to testosterone 50 mg/day for 6 months (sequence A) or to testosterone 50 mg/day for 6 months followed by crossover to oestradiol 1·5 mg/day for 6 months (sequence B). Participants also received oestradiol or testosterone dummy to avoid identification of the active substance. All participants received oestradiol 1·5 mg/day during a 2 months' run-in phase. The primary outcome was mental health-related quality of life, as measured with the standardised German version of the SF-36 questionnaire. Secondary outcomes were psychological wellbeing, as measured with the Brief Symptom Inventory (BSI), sexual function, as measured with the Female Sexual Function Index (FSFI), and somatic effects, such as signs of virilisation and effects on metabolic blood values. The primary analysis included all patients who were available at least until visit 5, even if protocol violations occurred. The safety analysis included all patients who received at least oestradiol during the run-in phase. This trial is registered with the German Clinical Trials Register, number DRK3136, and with the European Clinical Trials Database, number 2010-021790-37. Findings We enrolled 26 patients into the study, with the first patient enrolled on Nov 7, 2011, and the last patient leaving the study on Jan 23, 2016. 14 patients were assigned to sequence A and 12 were assigned to sequence B. Ten participants were withdrawn from the study, two of whom attended at least five visits and so could be included in the primary analysis. Mental health-related quality of life did not differ between treatment groups (linear mixed model, p=0·794), nor did BSI scores for psychological wellbeing (global severity index, p=0·638; positive symptom distress index, p=0·378; positive symptom total, p=0·570). For the FSFI, testosterone was superior to oestradiol only in improving sexual desire (linear mixed model, p=0·018). No virilisation was observed, and gonadotrophin concentrations remained stable in both treatment groups. Oestradiol and testosterone concentrations changed substantially during the study in both treatment groups. 28 adverse events were reported for patients receiving oestradiol (23 grade 1 and five grade 2), and 38 adverse events were reported for patients receiving testosterone (34 grade 1, three grade 2, and one grade 3). One serious adverse event (fibrous mastopathy) and 20 adverse events (16 grade 1 and four grade 2) were reported during the run-in phase, and 12 adverse events during follow-up (nine grade 1 and three grade 2). Interpretation Testosterone was well tolerated and as safe as oestrogen for hormone-replacement therapy. Testosterone can be an alternative hormone substitution in CAIS, especially for woment with reduced sexual functioning. Funding German Federal Ministry of Education and Research.

Gradual, temperature-induced change of secondary sexual characteristics in Trichogramma pretiosum infected with parthenogenesis-inducing Wolbachia.

Intersex is an intermediate stage of sexual differentiation in insects. Determining intersex morphology and the cause of its production will aid in the understanding of the mechanism of sexual differentiation in insects. In this paper, Wolbachia-infected Trichogramma pretiosum (T. preW+) that shows thelytokous parthenogenesis were used as subjects. In order to determine the causes of the T. preW+ intersex and the influence of parental generation temperature on gradual changes in secondary masculinization in intersex offspring, we examined the occurrence of intersex offspring (F1 and F2 generation) after the parental generations were treated with high temperature (27, 29, 31, and 33 °C) and described the external morphology of the intersexes. The results showed that the T. preW+ parental generation temperature is positively correlated with the probability of intersex offspring. The probability of F1 intersex is significantly higher than that of F2 intersex in different high temperature. The degree of secondary masculinization in T. preW+ intersexes increases as parental generation temperature increases. In addition, our study first identified 11 intersex types in T. preW+ and found that the primary and secondary sexual characteristics showed a regular distribution. We also found that the D type and H type of intersex have the highest frequency of appearance. The external genitalia of most intersexes were female, and only three intersex types have male external genitalia. Conclusions were ultimately obtained: Wolbachia is a direct factor that causes the occurrence of intersexes, while high temperature is an indirect factor that determines the external morphology of intersexes. The effects of high temperature on T. preW+ intersexes is passed through the parental generation to offspring, and this maternal effect weakens as the number of generations increases. In T. preW+ intersex individuals, most exhibit female primary sexual characteristics, and secondary sexual characteristics exhibit signs of masculinization.

Clinical features and genetic characteristics of 33 patients with simple virilizing form of 21-hydroxylase deficiency

Objective: To analyze the clinical features and genotypes of adult patients with simple virilizing form of 21-hydroxylase deficiency (SV 21-OHD). Methods: This is a retrospective study including 33 patients with SV 21-OHD from January 2015 to March 2018 in the Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine. Results: The diagnostic age of the patients was (26.3±6.5) years old. All patients presented with signs of masculinization, such as short stature (100%), clitoromegaly/microphallus (89.65%, 26/29), undeveloped breasts (82.76%, 24/29), deep voice (55.17%,16/29) and primary amenorrhea (89.65%, 26/29). The serum levels of 17-hydroxyprogesterone (17-OHP), androstenedione (AD) and testosterone were significantly elevated in 90.9%, 93.9% and 91.2% of the patients, respectively. Thirteen types of mutations were identified in CYP21A2 from these patients. Among them, I173N accounted for 40% and I2 G accounted for 18.33%. Four patients were found with multiple mutations in CYP21A2. Conclusions: Short stature, clitoromegaly/microphallus and primary amenorrhea are the most common clinical features in adult patients with SV 21-OHD. Serum levels of 17-OHP and AD are important indices for the diagnosis and monitoring of the patients. I173N and I2 G are the two most prevalent mutations in patients of the present study. Limitation of clinical recognition and delay in treatment contribute to the short stature of the SV 21-OHD patients.

Androgen-secreting adrenal tumor with hypertension and lack of virilization signs: A clinical case

Androgen-secreting adrenal tumor with hypertension and lack of virilization signs: A clinical case

SAT-289 An Unusual Virilizing Ovarian Tumor in Adolescence

Background: The etiology of hyperandrogenism in adolescent females includes polycystic ovarian syndrome, non-classical congenital adrenal hyperplasia (CAH), Cushing’s syndrome, androgen-secreting tumors (adrenal or ovarian) or exogenous use. Ovarian tumors producing androgens comprise <5% of all ovarian neoplasms and usually originate from sex cord stromal cells. There are sporadic case reports of mature cystic teratomas (MCTs), a type of germ cell tumor, causing hyperandrogenism in women but only two reported cases of virilizing MCTs in adolescent girls (1, 2). We present a third case of this nature. Case presentation: A 17-year old girl with no past medical history presented with worsening abdominal distension and discomfort. She was also noted to have excessive thick facial hair which she stated had been present throughout adolescence. She reported recent irregularity in her menstrual periods. She had no history genital abnormalities at birth or premature adrenarche, thelarche or menarche. She denied using anabolic steroids or other medications. Family history was negative for CAH or sudden infant death. On examination, there was significant abdominal distension, terminal hair over the chin, upper lip, side-burns and abdomen, as well as severe clitoromegaly with prominent glans measuring 3cm x 1.5cm, but no evidence of acanthosis nigricans. Chemistry showed testosterone of 178.3 ng/dL (3.75 - 49.57 ng/dL), DHEA-S of 550.4 mcg/dL (150.0 - 590.0 mcg/dL) and 17-hydroxyprogesterone of 224.7 ng/dL (26 - 325 ng/dL). Her abdomino-pelvic ultrasound and CT scan showed a 35.5 cm cystic mass with focal fatty components and dystrophic calcifications suggestive of MCT. Adrenal glands were normal. The patient underwent an exploratory laparotomy with left salpingo-oopherectomy and right cystectomy. Preliminary pathology results showed bilateral MCTs. Two weeks post-operatively, testosterone level decreased to 32.5 ng/dL. Conclusion: Given the normalization of testosterone after surgery, the bilateral MCTs are the suspected source of the patient’s androgen excess. MCTs are the most common ovarian neoplasm in adolescent females, but they are an exceedingly rare cause of hyperandrogenemia. They can be slow-growing and local manifestations may not present until years later. However, testosterone-secreting MCTs may be brought to a physician’s attention due to signs of virilization. A multidisciplinary approach with primary care physicians, endocrinologists, gynecologists and pathologists is needed to make an accurate diagnosis in a timely manner.

Acne in childhood

Abstract Acne is a common, chronic inflammatory disease of the skin. While it is primarily a skin disorder of adolescence, acne also occurs, less commonly, in children who have not yet reached puberty. This specific group of acne patients can be categorised into four categories, based on the time of onset; neonatal, infantile, mid-childhood and pre-pubertal acne. The presentation of acne in this younger population may be associated with systemic pathologies different from those in adolescent acne. Clinical assessment should focus on securing symptoms and signs of virilisation and early referral to a paediatric endocrinologist should be considered if these are identified. Treatment regimens should be adopted such that they target the underlying pathophysiology of acne as well as the presenting clinical lesions. Antibiotics should be used judiciously to avoid the emergence of antibiotic resistant bacteria as this can impact on treatment response and may also contribute to resistance in commensal bacteria beyond the skin.

Oestrogen versus androgen in hormone-replacement therapy for complete androgen insensitivity syndrome: a multicentre, randomised, double-dummy, double-blind crossover trial

Women with complete androgen insensitivity syndrome (CAIS) after gonadectomy have complained about reduced psychological wellbeing and sexual satisfaction. The aim of this study was to compare the effectiveness of hormone-replacement therapy with either androgen or oestrogen in women with 46,XY karyotype and CAIS after gonadectomy. This national, multicentre, double-blind, randomised crossover trial was performed at three university medical centres and three specialised treatment institutions in Germany. Eligible participants were women aged 18-54 years with 46,XY karyotype, genetically diagnosed CAIS, and removed gonads. Participants were randomly assigned (14:12) by a central computer-based minimisation method to either oestradiol 1·5 mg/day for 6 months followed by crossover to testosterone 50 mg/day for 6 months (sequence A) or to testosterone 50 mg/day for 6 months followed by crossover to oestradiol 1·5 mg/day for 6 months (sequence B). Participants also received oestradiol or testosterone dummy to avoid identification of the active substance. All participants received oestradiol 1·5 mg/day during a 2 months' run-in phase. The primary outcome was mental health-related quality of life, as measured with the standardised German version of the SF-36 questionnaire. Secondary outcomes were psychological wellbeing, as measured with the Brief Symptom Inventory (BSI), sexual function, as measured with the Female Sexual Function Index (FSFI), and somatic effects, such as signs of virilisation and effects on metabolic blood values. The primary analysis included all patients who were available at least until visit 5, even if protocol violations occurred. The safety analysis included all patients who received at least oestradiol during the run-in phase. This trial is registered with the German Clinical Trials Register, number DRKS00003136, and with the European Clinical Trials Database, number 2010-021790-37. We enrolled 26 patients into the study, with the first patient enrolled on Nov 7, 2011, and the last patient leaving the study on Jan 23, 2016. 14 patients were assigned to sequence A and 12 were assigned to sequence B. Ten participants were withdrawn from the study, two of whom attended at least five visits and so could be included in the primary analysis. Mental health-related quality of life did not differ between treatment groups (linear mixed model, p=0·794), nor did BSI scores for psychological wellbeing (global severity index, p=0·638; positive symptom distress index, p=0·378; positive symptom total, p=0·570). For the FSFI, testosterone was superior to oestradiol only in improving sexual desire (linear mixed model, p=0·018). No virilisation was observed, and gonadotrophin concentrations remained stable in both treatment groups. Oestradiol and testosterone concentrations changed substantially during the study in both treatment groups. 28 adverse events were reported for patients receiving oestradiol (23 grade 1 and five grade 2), and 38 adverse events were reported for patients receiving testosterone (34 grade 1, three grade 2, and one grade 3). One serious adverse event (fibrous mastopathy) and 20 adverse events (16 grade 1 and four grade 2) were reported during the run-in phase, and 12 adverse events during follow-up (nine grade 1 and three grade 2). Testosterone was well tolerated and as safe as oestrogen for hormone-replacement therapy. Testosterone can be an alternative hormone substitution in CAIS, especially for woment with reduced sexual functioning. German Federal Ministry of Education and Research.

A case of postmenopausal ovarian hyperandrogenemia diagnosed only by selective catheterization of ovarian vein

Hyperandrogenemia in a postmenopausal woman is usually related to a tumor in either ovaries or adrenal glands. To differentiate between these two endocrine organs is a diagnostic challenge when the tumor size is too small to be detected with the aid of usual imaging modalities. 54 years-old postmenopausal woman with signs of virilization was referred to our institution with serum total testosteron levels of 294 ng/dl. Contrast-enhanced computed tomography (CT) revealed a lesion consistent with the tumor 1 cm in diameter in the adrenal gland and magnetic resonance imaging (MRI) could not confirm this finding. The location of androgen hypersecretion could only be determined after selective venous catheterization and hormonal sampling of both adrenal and ovarian veins. The right ovarian venous total testosterone level was found as &gt; 1009.40 ng / dl. A right-sided ovarian Leydig cell tumor was diagnosed in the specimen of laparoscopic hysterectomy and bilateral salpingo-oopherectomy. This case report underlines the importance to carry on the search with the selective venous catheterisation and hormonal sampling from both the ovarian and the adrenal veins when there is difficulty to demonstrate the true source of androgen hypersecretion in a postmenopausal woman.

'Men just drink more than women. Women have friends to talk to'-Gendered understandings of depression among healthcare professionals and their implications.

Little is known about how gendered understandings of patients can inform professionals' discretionary actions and decisions to include or exclude in clinical practice. Using Connell's poststructuralist perspectives on gender as an analytic framework, this article aims to investigate how professionals' articulations of depression are framed by signs of masculinity and femininity, and how these articulations inform service provision to patients with depression in clinical psychiatry. Building on interview data drawn from an ethnographic study, the article shows how the professionals' articulations reflected a gender binary that framed how the feminized patients were often connected to psychiatric care while masculinized patients were referred to separate alcohol or substance use treatment outside the psychiatric institution. The article discusses the societal and institutional conditionality of gendered understandings in psychiatry. In spite of several limitations, the article elucidates how professionals' understandings might have wide-ranging implications for the accuracy of epidemiological research and policy, and how they reflect a power struggle between patients and professionals about the legitimate right to interpret patients' conditions and efforts to manage their illness-related problems.

Scrotal Hair in Infancy: Outcome Verification of an Isolated Condition Needing Minimal Assessment

Rarely, infant boys present with a few, pigmented scrotal hairs and often laboratory assessment is done. This report aims to ascertain any possible pathology of this condition by providing outcome data for 8 patients. This report reviews the clinical history of eight male infants, who initially presented with scrotal hair growth without other signs of virilization. Follow-up documented no progression or recurrence or evidence of androgen excess among 4 of the 8 patients beyond infancy and 4 patients beyond the age of puberty. Only one did not show regression of pubic hair during infancy, but persistence to age 7 when hormone levels were shown to be normal. Hence, these data, plus a summary of the published literature that confirms that this finding, without other evidence of androgen excess, is benign and self-limited and does not require laboratory assessment, but only clinical follow-up.

Grading of hirsutism based on the Ferriman-Gallwey scoring system in Kosovar women.

IntroductionHirsutism is defined as excess terminal hair that commonly appears in a male pattern in women.AimTo examine severity and distribution of hirsutism with Ferriman-Gallwey visual scoring system in hirsute women in Kosovo.Material and methodsThis prospective study included 160 women, 135 with hirsutism and 25 as a control group. The Ferriman-Gallwey score is used to evaluate hirsutism. The examiner scored the subjects on a scale of 0–4 for terminal hair growth on eleven different body areas according to the Ferriman-Gallwey scoring system. An Ferriman-Gallwey score of 8 or more was considered diagnostic of hirsutism. A thorough physical examination with specific emphasis on signs of virilization (including frontal baldness, loss of female body contours, increased muscularity, acne, clitoromegaly, and atrophy of breast) was done in all patients.ResultsThe positive family history of hirsutism was present in 63.7%. In 51.1% of women with hirsutism, the menstrual cycle was regular, 25.2% had oligomenorrhea, 13.3% amenorrhea, 7.4% dysmenorrhea, 1.5% polymenorrhea and 1.5% oligomenorrhea and dysmenorrhea. The age group with the highest scoring comprised women under 20 years and 20–29 years group with an average value of 23.9 and 24.8, respectively. In our study population, 40% of the patients had an Ferriman-Gallwey score of 3 for the upper lip and 47% of patients had an Ferriman-Gallwey score of 3 for the chin.ConclusionsThe Ferriman-Gallwey scoring system has a great significance and value to establish the diagnosis of hirsutism and is an acceptable screening method.

Adrenocortical carcinoma characterized by gynecomastia: A case report.

.We present a 4-yr-old boy with adrenocortical carcinoma (ACC), diagnosed due to the appearance of gynecomastia as the presenting symptom. Six months prior to admission, an acute growth spurt along with the development of bilateral breast swelling was observed. He did not present any features of virilization, including enlargement of the testes, increase in testis volume, and penis size. Laboratory investigations showed gonadotropin-independent hypergonadism, with low LH/ FSH levels and elevated estradiol/testosterone levels. Abdominal computed tomography revealed a large heterogeneous mass adjacent to the right kidney and below the liver. Pathological investigations of the biopsy specimen demonstrated that the tumor was an ACC. Pre- and post-operative combination chemotherapy with mitotane was administered and surgical resection was carried out. Post-surgery, the elevated estradiol/testosterone concentrations reverted to within the reference range. Urinary steroid profile and tissue concentration analysis of estradiol and testosterone indicated the presence of estrogen in the ACC tissue. An investigation for TP53 gene aberrations revealed the presence of a germline point mutation in exon 4 (c.215C>G (p.Pro72Arg)). In ACC, the most common symptom is virilization, and feminization, characterized by gynecomastia, is very rare. However, a diagnostic possibility of ACC should be considered when we encounter patients who have developed gynecomastia without the influence of causative factors such as obesity or puberty, and do not present with the typical signs of virilization.

Sertoli-Leydig Cell Tumor of the Ovary in a Postmenopausal Woman

Sertoli-Leydig cell tumor of the ovary represents less than 0.5% of all ovary neoplasms. It is a tumor that affects predominantly young woman, who most of the times associate signs of virilization. It has recently been associated with mutations in DICER1. In this report, we describe a case of Sertoli-Leydig cell tumor in an asymptomatic 61- year-oldwoman who underwent a laparoscopic bilateral anexectomy for a heterogenous cystic lesion found in her left ovary. The microscopic examination of the lesion, showed a solid-cystic tumoral proliferation in the region identified as ovarian hilum, formed by two distinct and intermixed cell populations (Leydig cells and Sertoli cells). The prognosis of this kind of tumor is usually good, unless it shows poor differentiation and/or heterologous elements or retiforme pattern. So, the recommended treatment of these tumors, is a conservative approach. In our case, the anexectomy was performed by expressed desire of the patient.

Patriotism, sentiment, and male hysteria: Putin’s masculinity politics and the persecution of non-heterosexual Russians

ABSTRACTA contributing factor to the current persecution of Russian non-heterosexual individuals is Vladimir Putin’s overcompensating masculinist wish to claim Russia’s role as a global powerhouse. While most scholars tend to define Putin’s performance of masculinity as a confident and charismatic leader, a James Bond type of a super hero action man, such dazzling façade of (hyper)masculine bravado belies deep anxieties and vulnerabilities resulting in political overcompensation. The discourse analysis of the speech acts in two of Putin’s public national addresses – the 1999 Millennium Manifesto and the 2013 Valdai Address – uncovers the signs of masculinity in crisis, or, as Pussy Riot has put it, ‘male hysteria’. Putin’s visions of Russian national identity and the use of emotional rhetoric visible in his ‘paternalistically sentimental’ statements helped justify discriminatory antigay legislation. Borrowing from Ahmed, non-heterosexual Russians have become for Putin the ideal ‘displaced object’ of national bad feeling: borne out of his insecurities and projected onto the nation’s cultural and historic identity.

Congenital Adrenocortical Tumor in an Asymptomatic Neonate with Positive Newborn Screen for Congenital Adrenal Hyperplasia: A Case Report

Adrenocortical tumors (ACTs) are rare in childhood, particularly in the neonatal period. ACTs in children usually secrete hormones that can cause virilization, precocious puberty, or Cushing syndrome. However, in many cases the diagnosis is delayed because of the generally healthy appearance of the child and the lack of a palpable abdominal mass. ACTs can also be misdiagnosed as congenital adrenal hyperplasia (CAH) especially if 17-hydroxyprogesterone (17-OHP) is elevated. We describe a case of neonatal ACT diagnosed in an asymptomatic newborn with positive/elevated 17-OHP on newborn screening. On examination there were no signs of virilization, Cushing syndrome, hemihypertrophy, or hypertension, and there was no palpable abdominal mass. While awaiting confirmatory results of an elevated 17-OHP level, an abnormally low adrenocorticotropic hormone level was noted. Abdominal ultrasound, obtained to evaluate the adrenal glands, showed a right adrenal mass with peripheral calcification. MRI revealed a 3.6 x 3.5 x 3.4 cm heterogeneously enhancing ovoid mass in the right adrenal gland. Diagnosis of an ACT was also confirmed by laboratory data, and histopathology of the tumor. Surgical resection was safely performed with perioperative steroid replacement. Genetic analysis of CYP21A2 and CYP11B1 genes was negative. A germ-line point mutation in the TP53 region was discovered, suggesting Li-Fraumeni syndrome. ACTs should be considered in the differential diagnosis of neonates with elevated 17-OHP detected by newborn screening for CAH. Adrenal ultrasound is recommended in cases of significantly abnormal CAH screen results to rule out or treat adrenal neoplasms.