Complete androgen insensitivity syndrome (CAIS) is an AIS condition that results in the complete inability of the cell to respond to androgens. As such, the insensitivity to androgens is only clinically significant when it occurs in individuals who are exposed to significant amounts of testosterone at some point in their lives. The unresponsiveness of the cell to the presence of androgenic hormones prevents the masculinization of male genitalia in the developing fetus, as well as the development of male secondary sexual characteristics at puberty, but does allow, without significant impairment, female genital and sexual development in those with the condition.
All human fetuses begin fetal development looking similar, with both the Müllerian duct system (female) and the Wolffian duct system (male) developing. Sex differentiation begins with the gonads, which in XX individuals become ovaries, and in XY individuals (including those with CAIS) typically become testicles due to the presence of the Y chromosome. It is at the seventh week of gestation that the bodies of non-CAIS individuals with the XY karyotype begin their masculinization: i.e., the Wolffian duct system is promoted and the Müllerian duct system is suppressed (the reverse happens with typically developing females). This process is triggered by androgens produced by the testicles. The bodies of unaffected XY individuals masculinize by, among other things, enlarging the genital tubercle into a penis, which in females becomes the clitoris, while what in females becomes the labia fuses to become the scrotum of males (where the testicles will later descend).
XY individuals affected by CAIS develop a normal external female habitus, despite the presence of a Y chromosome, but internally, they will lack a uterus, and the vaginal cavity will be shallow, while the gonads, which differentiated into testes in the earlier separate process also triggered by their Y chromosome, will remain undescended in the place. This results not only in infertility in individuals with CAIS, but also presents a risk of gonadal cancer later on in life.
CAIS is one of the three categories of androgen insensitivity syndrome (AIS) since AIS is differentiated according to the degree of genital masculinization: complete androgen insensitivity syndrome (CAIS) when the external genitalia is that of a typical female, mild androgen insensitivity syndrome (MAIS) when the external genitalia is that of a typical male, and partial androgen insensitivity syndrome (PAIS) when the external genitalia is partially, but not fully masculinized.
Androgen insensitivity syndrome is the largest single entity that leads to 46,XY undermasculinization.
Signs and symptoms
Physical
Individuals with complete androgen insensitivity syndrome (grades 6 and 7 on the Quigley scale) are born with an external female phenotype, without any signs of genital masculinization, despite having a 46,XY karyotype. CAIS is usually recognized at puberty, which may be slightly delayed, but is otherwise normal except for absent menses and diminished or absent secondary terminal hair. Axillary hair (i.e. armpit hair) fails to develop in one third of all cases. The vulva is normal, although the labia and clitoris are sometimes underdeveloped. Vaginal depth varies widely for CAIS, but is typically shorter than normal; one study of eight people with CAIS measured the average vaginal depth to be 5.9 cm (vs. 11.1 ± 1.0 cm for unaffected women ). In some extreme cases, the vagina has been reported to be aplastic (resembling a "dimple"), though the exact incidence of this is unknown.
The gonads in people with CAIS are testes; during the embryonic stage of development, testes form in an androgen-independent process that occurs due to the influence of the SRY gene on the Y chromosome. They may be located intra-abdominally, at the internal inguinal ring, or may herniate into the labia majora, often leading to the discovery of the condition. Testes in those affected have been found to be atrophic upon gonadectomy.
Testosterone produced by the testes cannot be directly used due to the mutant androgen receptor that characterizes CAIS; instead, it is aromatized into estrogen, which effectively feminizes the body and accounts for the normal female phenotype observed in CAIS. However, up to 5% of individuals with CAIS do not have an AR mutation. The receptor in question is encoded by the AR gene located on the X chromosome at Xq11–12. At least 15 different mutations were known in 2003, and they are all recessive, which makes the disease follow X-linked recessive inheritance.
Immature sperm cells in the testes do not mature past an early stage, as sensitivity to androgens is required in order for spermatogenesis to complete. Germ cell malignancy risk, once thought to be relatively high, is now thought to be approximately 2%. Wolffian structures (the epididymides, vasa deferentia, and seminal vesicles) are typically absent, but will develop at least partially in approximately 30% of cases, depending on which mutation is causing the CAIS. The prostate, like the external male genitalia, cannot masculinize in the absence of androgen receptor function, and thus remains in the female form.
The Müllerian system typically regresses the same way it does in unaffected male fetuses due to anti-Müllerian hormone originating from the Sertoli cells of the testes. Thus, people with CAIS, despite having a vagina due to androgen insensitivity, are born without fallopian tubes, a cervix, or a uterus, and the vagina ends "blindly" in a pouch. Müllerian regression does not fully complete in some cases of CAIS, resulting in Müllerian "remnants". Although rare, a few cases of people diagnosed with CAIS and having Müllerian structures have been reported. In one exceptional case, a 22-year-old with CAIS was found to have a cervix, uterus, and fallopian tubes. In an unrelated case, an almost fully developed uterus was found in a 22-year-old adult with CAIS.
Other subtle differences that have been reported include slightly longer limbs and larger hands and feet due to a proportionally greater stature than unaffected women, larger teeth, minimal or no acne, well developed breasts, a greater incidence of meibomian gland dysfunction (i.e. dry eye syndromes and light sensitivity), and dry skin and hair resulting from a lack of sebum production.
Endocrine Hormone levels have been reported in gonadally intact people with CAIS in a number of studies. Hormone levels are similar to those of males, including high testosterone levels and relatively low estradiol levels. However, luteinizing hormone (LH) levels are elevated while sex hormone-binding globulin (SHBG) levels are more consistent with those of females. People with CAIS have low levels of progesterone similarly to males. The production rates of testosterone, estradiol, and estrone have been reported to be higher in gonadally intact with CAIS than in men.
Comorbidity
All forms of androgen insensitivity, including CAIS, are associated with infertility, though exceptions have been reported for both the mild and partial forms.
CAIS is associated with a decreased bone mineral density. Some have hypothesized that the decreased bone mineral density observed in women with CAIS is related to the timing of gonadectomy and inadequate estrogen supplementation. However, recent studies show that bone mineral density is similar whether gonadectomy occurs before or after puberty, and is decreased despite estrogen supplementation, leading some to hypothesize that the deficiency is directly attributable to the role of androgens in bone mineralization.
CAIS is also associated with an increased risk for gonadal tumors (e.g. germ cell malignancy) in adulthood if gonadectomy is not performed. The risk of malignant germ cell tumors in women with CAIS increases with age and has been estimated to be 3.6% at 25 years and 33% at 50 years. The incidence of gonadal tumors in childhood is thought to be relatively low; a recent review of the medical literature found that only three cases of malignant germ cell tumors in prepubescent girls have been reported in association with CAIS in the last 100 years. Some have estimated the incidence of germ cell malignancy to be as low as 0.8% before puberty.
Vaginal hypoplasia, a relatively frequent finding in CAIS and some forms of PAIS, is associated with sexual difficulties including vaginal penetration difficulties and dyspareunia.
At least one study indicates that individuals with a DSD condition may be more prone to psychological difficulties, due at least in part to parental attitudes and behaviors, and concludes that preventative long-term psychological counseling for parents as well as for affected individuals should be initiated at the time of diagnosis. A retrospective study shows that the prevalence of anxiety and depressive disorders among CAIS individuals is approximately twice as high as in male referents without DSD, but no evident corresponding difference has been found compared to female referents.
Lifespan is not thought to be affected by AIS.
Despite the well-developed breasts in CAIS women, and for reasons that are not well-understood, breast cancer has never been reported in CAIS women and does not seem to occur or occurs only rarely. Only one case report of juvenile fibroadenoma exists. A few cases of breast cancer have been reported in individuals with partial androgen insensitivity syndrome.
In contrast to bone health, both transdermal estradiol treatment and testosterone treatment in women with CAIS results in worsening in lipid profiles. A case report in 2009 also shows that CAIS individuals with intact testes (with endogenous hormone) are more likely to be obese. A study which includes five CAIS and two PAIS adolescents with ages ranging from 15 to 24 shows elevated homeostatic model assessment for insulin resistance (HOMA-IR) scores for all subjects. Growing evidence indicates that complete androgen receptor (AR) dysfunction disrupts systemic metabolic homeostasis and neither external nor endogenous estrogen can normalize it.
AR absence is related to decrease in mature neutrophils in mice, but there is no evidence that human CAIS individuals have impaired neutrophil function. The proteome related to inflammation is predominantly inhibited in CAIS. Upregulation of IFN-β and IL-6 are reported in the blood of CAIS individuals. Leukocytes of CAIS individuals exhibit relative resistance to DNA damaging.
Diagnosis
CAIS is usually not suspected until the menses fail to develop at puberty, or an inguinal hernia presents during premenarche. As many as 1–2% of prepubertal girls that present with an inguinal hernia will also have CAIS.
A diagnosis of CAIS or Swyer syndrome can be made in utero by comparing a karyotype obtained by amniocentesis with the external genitalia of the fetus during a prenatal ultrasound. Many infants with CAIS do not experience the normal, spontaneous neonatal testosterone surge, a fact which can be diagnostically exploited by obtaining baseline luteinizing hormone and testosterone measurements, followed by a human chorionic gonadotropin (hCG) stimulation test.
The main differentials for CAIS are complete gonadal dysgenesis (Swyer syndrome) and Müllerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome or MRKH). Both CAIS and Swyer syndrome are associated with a 46,XY karyotype, whereas MRKH is not; MRKH can thus be ruled out by checking for the presence of a Y chromosome, which can be done either by fluorescence in situ hybridization (FISH) analysis or on full karyotype. Swyer syndrome is distinguished by the presence of a uterus, poor breast development and shorter stature. The diagnosis of CAIS is confirmed when androgen receptor (AR) gene sequencing reveals a mutation, although up to 5% of individuals with CAIS do not have an AR mutation.