Epidemiology and Population Genetics

Results of newborn screening in a number of localities around the world23–27 yield a worldwide incidence of classic 21-hydroxylase deficiency of approximately 1 in 14,500 live births, ranging from 1 in 8586²⁸ to 23,000.²⁹ It has been estimated that 75% have the salt-wasting phenotype.³⁰ Applying the Hardy-Weinberg formula for a population at equilibrium gives a computed heterozygote frequency for classic 21-hydroxylase deficiency of 1 in 61 persons. In areas where patient retesting is difficult/inefficient, it may be necessary to lower the treatment threshold to save lives of affected individuals who die before the diagnosis is confirmed and treatment is started.³¹

Nonclassic 21-hydroxylase deficiency, one of the most common autosomal recessive diseases, is more frequent than cystic fibrosis. The frequency is ethnic specific, as first determined by Speiser and colleagues.³² Incidences are 1 in 27 Ashkenazi Jews, 1 in 40 Hispanics, 1 in 50 Yugoslavs, 1 in 300 Italians, and 1 in 100 in a heterogeneous New York population.^32–34 In an attempt to determine an earliest date for the appearance within the Ashkenazi Jewish population of a founder mutation, DNA analysis was undertaken for representative individuals from the Roman Jewish ghetto, a community already established by the time of the second Diaspora (70 ce). No evidence was seen in Roman Jews of the B14-related nonclassic 21-hydroxylase deficiency mutation, thus suggesting a date after 70 ce for the appearance of this mutation among Ashkenazi Jews.³⁵ Further genetic characterization of this population in terms of its affinity to the general European population and to other Jewish groups continues.³⁶ The nonclassic 21-hydroxylase deficiency mutation can be dated to between 70 ce and the second millennium, based on the significantly higher frequency observed in Ashkenazi Jews compared with Sephardic Jews.

Classic 21-Hydroxylase Deficiency

Salt Wasting

Salt wasting is characterized by hyponatremia, hyperkalemia, metabolic acidosis, inappropriate sodium excretion in the urine, and low serum aldosterone with concomitantly high plasma renin activity (PRA).

Salt wasting results from inadequate secretion of salt-retaining steroids, especially aldosterone. In addition, hormone precursors elevated in 21-hydroxylase deficiency may act as mineralocorticoid antagonists (e.g., 17-hydroxyprogesterone). Newborns are especially prone to the development of a salt-wasting crisis because the sodium-conserving mechanism of their renal tubules is only marginally competent. The adrenal medulla of patients with CAH may be incompletely formed in some patients. Merke and coworkers⁵³ noted that the epinephrine and metanephrine concentrations of subjects manifesting a salt-wasting crisis were approximately 50% of those of controls; pathologic evaluation of adrenal medullary tissue (removed during adrenalectomy) demonstrated depletion of secretory vesicles.

A single enzyme is responsible for 21-hydroxylation in both the zona fasciculata and the zona glomerulosa. The pathogene-tic difference between salt wasting and simple virilizing 21-hydroxylase deficiency may simply be the result of a quantitative difference in enzyme activity caused by conformational changes induced by the specific mutations. In vitro expression studies show that as little as 1% of normal activity of 21-hydroxylase allows adequate aldosterone synthesis to prevent significant salt wasting.54,55 The issue is complicated by the occasional finding of discordance for salt-wasting expression among siblings with identical mutations in their inherited 21-hydroxylase genes, and by the observed improvement in salt wasting in some individuals over time.^48,56–58 In one case, a girl born with male genitalia and salt wasting, presumably with severe enzyme deficiency, was no longer a salt waster by age 4. Another important case finding was that of a girl with a homozygous deletion of the 21-hydroxylase gene and a history of multiple salt-wasting crises in infancy, who discontinued her therapy in adolescence and was found at that time to be secreting aldosterone.⁵⁹

Nonclassic 21-Hydroxylase Deficiency

Nonclassic 21-hydroxylase deficiency is distinguished from the classic form symptomatically by its age at onset and biochemically by its less severe impairment of steroid 21-hydroxylation; because of these two factors, it does not result in ambiguous genitalia in the newborn female. It often initially manifests just before the age of normal puberty, although it may present at any age after birth. Patients may be homozygous for a mild genetic defect or may have compound heterozygotes for one severe mutation and one mild mutation. Nonclassic 21-hydroxylase deficiency was first defined in the course of family studies of patients with classic CAH. Family members who should have been carriers for 21-hydroxylase deficiency were found to have overt hormonal disturbances that were associated with distinct alleles at the 21-hydroxylase locus. These alleles were determined to be in linkage disequilibrium with the HLA locus on chromosome 6. It thus was found through these studies that the gene locus for 21-hydroxylase lies between HLA-B and HLA-DR.⁶⁰

In addition to linkage of the 21-hydroxylase locus with the neighboring HLA-B and HLA-DR antigen loci, 21-hydroxylase deficiency alleles are found in linkage disequilibrium with other HLA genes or haplotypic combinations that may include specific alleles of the neighboring genes C4A and C4B encoding the fourth component of serum complement.⁶¹ The two most prominent such cases are linkage disequilibrium of the extended haplotype HLA-A3,Bw47,DR7 with the classic salt-wasting form, and HLA-B14,DR1 with nonclassic 21-hydroxylase deficiency.⁶²

11β-Hydroxylase Deficiency Congenital Adrenal Hyperplasia

Abnormal steroid secretion attributed to defective 11β-hydroxylation was first described by Eberlein and Bongiovanni¹⁶ in 1955. It has proved to be the second most common form of CAH (5% to 8% of all cases in the general population).⁹⁵ In the cortisol pathway, conversion of 11-deoxycortisol to cortisol is reduced. As a result, 11-deoxysteroids (11-deoxycortisol and 11-DOC) accumulate. The hyperandrogenism resulting from shunting of cortisol precursors is similar to that of 21-hydroxylase deficiency, including genital ambiguity in classically affected females.

Approximately two thirds of patients with 11β-hydroxylase deficiency become hypertensive, with or without hypokalemic alkalosis, sometime early in life. Hypertension does not correlate with the presence or degree of hypokalemia or with the extent of virilization.⁹⁶

In addition to the classic form (i.e., present at birth), milder nonclassic forms of 11β-hydroxylase deficiency have been reported3–8 and may represent allelic variants, analogous to 21-hydroxylase deficiency. No biochemical defect has been demonstrated consistently in the obligate heterozygote parents of patients with the classic form, either in the baseline state or with ACTH stimulation.⁹⁷ As noted earlier, such a biochemical defect can be demonstrated in 21-hydroxylase heterozygotes. As in 21-hydroxylase deficiency, persons with identical 11β-hydroxylase mutations may differ in the severity of their signs and symptoms of androgen and mineralocorticoid excess, suggesting a role for epigenetic or nongenetic factors in the expression of clinical phenotype.⁹⁸

Corticosterone Methyl Oxidase Deficiency

The conversion of corticosterone to 18-hydroxycorticosterone is referred to as CMO I activity, whereas the subsequent 18-oxidation to aldosterone is known as CMO II activity. In the zona glomerulosa, these steps are catalyzed by distinct domains within a single enzyme, P450c11B2, also referred to as P450c18, aldosterone synthase, and P450aldo. Deficient CMO I activity typically results in (practically) no aldosterone production and phenotypically is more severe than CMO II deficiency. Defects in CMO I activity have been reported but appear to be less common than those of CMO II.117,118 Defects in both CMO I and CMO II activity are inherited as autosomal recessive conditions, and because cortisol synthesis is not affected in either condition, defects of P450aldo are not considered to be forms of CAH.

Infants with CMO II deficiency are subject to potentially fatal electrolyte abnormalities; in childhood, however, recurrent dehydration, a variable degree of hyponatremia and hyperkalemia, and poor growth are characteristic.119,120 Adults may be asymptomatic, their affected status coming to light only in the course of family studies of a symptomatic child. CMO II deficiency has been found at an increased frequency among Jews of Iranian origin.¹²¹ Molecular genetic analyses of such families have demonstrated two missense mutations in the CYP11B2 genes of affected individuals: the replacement of arginine by tryptophan at position 181 (R181W) and the replacement of valine by alanine at position 386 (V386A).¹²²

CMO I deficiency is characterized biochemically by essentially unmeasurable aldosterone levels with low or normal 18-hydroxycorticosterone levels. Patients with CMO II deficiency typically have normal (or low) aldosterone levels with elevated 18-hydroxycorticosterone levels (i.e., an elevated serum 18-hydroxycorticosterone-to-aldosterone ratio), along with a low corticosterone-to-18-hydroxycorticosterone ratio. Alternatively, CMO II deficiency can be identified by an elevated ratio of the major metabolites of these steroids (tetrahydro-18-hydroxy-11-dehydrocorticosterone and tetrahydroaldosterone) in urine.¹²⁰

Dexamethasone (Glucocorticoid)-Suppressible Hyperaldosteronism

Dexamethasone-suppressible hyperaldosteronism (DSH; also known as glucocorticoid-remediable aldosteronism) is a rare form of hypertension123,124 in which aldosterone synthesis appears to be regulated abnormally by ACTH.¹²⁵ Dexamethasone-suppressible hyperaldosteronism is characterized by (1) rapid and complete suppression of aldosterone secretion on dexamethasone administration, (2) continued increase in aldosterone with long-term administration of ACTH, (3) suppressed PRA, and (4) a dominant mode of inheritance.¹²⁶ Urinary excretion of 18-hydroxycortisol and 18-oxocortisol is increased.^127,128

Individuals with DSH have been shown to have an intergenic recombination, juxtaposing the promoter of CYP11B1 with the coding sequence of CYP11B2.129,130 The fusion or chimeric gene creates an alteration in the regulation of synthesis of aldosterone, making the zona glomerulosa sensitive to ACTH rather than to renin-angiotensin, resulting in glucocorticoid-responsive hyperaldosteronism and hypertension.

Classic 3β-Hydroxysteroid Dehydrogenase Deficiency

3β-HSD deficiency is an autosomal recessive form of CAH that was first described by Bongiovanni¹³⁵ in 1962. The exact frequency of this rare disorder is unknown. It has been postulated that individuals with defects early in the pathway of steroidogenesis, which severely impair cortisol synthesis (i.e., 3β-HSD and StAR), have poor survival rates.

Owing to reduced 3β-HSD enzyme activity in the gonads, genetic males are incompletely masculinized and exhibit genital ambiguity at birth. In affected females, conversely, very high levels of circulating DHEA converted peripherally to active androgens produce a limited androgen effect. Clitoral enlargement occurs and, rarely, labial fusion. As with the 21-hydroxylase and 11β-hydroxylase enzymes, the severity of the enzyme defect may not be determined on the basis of the appearance of the external genitalia at birth. Deficient steroid production in 3β-HSD deficiency may result in salt wasting, although this clearly is not true in every case.136,137

Nonclassic 3β-Hydroxysteroid Dehydrogenase Deficiency

As with nonclassic 21-hydroxylase deficiency, nonclassic 3β-HSD deficiency is an attenuated enzyme defect with no major developmental abnormalities.69,138 Signs of virilization appear in females after adrenarche or at the time of puberty.

The possibility that nonclassic 3β-HSD deficiency may be a significantly underdiagnosed cause of excess androgen symptoms, including hirsutism and infertility, has been suggested.¹³⁹ Review of clinical data on more than 700 women with signs of androgen excess demonstrated decreased 3β-HSD activity in 16%.¹⁴⁰ It has been suggested that nonclassic 3β-HSD deficiency may be more frequent than nonclassic 21-hydroxylase deficiency in women with androgen excess syndrome.¹⁴⁰ In a group of 25 menarchal women with 3β-HSD deficiency, an improvement in regulation of menses and in acne was observed to result from glucocorticoid therapy of at least 3 months’ duration.¹³⁹ Hirsutism was less well reversed by treatment. Polycystic ovary disease was noted in 50% of these women.

Isolated 17α-Hydroxylase Deficiency

The enzyme domain that performs the 17α-hydroxylase activity is functionally distinct from the domain that performs the 17,20-lyase function. Therefore, it is reasonable to expect that isolated deficiency of either function may be found. However, because the product of 17α-hydroxylation is the precursor for 17,20-lyase action, isolated 17α-hydroxylase deficiency may be difficult to identify because it should present as the more common combined 17α-hydroxylase/17,20-lyase deficiency. Individuals with “pure 17α-hydroxylase deficiency” would be expected to present with hypokalemic hypertension with alkalosis, possibly with normal gender development. These individuals could be identified by expression studies of mutant enzymes in cell culture, and it has been suggested that more than 20% residual 17,20-lyase function would not be apparent. Clinically, at least one such description has been reported,¹⁴⁷ but in reality, these cases represent a quantitative rather than a qualitative difference. Individuals with isolated 17α-hydroxylase deficiency would be phenotypically identical to patients with DSH.

Isolated 17,20-Lyase Deficiency

Deficiency of 17,20-lyase activity impedes synthesis of C₁₉ sex steroids in the adrenal and gonads¹⁴⁸ without affecting cortisol synthesis in the adrenal gland and therefore is not a form of CAH but is a potential cause of abnormal gender development. Urinary pregnanetriolone, a metabolite of 17-OHP, is increased and increases further after ACTH and human chorionic gonadotropin stimulation. DHEA and testosterone excretion does not increase appreciably. At birth, such individuals all have normal female genitalia, regardless of chromosomal gender, and generally present at adolescence with primary amenorrhea and/or lack of gender development. Other oversecreted steroids (e.g., corticosterone) subserve the glucocorticoid function. It is important to note that one longitudinal study of a 46,XY individual who began receiving estrogen replacement at puberty revealed apparently progressive extinction of 17α-hydroxylating activity from ages 20 to 26.¹⁴⁹ Thus, this patient, who started life with an isolated 17,20-lyase defect, converted to a combined 17α-hydroxylase/17,20-lyase defect at puberty, suggesting the need for continued vigilance in cases of isolated 17,20-lyase deficiency.

Combined 17α-Hydroxylase/17,20-Lyase Deficiency

A defect in 17α-hydroxylase/17,20-lyase will result in diminished production of cortisol and sex steroids, the production of which requires the 17,20-lyase function. The enzyme defect affects steroid synthesis in both the adrenals and the gonads and reduces production of all androgens and estrogens. Because of high corticosterone (B) levels, patients with P450c17 abnormalities do not manifest adrenal crises and therefore often go undiagnosed, often until evaluated for abnormal pubertal development.¹⁵⁰ In the genetic male, there is pseudohermaphroditism, whereas in the female, infantile genitalia are present.¹⁵¹ At puberty, gonadotropins increase to very high concentrations, the very low sex steroid production failing to provide adequate regulatory feedback. Breast development may occur in males.¹⁹ In the female at pubertal age, no secondary gender characteristics develop, and primary amenorrhea may be noted. Phenotypically, such subjects may be similar to individuals with androgen insensitivity syndrome. 17,20-Lyase deficiency (isolated or as combined 17α-hydroxylase/17,20-lyase deficiency) occurs approximately 65% as often as androgen insensitivity syndrome.¹⁵²

Nonclassic combined 17α-hydroxylase/17,20-lyase deficiency has been described in a subset of women undergoing evaluation for infertility. These women had normal potassium levels, blood pressure, and female external genitalia but high follicular phase progesterone combined with low estrogen levels.¹⁵³

Combined Disorders of 21- and 17α-Hydroxylase/17,20-Lyase Deficiency

The combination of prenatal androgen excess with postnatal androgen deficiency has been reported. In some of these patients (postnatal), steroid profiles are consistent with combined (partial) 21-hydroxylase and 17α-hydroxylase/17,20-lyase deficiencies. Female newborns may have severe virilization (Prader III or IV), and males may be normal or undervirilized. Many of these subjects also have skeletal and other abnormalities consistent with Antley-Bixler syndrome (type 2). Steroid analysis of such subjects (especially after the neonatal period) typically demonstrates elevation of progesterone, 17-hydroxyprogesterone, and corticosterone. Pregnancies are commonly marked by maternal virilization—with both male and female fetuses—and low (maternal) estriol levels. Mild forms may be detected by the low maternal estriol level, with completely normal ultrasound.¹⁶² Subjects with combined 21-hydroxylase and 17α-hydroxylase/17,20-lyase deficiencies, with or without Antley-Bixler syndrome (type 2), have been shown to have mutations in the P450 oxidoreductase gene, POR.^163,164 P450 oxidoreductase is an important cofactor for electron transfer from nicotinamide adenine dinucleotide phosphate (NADPH) to the 21-hydroxylase and 17α-hydroxylase/17,20-lyase (as well as many other) enzymes.¹⁶⁴ Maternal gestational virilization is likely due to the P450 oxidoreductase effect on P450 aromatase.^163,165

Lipoid Congenital Adrenal Hyperplasia

Lipoid CAH is a rare form of CAH that was originally described in 1955 by Prader and associates17,166 and represents the most extreme form of CAH with only negligible production of all steroids. Massive accumulations of cholesterol in the adrenocortical tissue (but not in the Leydig cells of the testis, where the enzyme is also active) lead to the characteristic fatty appearance of the glands and the descriptive name used for this disorder.

The cholesterol side-chain cleavage enzyme (P450scc, also known as cholesterol desmolase and encoded by CYP11A) catalyzes the conversion of cholesterol to pregnenolone in the first and rate-limiting step in the production of corticosteroids, and therefore was the most logical but not the only genetic candidate proposed for lipoid CAH. Mutations leading to lipoid CAH occur in CYP11A and in the gene coding for the StAR protein, encoded by the StAR gene on chromosome 8p11.2. StAR serves to shuttle cholesterol to the inner mitochondrial membrane, where the P450scc enzyme is located.²² Mutations in StAR appear to be more common than those in CYP11A.

Affected individuals exhibit hypogonadism, severe fluid and electrolyte disturbances, hyperpigmentation, and susceptibility to infection. They often do not survive infancy. Lipoid CAH is rare in most populations but appears to occur at a somewhat higher frequency and with less severity among Japanese, Koreans, and Palestinian Arabs.167,168 Phenotypic variability exists, with some patients described as having small adrenal glands without significant intracellular lipid deposits.

Both dominant and recessive mutations have been described in CYP11A. Tajima and colleagues¹⁶⁹ described an apparent somatic mutation present in multiple tissues in the affected subject but not found in either parent. This child was born with normal weight and length and was assigned a female gender. She was clinically unaffected (and untreated) until after 4 years of age, when she developed acute adrenal failure. No uterus was identified, and a karyotype at that time revealed 46,XY. This mutation appears to lead to a protein with essentially no enzymatic activity.

Another child with adrenal insufficiency was found to be a compound heterozygote for mutations in CYP11A. One mutation arose de novo, whereas the other was inherited from the mother, who was clinically unaffected.¹⁷⁰

Baker et al described two families with mutations in the StAR gene, with a mild phenotype. The affected children presented with adrenal failure at the relatively late age of 2 to 4 years, but with normal genital development; the mutant StAR protein was shown to retain 20% of wild-type activity. They referred to this phenotype as “nonclassical lipoid CAH.”¹⁷¹

The pathology of lipoid CAH appears to result from two distinct but related events. The first event results from deficient steroid hormone production. The second event is increasing lipid deposition inside the cell, which results in increasing intracellular damage/death. This latter event is theorized to lead to the salt-wasting adrenal crisis that often results in death in infancy.¹⁷² The case report by Tajima and colleagues also would appear to confirm this hypothesis.¹⁶⁹ Histologic examination of a StAR knockout mouse supports this theory, with significant lipid deposits noted in the adrenals and mild accumulation in the testes but none in the ovaries.¹⁷³

Hormone Replacement Therapy

The fundamental aim of endocrine therapy for CAH is to provide replacement of the deficient hormones. Since 1949, when Wilkins and colleagues¹⁸⁹ and Bartter¹⁹⁰ discovered the efficacy of cortisone therapy for CAH due to 21-hydroxylase deficiency, glucocorticoid therapy has been the cornerstone of treatment for all forms of cortisol deficiency. Glucocorticoid administration replaces the deficient cortisol and suppresses ACTH overproduction; a concomitant reduction in adrenal cortex activity occurs, thereby reducing the production of other adrenal steroids (i.e., precursor by-products) and remission of (most) symptoms over time. Patients with nonclassical 21-hydroxylase deficiency may have resolution of symptoms within 3 months of initiating corticosteroid treatment.¹⁹¹

Adrenal suppression in 21-hydroxylase, 11β-hydroxylase, and 3β-HSD deficiency reduces the excess production of androgens, averting further inappropriate virilization, slowing accelerated growth and bone age advancement to a more normal rate, and allowing normal onset of puberty. An improved body habitus is seen with a progressively earlier start of treatment (Fig. 8-11). Individuals with the salt-wasting type of 21-hydroxylase or 3β-HSD deficiency require the administration of a salt-retaining steroid to maintain adequate sodium balance. Suppression of adrenal activity in 11β-hydroxylase and 17α-hydroxylase deficiency normalizes DOC/mineralocorticoid secretion and often results in remission of hypertension. In lipoid CAH and adrenal failure, total hormone replacement is required.

Excessive glucocorticoid administration should be avoided because this produces cushingoid facies, growth retardation, inhibition of epiphyseal maturation, and decreased bone mineral density.

Hydrocortisone (cortisol) is the corticosteroid of choice for children with all forms of CAH. It is the physiologic hormone and is used most often in the treatment of children because of easy dose adjustment. Oral administration is the preferred and usual mode of treatment, conventionally given in two divided doses: 10 to 15 mg/m² hydrocortisone divided as one third in the morning and two thirds in the evening. We prefer to use the tablet form of hydrocortisone, even in young infants, until stable liquid formulations have been introduced. As noted previously, excessive replacement with glucocorticoids will be detrimental, and although some children may (temporarily) require more than 15 mg/m² per day, individuals have been reported to develop cushingoid features with as little as 16 mg/m² per day of hydrocortisone.

If poor hormonal control with hydrocortisone is noted at the standard dose, the dose may be increased temporarily to 20 (or even 30) mg/m² per day, or the regimen may be changed to a synthetic hormone analogue such as prednisone or dexamethasone. These agents are more potent and longer acting, although their relative glucocorticoid and mineralocorticoid effects differ, and the smaller amounts used make dose adjustment more crucial. Because of individual variations in the activity of hepatic enzymes metabolizing 11-oxosteroids, and thus in plasma clearance and half-life, in some patients, prednisolone (the 11β-hydroxy analogue of prednisone, also called Δ¹ cortisol) is more effective than prednisone (Δ¹ cortisone) as glucocorticoid replacement. Individuals without overt salt wasting have been shown to have elevated renin levels,192–198 and its fluctuation may correlate with ACTH. Addition of a mineralocorticoid to the therapeutic regimen in individuals with the simple virilizing form of 21-hydroxylase deficiency has been shown to result in improved hormonal control at the same glucocorticoid dose. A longer-term benefit of a reduced glucocorticoid requirement is improved statural growth.^197,198

In non–life-threatening illness or stress, the glucocorticoid dose should be increased to two or three times the maintenance dose for the duration of the stress. Each family must be given injectable hydrocortisone for emergency use (25 mg for infants, 50 mg for young children, and 100 mg for older children and adults). In the event of a surgical procedure, a total of 5 to 10 times the daily maintenance dose (depending on the nature of the surgical procedure) may be required over the first 24 hours. For elective surgery, we recommend hydrocortisone 100 mg/m² PO at midnight preceding the operation, followed by 100 mg/m² IM on call to the operating room, and then another 100 mg/m² IV drip for every 6 hours of surgery. During the first 24 hours after surgery, the patient should receive 100 mg/m² per day, divided into four doses. Beginning on the second postoperative day, when there are no complications, the dose can be tapered rapidly, dropping to 50 mg/m² per day, and then on the following day, the normal preoperative corticosteroid schedule can be resumed in cases without complications. Appropriate stress doses should be given for complications. Stress doses should not be given in the form of dexamethasone because of the delayed onset of action. Mineralocorticoid doses need not be increased in response to stress.

Patients with the salt-wasting forms of adrenal failure and CAH (21-hydroxylase, 3β-HSD deficiency, and the lipoid form) require mineralocorticoid replacement. The cortisol analogue 9α-fluorohydrocortisone (fludrocortisone, Florinef, 9α-FF) is used for its potent mineralocorticoid activity. Additionally, salt should be allowed ad libitum. In an adrenal crisis, liberal infusions of isotonic saline and parenteral hydrocortisone should be administered at a dose of 100 mg/m²/dose. At this dose, hydrocortisone subserves all necessary mineralocorticoid function.

Several conditions (including those with complete adrenal failure), for example, cholesterol desmolase, StAR, 3β-HSD, and 17α-hydroxylase/17,20-lyase deficiency, also require sex steroid replacement, regardless of the gender of rearing. (Subjects with SF1 abnormality may require sex steroid replacement, depending on the chromosomal gender.) Sex steroids should be added at the developmentally appropriate time to allow children to optimally resemble their peers. CMO I/CMO II (aldosterone synthase)–deficient individuals will require salt and mineralocorticoid replacement, whereas the hypertension seen in subjects with 11β-hydroxylase or 17α-hydroxylase deficiency may not resolve with glucocorticoid replacement, especially when the hypertension has been long-standing.

It is of the utmost importance for all patients with adrenal insufficiency and those on steroid replacement/suppressive therapy (e.g., for CAH) to wear a Medic-Alert bracelet or medallion listing the medical condition, long-term medications, and standard emergency procedures for the particular diagnosis (e.g., administration of fluids and hydrocortisone). In addition, the patient and family members must be trained in the intramuscular administration of hydrocortisone.

Monitoring Treatment

Glucocorticoid doses should be titrated to optimize biochemical control balanced against physiologic parameters (e.g., in a growing child with 21-hydroxylase deficiency, a 17-OHP of between 500 and 1000 ng/dL and suppressed androgens while maintaining a good growth velocity). The goal, with respect to corticosteroid replacement, is to give the minimal dose required for optimal control. Serum 17-OHP and Δ⁴ androstenedione concentrations determined by radioimmunoassay can be used to monitor biochemical control in patients with 21-hydroxylase deficiency.199–201 In females and prepubertal males (but not in newborn and pubertal males), the serum testosterone level is also a useful index.²⁰⁰ Combined determinations of PRA, 17-OHP, and serum androgens, as well as clinical assessment of growth and pubertal status, all must be considered when the doses of glucocorticoid and salt-retaining steroid are adjusted for optimal therapeutic control. A combination of hydrocortisone and 9α-FF has proved to be a highly effective treatment modality.¹⁹⁹ Measurement of PRA can be used to monitor efficacy of treatment in most forms of CAH. PRA is elevated in the salt-losing state and is suppressed in the volume-overloaded state. Its normalization indicates improved hormonal control.

Although glucocorticoid treatment has been available since 1950, little agreement has been reached as to which regimen gives the best outcome in terms of height. Recent studies suggest that even the most compliant patient may not achieve a final height compatible with parental stature. It is not known whether this is due to overtreatment, to failure of oral glucocorticoid therapy given twice or even three times daily to suppress excess androgen production, or to simultaneous overtreatment and undertreatment. A simple home-based system to monitor the hormonal status of patients at frequent intervals may improve hormonal control and final growth. Salivary 17-OHP concentration may provide an easy means for monitoring hormone levels on a daily basis.⁸⁶ Similar considerations may apply to the preservation of fertility.

Management of the Child with Ambiguous Genitalia

The newborn with ambiguous genitalia represents a medical emergency. Determination of genetic gender by karyotype and accurate diagnosis of the specific underlying defect are essential for initial management, but these factors do not address questions of gender identity and sexual orientation—questions that often are raised by confused parents at an extremely vulnerable time. It is well established that steroids influence aspects of central nervous system development,202,203 but the data are controversial regarding specific androgen effects resulting from CAH.^204–206 It has been proposed that a masculinized gender role in girls, with behavioral manifestations such as tomboyishness, results from prenatal androgen excess in CAH. In a controlled play situation, Nordenstrom and colleagues²⁰⁷ observed that girls with CAH played with masculine toys more than controls, and they demonstrated that the degree of masculine play correlated with the degree of virilization. Girls with CAH were shown to score similarly to control males on tests of spatial cognition.²⁰⁸ In adult women, Long et al²⁰⁹ found that self-reported femininity decreased and masculinity increased with prenatal androgen exposure. Similarly considered, behavioral changes resulting from alterations in the androgen milieu are seen in studies on male pseudohermaphrodites with 5α-reductase or 17β-hydroxysteroid dehydrogenase deficiency, who often elect a male gender identity at puberty.^{210, 211} However, a great body of psychological studies indicate that in humans, unlike other mammals, the gender of rearing overrides prenatal hormonal effects.^212,213

When a gender of rearing is assigned to a pseudohermaphrodite, the genetic gender is of less consideration than the physiologic and anatomic character of the genitalia, their potential for development and function, and the psychosocial milieu of the infant. Gender assignment of female pseudohermaphrodites with 21- or 11β-hydroxylase deficiency or 3β-HSD deficiency in the newborn period should be female. In fact, Dessens et al²¹⁴ found that gender dysphoria in 46,XX CAH patients was 12.1% when the children were raised as males, compared with 5.2% when they were raised as females.

Wide individual variability has been noted in the presentation of ambiguous genitalia in these patients. When medical treatment is begun early in life, the initially large and prominent clitoris may shrink slightly. As the surrounding structures grow normally, the clitoris becomes much less prominent, and surgical revision may not be required. When clitoral enlargement is conspicuous enough to interfere with parent-child bonding or formation of female gender identity in the patient or raises doubts in the parents about the true gender of the infant, corrective surgery of the genitalia should be carried out as early as possible, and certainly when the child is younger than 2 years of age.²¹³ Psychoendocrinologically trained psychologists and/or psychiatrists provide a vital component of the treatment regimen because one of the major goals of therapy is to ensure that gender role, gender behavior, and gender identity are isosexual with the gender of assignment.^215,216

Clitoral surgery must aim to preserve erectile tissue along with the dorsal neurovascular bundle and thus clitoral erotic sensation. It must be determined before menarche that vaginal formation permits adequate outflow of blood, and an early procedure ensuring this may have to be performed in rare cases. Vaginoplasty performed before regular sexual intercourse may require continual mechanical dilatation of the vagina. Surgery before the patient is able to take responsibility for this risks recurrent stenosis, formation of adhesions, and scarring, with a need for further surgery and permanent harm to the vaginal orifice. Too long a delay, conversely, risks harm to the patient’s sense of self as a normal female. All these factors are taken into account when the age for the necessary procedure(s) is chosen; this generally is done during the patient’s early to middle adolescence. In some patients, mechanical dilatation may be sufficient. In the hands of an experienced surgeon, vaginoplasty can yield excellent results.²¹⁷ Because of the normal internal genitalia and gonads in these patients, normal puberty, fertility, and child-bearing are possible with early and proper therapeutic intervention.

Rare cases of late diagnosis of classic 21-hydroxylase, 11β-hydroxylase, and 3β-HSD deficiency with interim misassignment as a male must be dealt with on an individual basis. Corrective surgery to change the gender of assignment is not recommended in a child older than 2 years of age. Primary responsibility should be taken by a psychoendocrinologist in consultation with the family.

For the male pseudohermaphrodite, a male gender assignment is by no means always best. The basic questions include the following: (1) Will the child be able to urinate standing? (2) Will sexual intercourse as a man be possible? If the male pseudohermaphrodite is to be raised as a female, surgical correction of the genitalia and gonadectomy are required. With appropriate therapeutic measures, relatively normal, albeit infertile, female gender development and activity usually ensue in adolescence and adulthood if the parents and the patient are well managed medically and psychologically. Administration of sex steroids is required to induce development of appropriate gender characteristics at puberty. Assigned males who have impaired androgen synthesis will require androgen replacement. Almost all male pseudohermaphrodites to be raised as males require surgery for correction of birth defects of the external genitalia caused by inadequate prenatal masculinization.

The process of assigning and accepting a gender of rearing for a child with ambiguous genitalia is extremely complicated. A team approach that combines the insights of pediatrician, endocrinologist, psychoendocrinologist, surgeon, and the child’s parents or guardian is essential. Moreover, it should be anticipated that ongoing counseling will be helpful to most families.

21-Hydroxylase Deficiency

Each pregnancy that occurs in a family in which steroid 21-hydroxylase deficiency has been identified has a 25% chance of resulting in an affected newborn. Since 1965, when Jeffcoate and associates²¹⁸ correlated a clearly elevated value for amniotic fluid pregnanetriol with the diagnosis of an affected child (confirmed at term), amniotic fluid steroid hormone assay has been done in pregnancies at risk.^219–221 Radioimmunoassay of amniotic fluid for 17-OHP has shown that in all patients affected with the salt-wasting form, the amniotic fluid 17-OHP concentration is unambiguously elevated^222–226; however, in simple virilizing 21-hydroxylase deficiency, the 17-OHP level may not be elevated above normal.²²⁷ The amniotic fluid Δ⁴ androstenedione and testosterone levels also have been measured, but the latter value is less useful because testosterone is normally high in the amniotic fluid of a male fetus.^225,228

Fetal cells (mostly fibroblasts) in the amniotic fluid may be cultured for DNA analysis. HLA serotyping in conjunction with hormonal assay was begun in 1979²²⁹ but is less sensitive than direct mutation analysis. Specific probes for 21-hydroxylase mutations allow direct and rapid identification of known mutations through the use of polymerase chain reaction (i.e., allele specific). Panels of oligonucleotide probes currently available for use in prenatal diagnosis²³⁰ are expected to identify well more than 95% of current 21-hydroxylase mutations.

According to the population studied, deletions of the active 21-hydroxylase gene (CYP21) occur in from 20% to more than 40% of patients (Northwest United Kingdom)231,232; the remaining 60% to 80% of cases represent missense and nonsense mutations, as well as small deletions, sometimes even complicated noncontiguous deletions. These mutations are commonly the result of gene conversions and nonreciprocal transfers of the nucleotide sequence of longer or shorter segments of the pseudogene (CYP21P) to the active gene, with deleterious results.

11β-Hydroxylase Deficiency

Levels of 11-deoxysteroids and metabolites in amniotic fluid and maternal urine have been found to be increased in pregnancies with a fetus affected with 11β-hydroxylase deficiency,233,234 suggesting that prenatal diagnosis of this disorder by hormonal measurement may be feasible,²³⁵ although the reliability of this method has not been reported on by other groups. However, the 11β-hydroxylase genes have been cloned, and many such mutations have been described. Where the mutations are known, prenatal diagnosis by DNA analysis of chorionic villus sampling (CVS) is possible and recommended. Experience with prenatal diagnosis in 11β-hydroxylase deficiency CAH is limited.

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