Amenorrhea Due to Defects 1n Steroid Biosynthesis*

H. OLIVER WILLIAMSON. M.D. AND RAJESH S. MATHUR. PH.D.

Depar1ment of Obstetrics and Gynecology, Medical University of South Carolina, Charleston. South Carolina

Amenorrhea as the first manifestation of a for the adrenal cortex, and the gonadotropins for the steroid biosynthetic defect is rather unusual. The gonads (Fig. 2). When circulating levels of glucocor­ common forms of congenital adrenal hyperplasia are ticoids or sex steroids reach sufficient levels for classic examples of steroid biosynthetic defects. Yet physiologic functions of the individual, the classic in genotypic females. this disorder is usually evident negative feedback mechanisms become operative so from birth because of virilization. Effective treatment that further releasing hormones from the hypo­ usually ensues and amenorrhea is only a problem thalamus are held in abeyance, and the specific tropic when control is inadequate. However. there are in­ hormones from the pituitary are not released until dividuals whose disorder will be manifest for the tirst there is further need for additional hormones. time in the postnatal or adult period. In addition. In the biosynthetic defects discussed here, the multiple other steroid defects have now been clearly steroid end products necessary for physiological delineated. Many of these individuals will have function are not formed in optimum amounts. This amenorrhea, virilization. or sexual ambiguities as triggers release of releasing factors from the part of the clinical picture. This paper will describe hypothalamus which in turn causes secretion of the some of the more clearly delineated steroidal bio­ tropic hormones from the pituitary. Next, stimula­ synthetic defects. Also, the clinical management or tion of the target glands (adrenal and/or gonads) patients with postnatal onset of 21-hydroxylase defi­ leads to excessive intermediate products being ciency form of congenital adrenal hyperplasia will elaborated up to the point of the defect. Clinical be discussed. manifestations of these disorders are due to a Steroidogenesis. One can better appreciate the deficiency of a normal end product, an excess of in­ biochemical defects and clinical manifestations of termediate substances with the possible peripheral these various steroid defects by having a rudimentary conversion to other hormones, or usually both. In knowledge of the basic steroid pathways involved. To defects involving steps early in the biosynthetic pinpoint the individual defects, it is helpful to recall pathways, the adrenals and gonads are involved. Ab­ the numbering sequen..:e of the carbon atoms of the normalities occurring later in the order of flow usual­ steroid molecule as shown in Figure I. For the pur­ ly involve only one gland or the other. Important sex poses of this discussion, one can consider cholesterol steroid precursors and weak androgens may be as the basic substance from which steroids are de­ formed by the adrenal and converted to more potent rived. It is at the point of its conversion to pregnenolone androgens and even estrogens in certain of these dis­ that tropic hormones have their effect; that is, ACTH orders. Such conversions apparently occur in the liver and skin and possibly other tissues. However, the • Presented by Dr. Williamson al the 46th Annual McGuire gonads do not form glucocorticoids. Lecture Series. December 5. 1974. al the Medical College or Specific Defects. Brief descriptions of biosyn­ Virginia. Richmond. thetic defects will be outlined starting at the more

MCVQUARTERLY 11(\): 15-32, 1975 15 WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 16 21 reported two patients with this disorder and collected five additional cases. All seven died before the eighth month of life with adrenal insufficiency even though 20 treatment with gluco- and mineralocorticoids had been employed. Although other steroid abnormalities may be present, it is probable that the main defect is in the transformation of cholesterol to pregnenolone II 16 (3). Early fatalities preclude this form of CAH in the 13 differential diagnosis of amenorrhea, though ul- timately a mild form of the defect with survival might be anticipated. 14 15 Three (3-hydroxysteroid dehydrogenase deficiency 2 (Fig. 4). Being unable to convert pregnenolone to progesterone, these individuals present with many of the features of the previously described desmolase 3 7 deficiency. Salt loss has been a prominent feature of OH 5� the adrenal insufficiency with the result that fatalities are usual. Inadequate testosterone leads to am­ 4 6 biguous genitals in genetic males whereas mild Cholesterol virilization of affected females has been attributed to testosterone being formed from increased amounts Fig. I-Numbering sequence for the first 21 carbon atoms in of dehydroepiandrosterone (DHA) and other pre­ steroid nomenclature. Useful in locating biosynthetic steroid defects described in this paper. cursors. Since it is a primitive defect, gonadal steroidogenesis is also affected. In Bongiovanni's series (4), three females out of a total of six in­ primitive, or early, stages of steroid biosynthesis dividuals with this form of CAH were surviving. He and proceeding to later-stage defects. Accordingly, postulated a partial defect as did Kenny and his co­ the order of presentation bears no relationship to workers (5). The latter authors also showed in­ relative frequency or importance of these dis­ creasing 3(3-hydroxysteroid dehydrogenase activity orders. with increasing age. Steroid excretion patterns in C-20 block with /ipoid adrenal hyperplasia these patients would suggest the development of (Desmolase deficiency CAH) (Fig. 3). Being unable alternate pathways which allow for survival of some f to convert cholesterol to pregnenolone, afected in­ infants. The presence of pregnenetetrol (with a dividuals lack life-sustaining steroids; hence the dis­ hydroxyl group at C 21) suggests the ability of 17- order is fatal. The condition is of interest lo the hydroxylase and 21-hydroxylase to act on this gynecologist in that it supports Jost's work regarding "primitive" molecule (6). This compound is not ex­ virilization of the genital tracts. Being a primitive creted in increased amounts in the usual 21- (early) defect, it involves steroidogenesis in the hydroxylase deficiency (7). Since this enzyme also gonads as well as in the adrenals. The fetal testes are plays an important part in the gonadal biosynthesis unable to form adequate androgens to virilize the of sex hormones (6), its absence would necessitate genitalia fully, leading to genital ambiguity in genetic substitutional sex-hormone therapy at pubescence. males. This is in contradistinction to the findings in Obviously sterility can be anticipated. the more common 21- and also 11-hydroxylase forms Seventeen cx-hydroxylase defect (Biglieri syn­ of congenital adrenal hyperplasia where genetic drome) (8) (Fig. 5). This being a primitive block, females are often born with ambiguous genitals. the gonads and adrenals are involved. Absence of Cholesterol accumulates in the adrenal of affected adequate sex steroids leads to hypogonadism and individuals; hence the designation "lipoid." Theo­ elevated gonadotropins. The elevated levels of desoxy­ retically, the treatment would be the administra­ corticosterone (DOC) and. corticosterone lead to tion of glucocorticoids and mineralocorticoids with hypokalemic alkalosis and hypertension, thus turning the addition of appropriate sex steroids at the time of off the renin-angiotensin mechanism with resultant pubescence. Prader, Gurtner, and Siebenmann ( I, 2) low or absent aldoslerone. This defect is clinically ex- WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESJS 17

0" CHs-C-S-CoA ·Acetate" C;H20H o,-zc·o 0 MINERALO­

"'� A.CT.H. 0 CORTICOIDS ALOOSTERONE _/ I qH, c H H20H _,?f ' , , C; CH,OH T c,o C•O 3-/3-ol-deH 21-0H � �+ - ISOMERASE Pre9nonediol HO :,... O h ,��,� PREGNENOLONE PROGESTERONf DESOXYCORTICOSTERONE CORTICOSTERONE (DOC) (CO. B• l 17-0H C;H, I I qH, �H20H �H20H � C•O t C•O C•O OH OH - • (tjoH ffi OH _, � netrlol HO� 0 0� 0 17-0H-PREGNENOLONE 17-0H-PROGESTERONE 11-0ESOXYCORTISOL CORTISOL (CO.SR) (CO. F.) GLUCO- 0 i i 0 CORTICOID

.,dr6OH A ---+ ··-��. \.. (17-KS) (17-KS) OH OH �,ffi � ffi SEX 0� HO� STEROIDS TESTOSTERONE ESTRAOIOL

Fig. 2-A bbreviated steroid flow sheet of major steroids produced in the hum,111. M incralrn.:onicoids arc regulated by a mechanism involv­ ing osmolar and presser receptors and in turn the renin-angiotensin mt.:chani:-.m and only to a minor degree by ACTH. The glucocorticoid (cortisol) plasma levels are modulated by negative feedback influence or the I I-hydroxyl group on the hypothalamus and in turn its releasing factor for ACTH. The major sex steroids. testosterone and the estrogen,. typified by cstradiol. arc produced from adrenal DHA and androstenedione in tissues peripheral to the adrenal su...:h as the liver and the �kin. Some degradation products of major steroids are pointed out by small arrows beneath the individual steroids.

pressed in the genetic female by hypertension and the Addition of sex steroids at pubescence is indicated, absence of puberty. In addition to the elevated but infertility can be expected. It would appear that gonadotropins, blood progesterone is high. In the these patients could be monitored for effectiveness of genetic male, ambiguous genitalia and absence of therapy by the measurement of plasma progesterone. puberty result from the inability to make either an­ Simple uiri/izing congeniwl adrenal hyperplasia drogens or estrogens; hence it is a cause of male (mild 21-hydroxylase defect) (Fig. 6). Being unable to pseudohermaphroditism (9). This syndrome in form optimal amounts of cortisol and corticosterone, genetic females is similar to the feminizing testicular these individuals exhibit augmented ACTH produc­ syndrome in the absence of secondary sex hair, bu! tion which leads to shunting towards the androgen differs in that breast development is absent and pathway and ultimate virilization. Aldosterone and hypertension is present. The treatment in females is cortisol (hydrocortisone) are formed in suboptimal adequate substitutional therapy with glucocorticoids. amounts so tha< overt adrenal insufficiency may not Preference is given to one without significant be necessarily manifes< (10, 11). The majority of fe­ mineralocorticoid activity; for example, prednisone. male patients will have exhibited considerable evi- WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 18 0" CH ,-C-5-CoA qH2 0H "Acetate"

ALDOSTERONE CHOLESTEROL ,# ,,# 0 H 0H C 2 H CH3 CH2 H / ' I C , I r c,o C•O 0 3-,8-ol-deH 21-�H � �t Pregnonediol !SOME RASE 0 ,,;;. 0� �,� ,ODS° CORTICOSTERONE PREGNENOLONE PROGESTERONE DE SOX YC ORT ICOS TERONE (DOC) (CO. B•) 0 0 0 H H �H2 H qH2 H 17- H I q , I q , 'f c,o t c,o O C•O H OH OH C• -OH O ffi _, � netriol • HOC(( 0 0 17-0H -PREGNENOLONE 17-0H-PROGESTERONE 11-DESOXYCORTISOL CORTISOL (CO.SR) (CO. F•)

i 0

DH A ---->-�· :�, \.. (17-KS) (17-KS) OH OH _,ffi 0� TESTOSTERONE "'c5°ESTRADIOL Fig. 3-Desmolasc defect (<.ilso called lipoid adrenal hyperpla�i,1 due tu a1.:1.·umulatio11 uf (huk:-tl'rul in ,H.lrc;nals). Usual\� fat�il due to defit:iency of both mineralocorticoids and glucocorticoids. Leads to sexual ambiguity in nwles due tu ddi1.:ie11t testostt:rone to m:.1sculinize in utero.

dence of virilization and usually sexual ambiguity at trogenic activity is not clinically manifest. Pre­ birth. leading to prompt diagnosis and treat111ent. In sumably. the excessive androgens effectively over­ the afTected male. however. the external genitalia ride the estrogenic activity. Most investigators have are nor111al and the diagnosis of CAH is therefore held that urinary gonadotropins are suppressed by less obvious. This doubtless accounts for the pre­ the excessive androgens ( 13. 14). However. Stevens do111inance of the disorder in females: that is. 111ales and Goldzieher ( 15) found detectable and often adult may die of undiagnosed hypoadrenalis111. levels of gonadotropins in 4 of 5 children with Diagnosis and treatment depend largely on sup­ CA H and variable levels in adults. Steroid suppressive pressibility of the hyperactive hypothalamic-pituitary­ therapy led to a fall of FSH in 3 of6 patients whereas adrenal axis by exogenous administration or LH was unchanged in 5 and rose in 2. suggesting that 11-hydroxylated glucocorticoids. Androgens are elt:­ co111pensatory pituitary hyperactivity in CAH is not vated in plasma and urine. Estrogen excretion may limited to the pituitary adrenal mechanism but has be elevated in these individuals ( 12. 13 ). Such es- repercussions in gonadotropin regulation as well. In WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 19 any event. once adequate suppressive therapy is in­ 111g or up. The degradation 111etabolite of 17 hydroxy­ stituted. postpubertal females rapidly feminize and progesterone ( I 70H-P). pregnanetriol, was found to become ovulatory. be elevated in the urine of these patients and has been Diagnosis can be suspected on the basis or used for years to conf-irm the diagnosis and to baseline urinary 17-ketosteroids ( 17-KS). Normal monitor therapy. Most laboratories report normal adult females ordinarily have values between 2 and 12 values in adult females to be 4 mg or less per 24 mg/24 hours. Patients with obesity. stress situations. hours. Patients with CAH have values from modestly essential and familial hirsutism or Stein-Leventhal above 4 mg up to manyfold this level. The sup­ syndro111e may have levels to 25 or even 30 mg/24 pressibility of this steroid as well as 17-KS by 2 mg of hours whereas patients with CAH usually will have dexamethasone every 6 hours for two days proves the baseline values on the order or 50 111g/24 hours. ACTH dependence of the disorder and differentiates Patients with adrenal adenomas ordinarily will have it from the autonomous virilizing adenomas and car­ values of approximately 100 mg. and patients with cinomas ( 16). However. it appears that pregnanetriol virilizing adrenal carcinomas will have values or 200 is not a primary intermediate in the formation of an-

0" CH,-C-S-CoA H 0 ·Acetate" 1 2 H

,o� O O O O CH LESTER L .#ALD STER NE 0 H 0H H H ,?f ' CH3 1 2 S 2 1 O C• I 0 3-/3-ol-deH ---+21- H � �• O Pre9nonediol I S M ERASE 0 h O O O O O O O CORTIC STERONE PREGNEN L NE PR GESTER NE" DESOXYC.o95RTICOSTERO NE �.�O (D C) (C . BK l 0 0 0 H H 17- H I 1H, I H3 SH2 H

H O A O O H ( 17-KS} _,ffi H 0�

O O TEST STERONE ,.o:SP ESTRADI L and glt11.:0L:orti1.:oid lormalion. Arnbiguou� Fig. 4-Defect of J/3 ol-dehydrogenase-isomerase. Fatal due tu decreased mi1h.:raloconicoic.J due to peripheral convc.:1· genitals in m..ilcs due 10 deficient androgen production to full) mas..:ulini1c in utcro. Partial virili1;.1tion ol fcmaks sion of DHA to androgens. WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 20

II 0 11 CH,-C-S-CoA '(H2 H "Acetote

"'� ,#ALOOSTERONE CHOLESTEROL /f ' 0 I 1 C CH2 H CHsC CH20H CH3 O O ... C•O • • -H�rb 3-,8-ol-deH • -- a9t. ctsP 0 h IS=SE Pretnanediol RE NENOLO NE o o� ,,05° ) ) CORTICOSTERONE iiii OESOXYCORTICOSTERONE P G PROGESTERONE 0 H 0H •i II IIIIII········"·� (DOC (CO. BK i CH2c H C, 2 CH• 17-0H t c,Hs I , 1 -+- C•O C C O •� • ·�oH OH OH OH � H � o:9-?. a9?h � netriol T SR 0 O o HO O F CORTISOL 17-0H -PREGNENOLONE 17- H-PROGESTERONE 11-0ESOXYCORTISOL (CO.SR) (CO. K)

OH A H (17-KS) _,ffiOH O 0� ,,oSP TESTOSTERONE ESTRAOIOL Fig. 5-Seventeen

II CHs-C-S-CoA H20H ·Acetate" 1

"� CHOL ESTEROL .o55AL OOSTERONE H20H 3 CH20H / ' q c1H C•O I 3-,8-ol-deH 21-0H o9t. � � t ISOMERASE Pre9nanediol 0 h CORTICOSTERONE PREGNENOLONE PROGESTERONE OESOXYCORTICOSTERONE . (CO. BK l .�(DOC) � o95 H20H qH20H 17-0H <;Hs I <;Hs q t C•O 'f C•O C•O ' OH OH ffi -. netrlol HO,(C( 0 �'" CORTISOL 17-0H-PREGNENOLONE 17-0H-PROGESTERONE 11-0ESOXYCORTISOL .ciSP.'" (CO.S�) (CO, FK)

i 0

OH A -..6·-��., (17-KS) (17-KS) OH OH _,ffi o�s "� TESTOSTERONE ESTRAOIOL

Fig. 6-Mild 21-hydroxylase defect. Glucocorticoids and mineralocorticoids may be formed, but al expense o_l adrenals becoming _ _ hyperplastic with overt production of androgen precursors which are converlcd to testosterone. This leads to vmltzat1on in adults, somatic precocity and pseudohermaphroditism in female infants. WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 22

0" C C H,- -S-CoA 1H20H "Acetote"

"� C ALOOSTERONE HOLESTEROL ,o55 ,.. I"•'" "'--- I"•'" I H '"• C q , C o9.?:·o �I ·O •O 3 eH � � I � oSP Pre9nonediol O h "'� \SOME RASE 0 h O C PROGESTERONE OESOXYCORTI OSTERONE CORTICOSTERONE PREGNENOLONE (DOC} (CO.B K } I H H20H qH20H 17-0H qH, I q , � C C•O T C•O T •O OH OH OH m _. netriol. HO-CXY 0 ,�?"-C C 11-0ESOXY ORTISOL ORTISOL 17-0H-PREGNENOLONE 17-0H-PROGESTERONE C ( O.SR} (CO. FK}

'

"°� OH A (17-KS} OH _,ffi OH 0� TESTOSTERONE ,,oSP ESTRAOIOL Fig. 7-Severe 21-hydroxylase defect. Virilization findings similar to the mild form but additionally salt loss occurs due to the mineralocor­ ticoid deficiency including aldosterone.

from the excessive ACTH activity. Clinically, these high. This suggested to them a selected inhibition of patients present as the 11-hydroxylase patients except the 11/3-hydroxylation of I 7a-hydroxylated steroids for hypertension and salt retention. Diagnosis can (30). be suspected on the basis of hypertension. Biochemi­ Eigh1een-hydroxy/ase dehydrogenase defec1 (Fig. 9). cal confirmation is by the finding of elevated levels of Ulick (31) described this disorder accompanied by tetrahydro-S (the degradation product of 11-desoxy­ low aldosterone resulting in low serum sodium. hi�h cortisol) in the urine. More specific radioimmuno­ potassium, dehydration, hypotension, high renin ac­ assays for DOC and 11-desoxycortisol may simplify tivity, and elevated levels of hydroxycorticosterone. diagnosis in the future. This disorder should not enter into the differential Late onset of this disorder has also been diagnosis of amenorrhea and the virilizing congenital reported (28, 29). Zachmann and co-workers exten­ adrenal hyperplasias. sively studied an infant girl with an 11-hydroxylase Seven1ee11 /3-hydroxysferoid dehydrogenase de­ deficiency who was normotensive and had normal feel (deficienf 1es1icu/ar J 7-ke1os1eroid reduc1ase ac­ levels of DOC though compound S was excessively livity) (Fig. 10). Goebelsmann and co-workers (32) WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 23 described a 46-year-old married phenotypic female found grossly elevated androstenedione levels along with clitoral enlargement, hirsutism, breast develop­ with elevated urinary 17-KS and plasma estrone, but ment, and a blind vaginal pouch. Chromosomal subnormal amounts of testosterone and estradiol. In karyotype was 46 X Y. Abdominal testes were re­ vitro incubation of testicular tissue from their sec­ moved. Prior to operation, testosterone was at low ond case confirmed a partial defect in testicular 17- normal male levels, though considerably above female KS reductase activity and documented increased 3JJ­ levels. Urinary 17-KS were 33 mg/24 hours. The find­ hydroxysteroid dehydrogenase activity. They felt that ing of androstenedione of 1.02 µg/ 100 ml (being ten­ failure of breast development was probably due to fold above normal male levels) suggested testicular lower estrogen levels than in previously reported I 7JJ-hydroxysteroid dehydrogenase deficiency. More cases. Accordingly. when one finds elevated 17-KS in recently, Givens and associates (33) described two an amenorrheic individual, further delineation or additional patients (sisters) with primary amenor­ the defect by steroid biochemical assays seems rhea. hirsutism. clitoral enlargement, 46 XY karyo­ warranted. Indeed, such investigations may show the type. but lacking breast development. They, too, Reifenstein syndrome as well as other forms of male

0 " CHs·C-S-CoAM 0 •Acetate yH2 H

O O CHOLESTEROL .o55ALD STER NE ,,# 0H C 0 CH3 H3 CH2 H / ' SH2 =O ' =O C C=O O H 3 eH :· * � l! � � DS° a;n ISOMERASE Pre9nonediol o ,.DS° 0 h h O O O O O O PREGNENOLONE PR GESTERONE DES XYC RTICOSTERONE C RTICOSTER NE (DOC) (C O.BK) H H H 0 H 0 17-0 yHs I q s � 2 H S 2 H O ' C=O 'f C=O C C= OH OH OH =� m _. netrio� HO ,(:(:( 0 O O 0 O O H O O 11-DESOXYCORTISOL .o9?·"C RTIS L 17- H-PREGNEN L NE 17-0 -PR GESTER NE C (CO.SR) ( O. F•)

0 ' i

,o� DH A .....6.-�0.:., ( 17-KS) (17-KS) OH OH _,ffi

0� ,o� O O TEST STER NE ESTRADIOL Fig. 8-Eleven-hydroxylase defect. Virilization due lO shunting ol' adrenal precursors to androgenic pathway. Hypertension results lrom accumulation of mineralocorticoids-principally desoxycorticostcronc. WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 24

0 " H 0 CH,-C-5-CoA 9 2 H "Acetate"

"� O O O ALD STERO CH LESTER L ,#� O 0H H � C,H2 H C s CHz I C s , C•O t C•O H H 0 3-/3-ol-de 21- H � -•� � �rtS � �. O Pre9nonediol OCC( IS MERASE 0 h OCC( O O O O O O O DES XYCORTIC STERONE C RTICOSTER NE ,,oSDPREGNEN L NE PROGESTER Nf O K (D C) (CO. B ) H 0 H H CH20H q zOH 17- H I q , I q , 1 C•O 'f C• O t C•O C• ° OH OH �OH m _. � � netriol 0 -- o� " HO(:() O O O O O 17-0H-PROGESTERONE 1 l·DESOXYC RTIS L C RTISOL 17-0H-PREGNEN L' NE O (C .SR) (CO. FK) i 0

--6·-��,\, DH A H (17-KS) (17-KS) O OH _,ffi 0� TESTOSTERONE ,,oSP ESTRADIOL Fig. 9-Dercct or 18-hydroxylase dehydrogenase. Aldostcronc deficit lead, tu dccrca,cd plasma sodium. high potassium. dehydration. hypolension. and high renin activity. No direct gynecologic c:ndocrinop,llh) a:-.:-.cH.:iatiun. pseudohermaphroditism to be due to this disorder of complex. Probably there are patients now classed steroid biosynthesis. with this syndrome whose disease primarily resides in Stein-Leventhal syndrome (Fig. 11). Early the adrenal cortex. others who have primarily an workers dealing with in vitro studies showed an ac­ ovarian defect: but the majority have a defect in cumulation of DHA and testosterone in incubation hypothalamic function. Accordingly. it is felt that studies on ovarian tissue from patients with this syn­ there is no such neat demonstration of a consistent drome. These studies suggested a partial defect in biochemical defect as outlined in Figure 11 in spite of the aromatizing enzyme to convert testosterone early works suggesting such. to estradiol as well as an inadequacy of 3/3-ol Case Presentations. Post-pubertal simple viriliza­ dehydrogenase activity. However, such observations tion. Patient M.S.H.. Duke Unit #5-59154 (Fig. 12). were not interpreted to imply the uniform existence A 17-year-old female was seen on referral November of invariable, all-or-none enzyme defects in the I, I 961. with defeminization. Menarche was at 11 polycystic ovarian tissue (34). Accumulating evidence years with regular menses for two years. At age 13. would suggest, however. that the issue is much more the patient had mumps and measles during a two- WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 25 week period. Infrequent and scant menses. averaging and on November 21, 1968, a 6 lb. 15 oz. normal one per year followed. Acne and hirsutism steadily female infant by Dr. William A. Peters. Her pelvis progressed after age 11. Loss of scalp hair had was normal by x-ray pelvimetry. During each de­ progressed for 5 months. Patient was said to be the livery, the patient was supported by parenteral product of a normal term delivery, though she was hydrocortisone, and her oral glucocorticoid was adopted. Pertinent laboratory findings are noted in doubled then gradually tapered to maintenance level Table I. Two rest days intervened between the during the immediate puerperium. In that the ACTH. metapyrone, and dexamethasone tests. Sup­ patient appeared so normal and was cycling spon­ pressive therapy was started, and the patient had an taneously, gl ucocorticoid therapy was discontinued ovulatory spontaneous menstrual period 6 weeks in September 1969. She has continued to have later proved by endometrial biopsy. She was mar­ cyclic menses without evidence of virilization. Dur­ ried, and while on suppressive therapy. delivered ing the past year. her urinary 17-KS were 13.7 ,pontaneously on January I, 196 7. under pudenda! mg/24 hrs on two occasions, and her 17-hydroxy­ ,lock anesthesia, a 5 lb. 8 oz. normal male infant corticosteroids (I 70H-CS) 2.9 and 4.3 mg/24 hours.

9H20H �C:O \ 0

0

CH,I C=O 3-,8-ol-deH a5!?. --+21-0H � t ISOMERASE PreQnonediol 0 h PREGNENOLONE PROGESTERONE DESOXYCORTICOSTERONE CORTICOSTERONE (DOC) (CO.BK) 17-0H 9H, H, H20H �H20H I I 9 � l c:o ' c:o c:o H OH OH - . (i::Y --+­ netrlol • HO,ex:r- 0 0 ,oS!?"11-DESOXYCORTISOL CORTISOL l�OK-PREGNENOLONE 17-0H-PROGESTERONE (CO.SR) (CO. FK)

t 0

DH A -a·-�� (17-KS) (17-KS) .y .rb OH , .,..._,

0� TESTOSTERONE ,,oSDESTRADIOL Fig. 10-Defect of 17/3-hydroxysteroid dehydrogenase . Extremely rare steroid defect where androstenedione increased some ten ld over . of normal levels while achieving low normal testosterone. Reported in male pseudohermaphrodites. hence a cons,derauon in d1fferent1al diagnosis from common forms of CAH. WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 26

II

cH,-C-S-CoA "Acetate"

HO .. C?LESTEROL I I I CH, CH3 'f c,o 11 c,o

3-,8-ol-deH � �t O Pre9nonediol I S M ERASE 0 h .. DS°O O II PREGNEN L NE PROGESTERONE I H 17-0H qHs I q 3 ' I t c,o c,oOH H O m II - , � netriol HO-CX)' 0 O O I O O 17-0H -PREGNEN L NE I 17-0H-PR GESTER NE l : i 0

� � 4 .. .c66O O DH A • L', -ANDR STENEDI NE' H (17-KS) (17-KS l I O • OH II--+,• O .ct98TESTOSTER NE • .. o:SPESTRADIOL Fig. 11-Aromati,ation defect leading to excessive accumulation or 11.::-.to:-.tcrnnc and panial JP·vl Jd1�Jrugcnasc dde(l cJusing dcvat1.:d h.:vcls of DHA de�cribed inconsistently with Stein·Lcvcnthal :-.)ndromc.

Co111111e111. Postnatal virilization of the female is ruled out. The chances of offspring having the dis­ more commonly due to an autonomous tumor or in­ order are remote. since the prevalence of the gene for gestion of hormones than due to the postnatal (ac­ the disorder is on the order of I in 128 for heter­ quired) form of congenital adrenal hyperplasia. ozygotes and I in 67.000 for the overt disease (35). However. ready suppressibility of this patient's However. the frequency will be on the increase in that greatly-elevated abnormal steroids bespeaks the affected individuals with proper treatment will no nature of her disorder. Since her onset occurred after longer be sterile (36). This patient is remarkable in most. if not full. statural growth had been achieved. that she has remained apparently normal for a pro­ she was not stunted. nor was her pelvic capacity com­ tracted period of time off of therapy in spite of a promised. Accordingly. delivery was spontaneous. severe abnormality of steroidogenesis when first diag­ Her children have been assessed for the possibility of nosed. Her 17-KS are now upper limits of normal and congenital adrenal hyperplasia. and this has been her I 70H-CS are low bespeaking the fact that she WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 27 probably is just minimally compensated. However. she has undergone the stress of rearing two small chil­ dren and moving to Europe without decompensating. Accordingly. our original hypothesis or decompensa­ tion due to psychologic stress of adolescence may bt: questioned (37). Postnatal simple virilization. Patient K.S.S .. Unit # 61682 (Fig. 13). A 13-year-old white female was seen January 18. 1963. because or "virilizing syn­ drome." She was born prematurely. Development was normal until age 4 when pubic and axillary hair became apparent. Her 17-KS were elevated. and glucocorticoid therapy was given elsewhere for two years. but discontinued by the mother when Cushingoid features developed. These rapidly dis­ appeared. but were followed by progressive hir­ sutism. One brother had prostatic hypertrophy diagnosed at age 19. Suppressive therapy was started January 23. 1963. and the patient was hospitalized elsewhere April 3. 1963. with right lower quadrant abdominal pain. Fifteen days later. menarche occurred and was followed by regular menses and rapid budding or breasts. Hirsutism gradually decreased. but her voice remained unchanged. Significant laboratory data are shown in Table I. Iliac crests were fused on the ab­ dominal film. With her last menstrual period in May 1967. and after an adequate trial of labor. Fig. 12-Paticnt M .S.H .. #F-59154. Normal reminine contour and patient was delivered by cesarean on February 5. cndocrint: mc.!asurements existed with comcdones and racial hir­ 1968. of a 5 lb. 7 oz. normal female. Opera- ,uti>rn. B.P. 120/70. Weight 61 kg.

TABLE I Urinar� S11.:ruiJ .... Patient Age Therapy 17-KS 17-0H-CS 17-Kctogcnic Prcgn..inetriol M.S.H. 17 None 82.8 I 1.-l I). 7 9.7 ACTH Gel 40 U IM q. 12hrs. X 3days 16-l.7 .ll.O I )6.6 2-l.9 Mctapyronc 500 mg 77-l -l1.8 128.0 -13.2 q. 4 hrs. X 2 days Dexamethasone -11.8 1.-l 9.8 2.9 0.5 mg. q. 6 hrs. X 2 days Dexamethasonc H 0 3.6 0.5 2 mg. 4. 6 hrs. X 2 days

K.S. 13 None 40.1 71.3 Dexamethasone I 8.3 107.8 0.5 mg q. 6 hrs. X 2 days Dexamethasonc 7.6 .ll.-l 0.5 mg q. 6 hrs. X 2 days Dexamcthasone 5. 7 2.7 11.6 1.-l 2 mg. q. 6 hrs. X 2 days WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 28 timate stunting from excessive sex steroids. In turn, this probably necessitated delivery by cesarean because of cephalo-pelvic disproportion. In the past, some patients with adrenal hyperplasia who could not tolerate steroid therapy have been subjected to adrenalectomy. However, such surgical therapy is no longer warranted, for proper monitoring should be achievable so that the disease can be brought under control without significant side effects from the medication. Hayek and associates have suggested the single dose of a long-acting suppressive agent at mid­ night for therapy of this disorder with good results: hence simplifying therapy (38). Such therapy is appealing and rational. However. one must use a fair­ ly long-acting steroid: therefore. oral hydrocortisone, the naturally occurring hormone that is missing, can not be utilized. Problems persist in such patients as this who have their sleep-wake patterns altered by work habits (she is a telephone operator working swing shifts). This may account for the need for an ad­ ditional a.111. dose. Reversibility of some signs of virilization occur (the patient has lost much body hair. though some facial shaving is still necessary). Rapid feminization as shown by breast development and ovulatory menses is to be expected once adequate therapy is instituted. Her hospitalizaiion was for suspected appendicitis. but the pain was apparently mittelschmerz. since she had her menarche two weeks later. Clitoromegaly and deep voice have persisted in this patient. since such changes. once they occur. do not reverse. Contraception in this patient. as well as Fig. 13-Paticnl K.S.S .. # 6168�. ShO\\:,, :-.tunlcd grtl\\th. L.11..:ial hir­ sutism. and android c:-.cu1chcon. Chc:,,t \\a:,, :,,havcd prior to in the first, is by intrauterine device. Estrogen­ photograph� i'vlusck hypcrtroph� \\ luteal phase with plasma estradiol 20.3 highly unlikely in this patient. since initial therapy ng%. suggest ovulation. However, her plasma tes­ had been discontinued for almost a decade before tosterone persisted in the range from 80 to 120 she was found hypertensive. ng% bespeaking continuing excessive testosterone Pa1ie111 L. 0. T., Uni/ # 235684-5. A 38-year-old production. Accordingly. an additional 2.5 mg of nulliparous obstetrical nurse was seen on referral prednisone is being added in the morning. because of inadequate control of adrenal hyperplasia Co111111e111. Failure to continue glucocorticoid while laking divided doses during the day. Some therapy as prescribed by her physician led to evidence of virilization probably was present at birth premature closure of this patient's epiphyses and ul- (clitoromegaly). though hirsutism did not become WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 29 manifest until after age 5. In 1954, the patient seen by another physician who treated her with pred­ elsewhere underwent vaginoplasty, abdominal ex­ nisone. Menses then resumed, and the patient spon­ ploration, and clitoridectomy with the findings or taneously achieved a pregnancy only to have mid­ follicular cyst of the ovary with occasional ova and a trimester loss with prolapsed cord, intrapartum hypertrophic clitoris (5 cm.). The adrenals were death, and delivery by cesarean. On physical exami­ thought normal to palpation. The patient was em­ nation, the patient had considerable facial hirsutism, pirically treated with Premarin® and thyroid and modest clitoromegaly, but normal size ovaries. had withdrawal bleeding. All therapy was discon­ The patient was again studied off therapy with ele­ tinued in 1964, and she had spontaneous regular vated l 70H-P of 4.4 µg%. Her plasma progesterone menses for one year with flowlasting 3-5 days and on was 132 ng%. With adequate suppression, plasma occasion had associated cramping. Her baseline 17- progesterone rose to 1.7 µg% (ovulatory level) and KS were 51 mg. rising to 109 with ACTH and sup­ I 70H-P fell to 160 ng% (normal). The patient spon­ pressing to 13.4 mg. with Decadron®. She was dis­ taneously resumed menses and became pregnant with charged on 25 mg. cortisone per day and was later last menstrual period November 11, 1974. On Janu­ changed to prednisone. However, she was seen on ary 8. 1975. continuing the same dose of 5 mg referral, and her urinary pregnanetriol was 31.5 mg/ prednisone at bedtime, her plasma testosterone was 24 hrs. She was shaving twice daily. The patient was 80 and plasma I 70H-P 137 ng%, and her plasma working swing shifts as a registered nurse. She was progesterone was greater than 1.6 µg%. advised to take 5 mg. prednisone before going to bed Comment. Patients with congenital adrenal and 2.5 on arising and an additional 2.5 mg during hyperplasia being adequately treated will be unable the day if necessary. Since institution of this therapy. to have plasma or urinary estriols as an index of fetal her plasma testosterone has ranged from 16 to 28 well-being in as much as these steroids cross the ng% with concomitant loss of chest and arm hair. placental barrier and suppress fetal-adrenal ac­ though facial shaving is still needed. Her plasma tivity-a most important source of precursors for estradiol has been between 2 and 43 ng%, though pregnancy estriol. Differential suppression tests she has remained anovulatory while cycling. as should be able to delineate patients with primarily shown by plasma progesterones repeatedly less than ovarian disorders as opposed to those with primarily 400 ng%. Her I 70H-P has ranged from 118 to adrenal disorders and prevent unnecessary wedge 496 ng%. resections in the future. Comment. Patients working swing shifts can ex­ Patient L.H.. Unit # 235525-8. A 27-year-old perience considerable difficulty in controlling their patient was seen in consultation because she had excessive androgen production since the ACTH surge developed Cushingoid features as a result of being on may come at a time when they are not receiving their prednisone for persistent amenorrhea. Menarche was larger dose of suppressive steroid. Also, changing at age 12 with an average of one cycle per year until shifts alter diurnal variation and may in itself be a age 18 when she was placed on oral contraceptives stressful situation causing further decompensation. If with regular withdrawal bleeding for three years. even suppression is not obtained by giving a dose Upon discontinuance, the patient remained amenor­ prior to anticipated ACTH surge, consideration of rheic for one year when she was seen by a gyne­ longer-acting injectable therapy such as utilized in in­ cologist and had bilateral wedge resection of ovaries. fants may be considered. Neither this patient, nor our She remained amenorrheic for another year except patient undergoing cesarean, had evidence of for scant spotting on rare occasion. The patient classical Stein-Leventhal type ovaries, although CAH was admitted to another university center and under­ has been noted associated with polycystic ovaries went dexamethasone suppression test with 17-KS, (40). The thickened capsules in such patients have suppressing from 21 mg/24 hours to 6 mg on the been attributed to excessive androgens. first day of high-dose dexamethasone. She also had Patient P.B., Unit # 233484-2. A 23-year-old adrenal and ovarian vein catheterization, showing gravida II, para I, abortus O had menarche at age 12 adrenal venous plasma testosterones quite elevated and cyclic menses until age 16 when she started skip­ with some elevation of ovarian and peripheral ping menses. At age 17, she had ovarian wedge resec­ values. She was placed on prednisone 10 mg every tions elsewhere with diagnosis of Stein-Leventhal other day with spontaneous menses occurring ap­ syndrome. However, menses did not resume. She was proximately every 6-7 weeks. She then relapsed into WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 30 amenorrhea. Medication was discontinued for retest­ attempt to downplay its importance. However, the ing. and after one month off of therapy. her clinical course of this patient, that is, the onset of plasma I 70H-P was 1.8 µgo/o (approximately five hirsutism and facial acne just prior to her evalua­ to tenfold the normal values) with plasma testoster­ tion. would suggest postnatal onset of her disorder. one 79 ng% (upper limits of normal for adult Patient C. G., Unit # 172230-/. A 20-year-old females in our laboratory are 60 ng%). plasma patient had onset of virilization at age 11, and the cortisol 10 µgo/o at 8 a.m.. plasma estradiol 24.1 diagnosis of congenital adrenal hyperplasia was made ng% (normal proliferative phase value), plasma at a medical university well known for its large series progesterone 94.5 ng% (anovulatory value). On of congenital adrenal hyperplasia patients. Initial suppressive therapy. I 70H-P fell to 165 ng%, tes­ attempts to control her here by continuing cortisone tosterone was 71 ng%. and plasma estradiol re­ acetate which had been instituted elsewhere failed, mained at 22.9 ng% with progesterone 78 ng%. and she was switched to prednisone in 1970. taking Stimulation with Clomid®. escalating doses to a 2.5 mg every eight hours. However, when seen in maximum of 150 mg/day times five days. indicates February. 1974, her 170H-P was greater than 1.4 the patient remains anovulatory with progesterone µgo/o. and her plasma progesterone greater than 1.6 50.5 ng%. plasma estradiol 24 ng%. while 170H-P µgo/o. with plasma testosterone 72 ng%. She was has remained 112 to 216 ng% during the time she anovulatory as shown by endometrial biopsy and is being maintained on p.m. suppressive prednisone. basal body temperature charts. Five mg. of pred­ Commenl. This patient with a mild form of 21- nisone at bedtime still failed to achieve suppression hydroxylation defect with firstmanifestations in post­ with plasma I 70H-P of 3.7 µgo/o, therefore, pred­ natal period did not achieve smooth suppression with nisone has been increased to 7 .5 mg/day while sterili­ alternate-day therapy. Even though nighttime ty investigation is being pursued. therapy has brought about normalization of I 70H-P Discussion. Differential diagnosis of congenital and near normal values of plasma testosterone. she adrenal hyperplasia includes disorders of adrenal and remains anovulatory and unresponsive to Clomid"" gonadal origin. Rarely are such entities as Morgagni­ at this time. In this patient, the elevation of 170H-P Stewart-Morel syndrome or Achard-Thiers syn­ in the plasma out of proportion to the progesterone drome of any importance in the differentialdiagnosis. would indicate that her primary pathway to I 70H-P if indeed they represent true syndromes. is through 17-hydroxy-pregnenolone rather than Cushing·s syndrome is readily differentiated by through progesterone. Also. findings would suggest overnight dexamethasone suppression test in most that even though near-optimal biochemical control of patients and by baseline values of glucocorticoids. the disorder can be achieved. fertility does not Rarely is virilization of the degree seen with CAH automatically ensue. She probably needs further sup­ present in patients with Cushing's syndrome. Ex­ pressive therapy. If optimum control is then achieved ogenous administration of virilizing hormones can as shown by normal plasma testosterone. I 70H-P. present a problem particularly when the patient does and urinary 17-KS. then a search for other causes or not know what she has received. Anabolic steroids amenorrhea are warranted, for they can be subject to have been given in wasting diseases, osteoporosis. such disorders as hypothalamic amenorrhea. and to improve libido. The differentiationof ovarian Patieni J. L., Unit # 161059. An I I-year-old hyperandrogenic syndromes including Stein­ patient was seen in consultation after she had seen a Leventhal syndrome can generally be made on the group movie at school on sexual development in basis of differential suppression tests employing which a photograph of abnormal external genitalia glucocorticoids to suppress the adrenal component was shown. She persisted in telling her teacher that and combination estrogen-progestogen preparation she had such abnormal genitalia. Although "show such as Enovid"" E for the ovarian component (41. and tell" in its fullest sense did not occur, this ex­ 42). True hermaphroditism usually is not much of a perience led to her being referred where the disorder problem since prepubescent hirsutism is not usually was well characterized. She is now on suppressive evident even though ambiguous genitalia may exist. therapy. Steroid assays readily differentiate the conditions. Comment. Clitoromegaly of this degree, had it Occasionally, patients with gonadal dysgenesis with a been present at birth, surely would have been Y stem line (usually) may present with signs or hir­ recognized, though possibly some physicians may sutism and clitoromegaly. This has been particularly WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS 31 true of patients with gonadoblastomas or Teter's 4. BONGIOVANNI AM. KELLENBENZ G: The adrenogenital syn­ gonocytomas III and IV. Again, steroid assays readi­ drome with deliciency of 3{3-hydroxystcroid dehydrogenasc. ly differentiate the condition. In patients with viriliz­ J Clin lnveJt 41:2086-2092. 1962. ing ovarian tumors such as an arrhenoblastoma, elevated androgens will not suppress with exogenous 5. KENNY FM, REYNOJ.11S JW, GREEN OC: Partial 3{3- administration of glucocorticoids. Further, their hydroxysleroid dehydrogenase (3{3-HSD) deficiency in family with congenit..il adrenal hyperplasia: Evidence of increasing urinary 17-KS are generally not of the magnitude or 3{3-HSD activity with age. PediatricJ 48:756-765, 1971 those seen with CAH. Summary. Enzymatic defects of adrenal and 6. BONGIOVANNI AM, ROOT AW: The adrenogcnital syndrome. gonadal steroidogenesis have been described, many N Engl J Med 268: 1283-1289, 1963. of which lead to amenorrhea and sexual ambiguity. Seven patients with congenital adrenal hyperplasia 7. KOGUT MD: Adrenogenital syndrome: Association wi1h 3-{3- are presented who were first diagnosed at times far hydroxysieroid dehydrogenase deficiency. A III J DiJ Child removed from the neonatal period. One such patient 110:562-565. 1965. had dramatic onset of hirsutism, amenorrhea, and profound elevation of androgens. After suppression. 8. BIGLIERI EG, HERRON MA, BRUST N: 17-hydroxylation deliciency in man. JC/in Invest 45: 1946-1954. 1966. she achieved two pregnancies, delivered. and subse­ quently has gone off therapy and continues to have 9. Editorial comment. Obst et Gynecol Surv 29: 147-148. 197 3. cyclic menses in spite of borderline steroid values. The usefulness of a single nighttime long-acting 10. NEW Ml, MILLER 8, PETERSON RE: Aldosterone excretion in glucocorticoid in achieving smooth suppression in normal children and in children with adrenal hyperplasia. patients with adrenal hyperplasia appears rational JC/in Invest 45:412-428. 1966. and is meeting with success. Diagnosis and monitor­ ing of therapy of such patients has been facilitated 11. BARTTER FC. HENKIN RI, BRYA GT. ET AL: Aldosterone by the availability of immunoassays for 170H hypersecretion in "non-salt-losing" congenital adrenal hyper­ progesterone, and testosterone in lieu of urinary 17- plasia. JC/in Invest 4 7: 1742-17 52, 1968. KS, and urinary and plasma pregnanetriol assays. 12. Go1.11z1EHER JW: Oestrogens in congenital adrenal hyper­ Authors' note: Since preparation of this presenta­ plasia. Acta Endocrinol 54:51-62. 1967. tion, Sa reductase deficiency has been described in association with male pseudohermaphroditism. 13. HALI. K, HOKFELT B: Clinical and steroid metabolic studies (Walsh et al, Familial incomplete male pseudo­ in four siblings with congenital virilizing adrenal hyper­ hermaphroditism, type 2, decreased dihydrotestoster­ plasia. Acta Endocrinol 52:535-549, 1966. one formation in pseudovaginal perineoscrotal hy­ pospadias, N Engl J Med 291:944-949, 1974). 14. WILKINS L: The Diagnosis and Trea1111ent of Endocrine Disorders in Childhood and Adolescence. ed. 2. Springtield. Acknowledgmenr: The authors wish to thank Dr. Illinois, Charles C Thomas. 1962. p. 346. Richard Horton for the testosterone antibody, Dr. Walter Wiest for the progesterone antibody. and Dr. 15. STEVENS VC, GOLDZIEHER JW: Urinary excretion of V. B. Mahesh for the estradiol antibody. gonadotropins in congenital adrenal hyperplasia. Pediatrics 41:421-427, 1968. REFERENCES 16. L11111LE GW: Tests of pituitary-adrenal suppressibility in the I. PRADER A, GURTNER HP, S1EBENMANN RE: Das Syndrom diagnosis of Cushing's syndrome. J C/in Endocrinol Metab des Pseudohermaphroditismus masculinus bei kongenitaler 20: 1539-1560, 1960. N eben nieren rinden-H yperpl asie oh ne Androgen ii berprod ru k­ tion. Helv Paediat Acta 10:397-412. 1955. 17. AXELROD LR, GOLDZIEHER JW: The metabolism of 17 cr­ hydroxyprogesterone and its relation to congenital adrenal 2. PRADER A, S1EBENMANN RE: Nebenniereninsuffizienz bei hyperplasia. J Clin Endocrinol Metab 20:238-252. 1960. kongenitaler Lipoid hyperplasie der Nebennieren. Helv Paediat Acta 12:569-595. 1957. 18. R EIFENSTEIN EC: 17-alpha-hydroxyprogesterone and the 3. BAULJEU EE, PEILLON F, MIGEON CJ: Adrenogenital Syn­ virilism of lhe adrenogenital syndrome associated with con· drome, in Eisenstein AB (ed): The Adrenal Cortex, Boston. genital adrenocortical hyperplasia-a review. J C/in Endo­ Lillie Brown and Company, 1967, p 603. crinol M etab 16: 1262-1275, 1956. 32 WILLIAMSON AND MATHUR: DEFECTS IN STEROID BIOSYNTHESIS

31. U1.1cK S, GAUTIER E, VETTER KK, ET AL: An aldosterone 19. PI-IAM-Huu-TRUNG MT, GOURMELEN M, GIRARD F: The simultaneous assay of cortisol and 17 alpha hydroxy­ biosynthetic defect in a salt-losing disorder. J C/in Endocri11ol progesterone in the plasma of patients with congenital Mernb 24:669-672. 1964. adrenal hyperplasia. Ac1a Endocrinol 74:316-330, 1973. 32. GoERELSMANN U, HORTON R, MESTMAN JH, ET AL: Male 20. FRANKS RC: Plasma 17 hydroxyprogesterone. 21 desoxycor­ pseudohermaphroditism due to testicular 17/3-hydroxysteroid tisol and cortisol in congenital adrenal hyperplasia. J Clin En­ dehydrogenase deficiency. J C/in E11docri11ol Me1ab 36:867- docrinol Meiab 39:1099-1102, 1974. 879. 1973.

21 LIPPE BM, LAFRANCHI SH, LAVIN N, ET AL: Serum 17-a­ 33. GIVENS JR. WISER WL. SUMMITT RL, ET AL: Familial male hydroxyprogesterone. progesterone. estradiol. and testoster­ pseudohermaphroditism without gynecomastia due to one in the diagnosis and management of congenital adrenal deficient testicular 17-ketosteroid reductase activity. N Engl J hyperplasia. J Pediatr 85:782-787, 1974. Med 291 :938-944. 1974.

22. LIPSETT MB, RITER BD: Urinary steroids in post-natal 34. GOLDZIEHER JW, AXELROD LR: Clinical and biochemical adrenal hyperplasia with virilism. Ac/a E11docri11ol 38:481-489. features of polycystic ovarian disease. Fertil S1eril 14:631- 1961. 653. 1963.

23. LOGAN RW. McMILLAN NL: Adreno-cortical hyperactivity 35. C1111.ns B. GRUMBACH MM, VANWYK JJ: Virilizing adrenal -two interesting cases. Pos1grad Med J 40:604-610. 1964. hyperplasia: A genetic and hormonal study. J C/in l11ves1 .15:213-222. 1956. 24. MAHESH VB, GREENBLATT RB, CONIFF RF: Adrenal hyper­ plasia-a case report of delayed onset of the congenital 36. SPEROFF L: The adrenogenital syndrome and its obstetrical form or an acquired form. J C/i11 E11docri11ol Me1ab 28: aspects. Obs1e1 G_r11ecol Surv 20: 185-214. 1965. 619-623. 1968.

37. STFMPFEt. RS. WILLIAMSON HO: Postnatal virilizing adreno­ 25. CARA J. BEAS F. SPACH C: ET AL: Increased urinary and cortical hyperplasia with defective C,, steroid hydroxylation plasma etiocholanolone and related steroids in a boy with and adequate adrenocorticotropin reserve. Am Dis Child virilizing adrenal hyperplasia and periodic fever. J Pedia1r J I 04:570. 1962. 62:521-530. 1963.

26. CARA J. GARDNER LI: Two new subvariants of viriliz.ing 38. HAYEK A, CRAWFORD JD, BODE HH: Single dose dex­ adrenal hyperplasia. J Pediair 57:461-470. 1960. amcthasone in treatment of congenital adrenocortical hyper­ plasia. Mernbolism 20:897-901. 1971. 27. DEGENHART HJ, V1ssER HKA. W1LMINK R, ET AL: Aldoster­ one- and cortisol secretion rates in infants and children f 39. MARKS JF, FtNK GW: Prolonged hypertension following with congenital adrenal hyperplasia suggesting diferent 21- . cess.:ition of desoxycorticosterone therapy in congenital hydroxylation defects in "salt-losers" and "non salt-losers . . adrenal hyperplasia. Pedialrics 40:184-187, 1967. Acta E11docrinol 48:587-601. 1965.

40. Luns OJ, HOBKIRK R, HOLLENBERG CH, ET AL: Poly­ 28. GABRILOVE JL. SHARMA DC. DORFMAN RI: Adrenocortical cystic ovaries associated with congenital adrenal hyper­ 116-hydroxylase deficiency and virilism first manifest in the plasia. Ca11 Med Assoc J 94: 1-7. 1966. adult woman. N Engl J Med 272:1189-1194, 1965.

29. TOAFF ME, TOAFF R, CHA YEN R, ET AL: Congenital adrenal 41. CRUIKSHANK D. CHAPLER R, YANNONE ME: Differential hyperplasia caused by 11/3-hydroxylase deficiency with onset adrenal and ovarian suppression: diagnosis and trec1tmcnt of of symptoms after one spontaneous pregnancy. Am J Ob.fie/ androgenic disorders in women. Obs/et Grnecol 38:724- Gy11ecol 121 :202-204, 1975. 730. 1971

30. ZACHMANN M. VOLLMIN JA, NEW Ml, ET AL: Congenital 42. BENJAMIN F, COHEN M, ROMNEY SL: Sequential adrenal and adrenal hyperplasia due lo deficiency of 11/3-hydroxylation of ovarian suppression tests in the differential diagnosis of the 17 a-hydroxylated steroids. J C/i11 Endocri11ol Me1ab 33: polycystic ovary (Stein-Leventhal) syndrome. Fertil S1eril 501-508, 1971. 21:854-859, 1970.