PLASMA PREGNENOLONE, PROGESTERONE, 17-HYDROXYPROGESTERONE, TESTOSTERONE AND 5α-DIHYDROTESTOSTERONE IN DIFFERENT TYPES OF CONGENITAL ADRENAL HYPERPLASIA

Unconjugated pregnenolone, progesterone, 17-hydroxyprogesterone, testosterone and 5a-dihydrotestosterone were simultaneously measured by radioimmunoassay in plasma from children with congenital adrenal hyperplasia (CAH) due to a deficiency of 21-hydroxylase (21-OHase), 11 β-hydroxylase (11β-OHase) or 3β-hydroxysteroid dehydrogenase (3β-HSD). These steroids were also measured in a reference group of children of similar age. The following concentrations of these five steroids were observed in the prepubertal children aged 0-4-10-9 years: pregnenolone <0-2-0-85 ng/ml; progesterone 0-17-0-68 ng/ml; 17-hydroxyprogesterone 0-10-0-53 ng/ml; testosterone <0-05-0-14 ng/ml, and 5α-dihydrotestosterone <0-05 ng/ml (detection limit of the method). The concentrations were clearly elevated in the plasma of children with CAH. A very high plasma concentration of 17-hydroxyprogesterone differentiates a 21-OHase deficiency from the two other types: children with this defect had levels mostly in excess of 100-fold that of normal. Plasma progesterone concentrations in these patients were also high being in the range found during the luteal phase level in the adult. Their plasma testosterone concentrations showed a scatter from normal values to high adult male levels being mostly at the level of adult females. The concentrations of 5a-dihydrotestosterone were at or above those of adult males. A high plasma concentration of pregnenolone with at most slightly elevated progesterone and 17-hydroxyprogesterone levels differentiated the 3β-HSD defect from the other two forms of CAH. The plasma profile of the five steroids determined in a patient with an 11 β-OHase deficiency was close to normal, but slightly elevated pregnenolone, progesterone and 17-hydroxyprogesterone levels were found to be characteristic of this enzyme deficiency.     

ADRENAL PROGESTERONE, 17α-HYDROXYPROGESTERONE AND CORTISOL RESPONSES TO SYNACTHEN IN NORMAL WOMEN AND WOMEN WITH VARIOUS GYNAECOLOGICAL DISORDERS

In apparently normal subjects there is marked heterogeneity in the adrenal's capacity to produce the progestogens progesterone (Po) and 17α-hydroxyprogesterone (17Po). We have now screened for the possibility that adrenal progestogens might be an aetiological factor in some patients with hitherto unexplained gynaecological disorders by measuring the responses to acute stimulation with ACTH after overnight dexamethasone suppression. Plasma progesterone (Po), 17α-hydroxyprogesterone (17Po), and cortisol were assayed in 65 gynaecologically normal women and in 187 with a variety of gynaecological problems including dysfunctional uterine bleeding, unexplained primary infertility, endometriosis, polycystic ovaries, idiopathic hirsutism, and premenstrual syndrome. Responses to ACTH were compared with those in normal subjects according to predominant diagnostic category or categories. There was a wide spectrum of progestogen response to Synacthen in all groups with close agreement between the 30- and 60-min increments in the serum levels for any one steroid. The test was reproducible from one cycle to the next for 17Po (a relatively weak progestogen) and cortisol but much less so for the strong progestogen Po. This variability was not due to spontaneous fluctuation in dexamethasone-suppressed serum Po levels and remains unexplained. The 60-min Po and 17Po increments tended to increase slightly with age. Overall, the 60-min Po increments were a little higher amongst the patients with unexplained primary infertility than amongst controls. There were no significant differences in 17Po increments between normal women and patients, with an equal incidence of marked hyperresponse (exceeding 6 nmol/l increment) in both populations. Unexpectedly, the 18 patients complaining of severe premenstrual symptoms had significantly lower cortisol responses than other groups. We conclude that except in overt 21-hydroxylase deficiency, adrenal progestogens are unlikely to be a major factor in causing gynaecological disorders.     

SALIVARY 17α-HYDROXYPROGESTERONE IN CONGENITAL ADRENAL HYPERPLASIA

A specific radioimmunoassay having the sensitivity (4 pg/tube) and precision required for the routine determinations of 17α-hydroxyprogesterone concentrations in mixed whole saliva, parotid fluid and plasma has been developed. The correlation between 17α-hydroxyprogesterone concentrations in matched samples of saliva and parotid fluid was excellent (r = 0.98): therefore saliva, being easier to collect, was used exclusively in later studies. The median 17α-hydroxyprogesterone concentration in mixed whole saliva collected from thirty-two healthy children was 390 pmol/litre ranging from 90–1520 pmol/litre. In a group (n=14) of treated CAH patients having a C21 hydroxylase deficiency, 17α-hydroxyprogesterone showed a 20 fold greater variation, ranging from 67 pmol/litre in patients receiving excessive glucocorticoid dosage to 26300 pmol/litre in inadequately treated patients. A close correlation (r = 0.91) in 17α-hydroxyprogesterone levels was observed in matched samples of saliva and plasma collected between 09.00 and 10.00 h from these patients. Concentrations of 17α-hydroxyprogesterone in saliva therefore could well replace those in plasma for monitoring treatment of these patients. Matched samples of mixed whole saliva, parotid fluid and plasma were also collected from one inadequately treated female patient at frequent intervals over a 24 h period. Two other patients, one male and one female, collected matched samples at 30 min intervals for 4 h following Synacthen stimulation. The pattern of 17α-hydroxyprogesterone in these samples suggests that salivary steroid concentrations are of potential value in assessing endocrine function in conditions such as CAH, where frequent sampling over prolonged periods is required.     

BLOOD-SPOT 17α-HYDROXYPROGESTERONE RADIOIMMUNOASSAY IN THE FOLLOW-UP OF CONGENITAL ADRENAL HYPERPLASIA

The value of plasma 17α-hydroxyprogesterone (17α-OHP) concentration in monitoring the treatment of congenital adrenal hyperplasia (CAH) was studied by using a capillary blood micromethod. The blood-spot 17-OHP radioim- munoassay method involves serial sampling throughout the day and sending the samples into a centre by mail. Follow-up of seven children treated for CAH due to 21-hydroxylase deficiency showed that a single measurement of plasma 17-OHP concentration cannot be relied upon to determine adequacy of control, since circadian variation and timing of the sample in relation to the last dose of glucocorticoid may influence the plasma level of 17α-OHP. Our data confirm the value of sequential 17α-OHP assays throughout the day in the follow-up of CAH. With the blood-spot method the 17α-OHP determinations can be used on a wide scale for monitoring therapy.     

THE EFFECT OF ENDOGENOUS PROGESTERONE ON SERUM LEVELS OF 5α-REDUCED ANDROGENS IN HIRSUTE WOMEN

This study was to examine indirectly the effect of endogenous progesterone, a known competitor for 5 alpha-reductase, on androgen metabolism in target organs in hirsute women. Serum levels of progesterone, testosterone (T), androstenedione (A), dihydrotestosterone (DHT) and 5 alpha-androstane 3 alpha 17 beta-diol (3 alpha-diol) and sex hormone binding globulin (SHBG) were assessed serially over a four week period in normal women, six hirsute women with regular menstrual cycles, eight hirsute women with oligomenorrhoea (and presumptive polycystic ovaries) and seven non-hirsute women with oligomenorrhoea. Serum T and A levels were significantly higher than normal in both hirsute and non-hirsute women with oligomenorrhoea, while serum SHBG was significantly lower than normal in the two groups of hirsute women. The calculated free T level was higher than normal in all three groups of patients. DHT levels were not significantly different from normal in any of the three groups of patients. The 3 alpha-diol level showed considerable overlap with normal in all groups of patients and was only significantly higher than normal in hirsute women with oligomenorrhoea (P less than 0.05). There was a small fall in DHT in the late luteal phase of the cycle of those women with a sustained rise in serum progesterone in the second half of the cycle, but no change in serum 3 alpha-diol. These studies suggest that serum 3 alpha-diol may not be as good an indicator of peripheral androgen metabolism in hirsute women as previously reported and that a rise in serum progesterone has only a minimal effect on circulating levels of the active 5 alpha-reduced androgen metabolites. Although in vitro 3 alpha-diol has been shown to be a potent inhibitor of 5 alpha-reductase this casts doubt on its role in this regard in vivo.     

SEMINAL PLASMA LEVELS OF TESTOSTERONE AND 5α–DIHYDROTESTOSTERONE IN AZOOSPERMIC PATIENTS

Testosterone (T) and 5 alpha-dihydrotestosterone (DHT) have been measured in seminal plasma of sixteen azoospermic patients with tubular damage (germinal cell arrest or Sertoli cell only syndrome) and five patients affected by azoospermia of obstructive origin. In both groups T values were not significantly different from controls, while DHT was significantly lower in patients affected by azoospermia of obstructive origin.     

MEASUREMENT OF GONADOTROPHINS, TESTOSTERONE, Δ4 ANDROSTENEDIONE AND DIHYDROTESTERONE IN IDIOPATHIC OLIGOSPERMIA

Basal concentrations of FSH, LH, testosterone, delta4 androstenedione and dihydrotestosterone, together with FSH and LH responses to single injections of LHRH were determined in eighty-four patients with oligospermia and in twenty-seven normal men. LHRH responses were heterogeneous and indicate that various disorders might cause this syndrome. In six cases there appeared to be an isolated deficiency in spermatogenesis, as indicated by an increased FSH response, whilst the LH response was normal as were the concentrations of the testicular hormones. In twenty cases a concomitant disorder of Leydig cell function and spermatogenesis is suggested as indicated by increased FSH and LH responses and decreased concentrations of testosterone and delta4 androstenedione (six) or concentrations at the lower limit of normal (fourteen). Furthermore, in five cases a hypothalamic and/or pituitary disturbance may be accepted on the basis of normal or decreased basal concentrations decreased and responses to LHRH with decreased concentrations of testosterone and delta4 androstenedione. Finally, in thirty-seven cases, oligospermia was not associated with any modification basal gonadotrophin concentrations or response to LHRH when compared with normal subjects.     

INTERRELATIONS BETWEEN PLASMA AND TISSUE CONCENTRATIONS OF 17 β-OESTRADIOL AND PROGESTERONE DURING HUMAN PREGNANCY

Oestradiol and progesterone concentration in plasma, decidua, myometrium and placenta obtained from women undergoing Caesarian section at term and abortion at weeks 16-22 of pregnancy were determined. There was a significant increase in oestradiol concentration (per g wet wt) both in placenta, decidua and myometrium from mid-term to term. Both at mid-term and term oestradiol concentrations in decidua and myometrium were much smaller than those in the plasma (per ml). Progesterone concentration in placenta and in myometrium did not increase from mid-term to term where it increased significantly in decidua. Decidual and myometrial progesterone concentrations at mid-term were 2-3 times higher than those in plasma, but at term the concentrations in both these tissues were lower than in plasma. The ratio progesterone/oestradiol in plasma, decidua, myometrium and placenta at mid-term was 8.7, 112.2, 61.4 and 370.0, respectively, and it decreased significantly in the myometrium and placenta but was nearly unchanged in plasma and decidua at term. The general conclusion to be drawn from the present study is the lack of correspondence between the plasma concentrations and the tissue concentrations of female sex steroids during pregnancy.     

CHANGES IN SERUM INSULIN CONCENTRATION DURING PUBERTY AND THEIR RELATIONSHIP TO GROWTH HORMONE

In 40 tall and short children we have demonstrated using oral glucose tolerance tests that there is an increase in serum insulin concentration during puberty with no change in blood glucose concentration. Fasting serum insulin concentration rose from a pre-pubertal value between 4.0 and 5.7 mU/l to values between 11.0 and 14.6 mU/l during puberty. This rise in both fasting serum insulin concentration and the incremental area under the insulin curve is probably due to changes in circulating GH concentrations. In 16 tall girls a rise in serum GH concentration was observed during pubertal growth and the rise was accompanied by a two- to three-fold increase in fasting serum insulin concentration. In 13 children in whom 24 h growth hormone profiles were recorded higher insulin concentrations were seen in those who secreted the most growth hormone. These data suggest that during pubertal growth in diabetic children the standard dosage of insulin administered (0.9 units/kg per day) should be doubled or possibly tripled to maintain good metabolic control and maximize pubertal growth.     

RESPONSE OF PLASMA TESTOSTERONE, URINARY 17-OXOSTEROIDS, OESTROGENS, AND ANDROSTERONE PLUS AETIOCHOLANOLONE TO HUMAN CHORIONIC GONADOTROPHIN IN DEXAMETHASONE-SUPPRESSED MEN

The administration of human chorionic gonadotrophin (HCG) to dexamethasone-suppressed men caused parallel changes in the concentration of plasma testosterone and in the urinary output of androsterone+aetiocholanolone, total 17-oxosteroids and oestrogens. Discrepant results occurred in only four of the thirty-seven men tested. With these exceptions, the response to HCG could be followed as well by measuring androsterone+aetiocholanolone, 17-oxosteroid or oestrogen excretion rates as by following plasma testosterone levels. The most sensitive index of response was the rate of appearance of oestrogens in urine, and the next that of androsterone+aetiocholanolone.     

PLASMA TESTOSTERONE AND ANDROSTENEDIONE LEVELS DURING MONITORED INDUCTION OF OVULATION IN INFERTILE WOMEN WITH 'SIMPLE' AMENORRHOEA AND WITH THE POLYCYSTIC OVARY SYNDROME

Twenty-seven infertile patients with ‘simple’ amenorrhoea-oligomenorrhoea and eighteen with the polycystic ovary (PCO) syndrome were treated for induction of ovulation with clomiphene, human menopausal gonadotrophin and human chorionic gonadotrophin. The treatment was monitored by plasma oestradiol, testosterone, andfostenedione and progesterone estimation. Women with PCO had significantly higher plasma androgen levels than women with ‘simple’ amenorrhoea (P < 0.01 to P < 0.001) both before treatment and during induction of ovulation. When ovulation was induced the pregnancy rate for women with the PCO syndrome with elevated androgens was 21% while for those with uncomplicated amenorrhoea it was 75%. It is concluded that high levels of circulating androgens might be a factor preventing conception in some patients in whom ovulation is apparently successfully induced.     

INDICES OF SERUM ANDROGENS IN NORMAL PUBERTY: CORRELATIONS OF TWO INDICES WITH CHRONOLOGICAL AGE,BONE AGE AND PUBERTAL DEVELOPMENT IN BOYS AND GIRLS*

Two indices of free serum androgenic activity, the normalized androgen ratio (NAR) and the free androgen index (FAI) were determined in 218 normal children aged 8–17·9 years. Before the onset of puberty and between chronological age 8 and 11·9 years, NAR and FAI were similar in both sexes, the NAR being < 0·8 and FAI < 0·1. In boys mean NAR value increased from 0·87 to 1·39 between 12·5 and 17·5 years, and mean FAI from 0·14 to 1·85, between 12·5 and 17·5 years. In girls mean NAR increased from 0·79 to 0·85 between 12·5 and 15·5 years, and mean FAI from 0·11 to 0·23, between 12·5 and 15·5 years. Both indices did not change significantly between 15·5 and 17·5 years in girls. A rapid increase in NAR and FAI occurred in boys from a mean testicular volume of 4·1 to >20 ml and from genital stage G2+ to 5+. In girls a gradual increase in NAR and FAI occurred from breast stage B2 + to 5+. Although the androgen indices increased in both sexes between pubic hair stages PH2 + and 6 +, the values in girls were always less than in boys at corresponding stages suggesting an increased androgen sensitivity of the female pubic hair follicle during adolescence. The peak rise in NAR and FAI in boys between 13 and 15 years correlated closely with the timing of the pubertal growth spurt in this sex. A similar rise was not seen in girls at the time of their peak growth velocity between 11 and 13 years and suggested that androgens play only a minor or complementary part in the female growth spurt.     

LACK OF THIRST, OSMORECEPTOR DYSFUNCTION, EARLY PUBERTY AND ABNORMALLY AGGRESSIVE BEHAVIOUR IN TWO BOYS

Two unrelated boys (C.C. 13 years; J.W. 18 years) presenting with early puberty and episodes of aggressive behaviour were found to have hypernatraemia and hypodipsia. Plasma vasopressin (AVP) levels were inappropriately low in relation to plasma osmolality, but the patients did not have diabetes insipidus since 24 h urinary volumes were less than 1 litre and the maximal urinary osmolality was 1232 in C.C. and 950 in J.W. Plasma renin activity was elevated (greater than 2000 mg AI/1/h) although aldosterone concentrations were normal. Excretion of a water load (20 ml/kg) was delayed, but plasma renin and aldosterone fell with increased naturesis. An infusion of 0.85 mol/l saline produced a rise in AVP in C.C. but not in J.W. Insulin and hypotension resulted in the release of AVP in both boys suggesting a selective defect of osmoreceptor function. Hyperprolactinaemia and an exaggerated PRL response to TRH were also noted but no intracranial lesion was demonstrable on CT scan. These boys appear to have a hypothalamic syndrome with early puberty, hyperprolactinaemia, hypodipsia and osmoreceptor dysfunction which may be associated with aggressive behaviour.     

DISCORDANT SERUM α-SUBUNIT AND FSH CONCENTRATIONS IN A WOMAN WITH A PITUITARY TUMOUR

We have studied a women who presented at the age of 51 with a large FSH and alpha-subunit producing pituitary adenoma. Following insertion of ventriculo-peritoneal shunts and external pituitary irradiation there was no change in the elevated serum concentrations of FSH, and alpha-subunit over a four year period although she developed both ACTH and TSH deficiency. Various drugs, however, did alter the FSH and alpha-subunit concentrations and these changes suggest possible mechanisms controlling FSH secretion. Ethinyloestradiol 0.03 mg daily for three weeks suppressed serum FSH to 77% of the basal level (240 +/- 35 i.u./l to 184 +/- 20 i.u./l) but alpha-subunit rose to 130% of basal level (281 +/- 50 ng/ml to 366 +/- 40 ng/ml). On ethinyloestradiol 0.1 mg daily, FSH suppressed to 17% of basal (40 +/- 11 i.u./l) with no change in alpha-subunit concentration, while on 0.2 mg daily suppression of FSH was similar but alpha-subunit fell to 59% of basal (190 +/- 28 ng/ml). Dexamethasone, 3 mg daily for one week reduced FSH to 53% of the initial concentration and alpha-subunit to 74% while bromocriptine 7.5 mg daily for three months, reduced FSH to 39% and alpha-subunit to 66% of basal. Neither thyroxine, 0.2 mg daily for four weeks, nor an LHRH analogue, (Buserelin, Hoechst) 200 micrograms, three times daily for three months elicited any effect. Chromatography on Sephadex G100 showed that serum FSH and alpha-subunit both had Kav values somewhat lower than those of their standard counterparts (FSH, 0.20 vs 0.25; alpha-subunit 0.35 vs 0.45).(ABSTRACT TRUNCATED AT 250 WORDS)     

DIFFERENT ASPECTS OF 5α-REDUCTASE DEFICIENCY IN MALE PSEUDOHERMAPHRODITISM AND HYPOTHYROIDISM

The 5α-reductase activity that mediates the transformation of testosterone to dihydrotestosterone in various anatomical sites of human beings, has been studied in different pathological conditions related to 5α-reductase deficiency. We have studied two patients with male pseudohermaphroditism due to 5α-reductase deficiency, four patients with the complete form of testicular feminization syndrome and four men with primary hypothyroidism. Results were compared with those obtained in seven normal men. In vivo: radioactive tracers of testosterone were administered to each subject by different routes: intravenous, oral and subcutaneous. The urinary metabolites of these labelled precursors were measured. The 5β: 5α ratios of 17-ketosteroids (aetiocholanolone: 5α-androsterone) and androstanediols (5β-androstane-3α, 17β-diol: 5α-androstane-3α, 17β-diol) were calculated in the urine recovered after each mode of administration of radioactive testosterone. When testosterone was administered subcutaneously these ratios were highly increased in one patient with male pseudohermaphroditism due to 5α-reductase deficiency. In all the other patients, the ratios were found to be in the normal range for men. After oral administration of radioactive testosterone, both 5β: 5α ratios were very high in hypothyroid and in 5α-reductase deficient patients. These results suggest that the defective 5α-reductase activity observed in hypothyroid patients is only localized in the hepatic compartment. Conversely, in male pseudohermaphroditism, the 5α-reductase defect might affect both hepatic and extra-hepatic compartments. In vitro: the diagnosis of 5α-reductase deficiency was confirmed in the two male pseudohermaphrodite patients after incubation with ³H testosterone of skin homogenates from the external genital area. No 5α-reduction of testosterone occurred in the two skin specimens studied. In contrast, 5α-reductase activity was normal in genital skin from hypothyroid and testicular feminization syndrome patients. In pubic skin, 5α-reductase activity was absent in patients with testicular feminization syndrome. It was in the normal range in homogenates from hypothyroid patients and varied in the 5α-reductase deficient patients. Based on these data, it may be postulated that the programming of hepatic and extrahepatic 5α-reductase enzymes is fundamentally different. In addition, the enzyme that mediates the appearance of secondary sex characteristics seems to be androgen dependent, while the 5α-reductases present in the external genital area and the liver are not androgen dependent.     

GONADOTROPHINS, OESTRADIOL AND PROGESTERONE DURING THE MENSTRUAL CYCLE IN BULIMIA NERVOSA

Gonadotrophins and gonadal hormones were studied during the menstrual cycle or during 5 weeks when no cycles occurred in 15 patients who were diagnosed as having bulimia by DSM III criteria. Nine healthy age-matched women served as controls. Based on plasma oestradiol (E2) values patients were divided into two groups. Group I (n = 8) did not show E2 increases greater than 444 pmol/l indicating that no follicular development took place. Group II showed normal follicular hormone production during the follicular phase but impaired progesterone (P4) levels during the luteal phase. Studies of episodic gonadotrophin secretion during the follicular phase revealed low average LH and FSH values and reduced amplitude but no significant changes of frequency in group I. Our data indicate that impaired follicular maturation as seen in about half of the bulimic patients is caused by impaired gonadotrophin secretion.     

HUMAN α-LACTALBUMIN AND HORMONAL FACTORS IN PREGNANCY AND LACTATION

Serum α-lactalbumin was monitored throughout pregnancy in twelve women and in a separate group of nineteen women during the first 3 months postpartum. During pregnancy α-lactalbumin rose significantly until the mid trimester (P < 0·001). From then until term, concentrations remained stable. Concentrations during labour were significantly higher (P < 0·01) than those seen at term, α-lactalbumin, 17β-oestradiol and progesterone concentrations behaved similarly during the first week of the puerperium in both lactating (n= 10) and non-lactating (n= 9) subjects. A large surge of α-lactalbumin closely followed the clearance of high circulating concentrations of sex steroids in both groups. Prolactin concentrations were significantly greater (P < 0·02) in lactating subjects by the third postpartum day. By the third postpartum week α-lactalbumin concentrations in lactating subjects had stabilized at labour levels in a milieu of high prolactin levels and depressed production on 17β-oestradiol and progesterone. Conversely, in non-lactating subjects α-lactalbumin concentrations fell, as did prolactin, coincidental with a rise in 17β-oestradiol, progesterone concentrations remaining barely detectable. The apparent control mechanisms for human α-lactalbumin secretion and thus, lactation, are discussed in the light of the data presented.     

PLASMA ANDROGENIC ACTIVITY IN WOMEN WITH ACNE VULGARIS AND IN HEALTHY GIRLS BEFORE, DURING AND AFTER PUBERTY

The possible relationship between plasma androgenic activity and acne vulgaris was investigated. Plasma testosterone and sex hormone binding globulin (SHBG) levels were determined in healthy girls during different stages of puberty, in healthy adult women and in women with acne vulgaris. Testosterone increase during puberty, whereas SHBG decreased during the early stages before it increased and stabilized plasma concentrations of testosterone and SHBG. Women with severe acne vulgaris had testosterone levels in the same range but the SHBG levels were significantly lower than those of healthy women and women with mild acne. These results show a high androgenic activity in the intermediate stages of puberty, when acne vulgaris is a common complaint and an increased androgenic activity in adult women with severe acne vulgaris.