OBJECTIVE

To ascertain the steroidogenic profile and location of steroidogenic enzymes in a steroid-secreting Sertoli-Leydig cell tumor of the ovary.

METHODS

Steroid levels from peripheral, left ovarian (tumor), and right ovarian venous blood were measured. Tumor tissue was examined for the steroidogenic enzymes 17 alpha-hydroxylase (P450c17) and 3 beta-hydroxysteroid dehydrogenase (3 beta HSD) by immunohistochemistry. Tumor cells were isolated and incubated in serum-free media. Thereafter, media were analyzed for steroid production, steroidogenic response to effectors, and metabolism of radiolabeled pregnenolone and androstenedione.

RESULTS

Levels of C19 steroids and 17-hydroxyprogesterone (<em>17OHP</em>) were elevated in peripheral blood. The majority (80%) of steroids in serum from the left ovarian vein (tumor) were C19 steroids (dehydroepiandrosterone [DHEA], 45%; androstenedione, 27%, testosterone, 7%, with 13% <em>17OHP</em>, 7% progesterone, and less than 1% estradiol (E2). Immunoreactivity for both P450c17 and 3 beta HSD was identified in clusters of large cells surrounded by nonimmunoreactive cells composing cord-like structures. Of the steroids that accumulated in the incubation medium of unstimulated, freshly isolated tumor cells, 84% were C19 steroids (DHEA, 44%; androstenedione, 36%; testosterone 2%, with 16% <em>17OHP</em> and less than 1% progesterone and E2. Basal steroid production was not stimulated by LH or FSH. However, treatment with forskolin (10 mumol/L), dibutyryl cAMP (1 mmol/L), or steroid precursors (22-hydroxycholesterol, 1 mumol/L; pregnenolone, 1 mumol/L) increased the production of all steroids measured. Forskolin treatment increased androstenedione (fivefold), DHEA (tenfold), and <em>17OHP</em> (40-fold) compared with basal levels. Incubation of freshly isolated cells with [3H]pregnenolone demonstrated the ability of these cells to metabolize this C21 steroid precursor to androstenedione, DHEA, and <em>17OHP</em>. However, [3H]androstenedione was not readily metabolized by these cells to either estrone or testosterone.

CONCLUSIONS

The steroidogenic properties of a steroid hormone-producing tumor were described. Cells isolated from this tumor produced steroids similar to those secreted by ovarian theca cells. These properties suggest that certain ovarian steroidogenic tumor cells may be an appropriate model for ovarian theca cells and could be used to develop steroid-secreting cell lines.

Alterations in adrenal steroid production have been suggested in females with rheumatoid arthritis (RA). The aim of the present study was to assess adrenocortical function in RA females. We examined 11 female RA patients (RA: age 30 +/- 2 years, BMI 21.0 +/- 0.7 kg/m(2)) and 10 matched healthy controls (C: age 31 +/- 1 years, BMI 21.6 +/- 0.6 kg/m(2)). Low-dose adrenocorticotropic hormone (ACTH) test (i.v. bolus of 1 microg synthetic ACTH) was performed at 10.00 h with blood sampling every 15 min for 90 min. Cortisol, 17-OH-progesterone (<em>17OHP</em>), androstenedione (ASD), and dehydroepiandrosterone (DHEA) were assayed in plasma. Baseline cortisol levels were higher in RA patients (RA: 385 +/- 38 versus C: 229 +/- 28 nmol/L, P= 0.007). In both study groups, ACTH administration increased all the four steroids measured (P < 0.001). Cortisol response to ACTH administration was diminished in RA patients when compared to controls (Delta(max): 284 +/- 24 in RA versus 424 +/- 31 nmol/L in C, P= 0.002). ACTH-induced maximal rise in plasma DHEA was significantly lower in RA patients when compared to controls (Delta(max): 2.59 +/- 0.68 in RA versus 5.57 +/- 1.25 ng/mL in C, P= 0.015). No significant between-groups differences were found in responses of ASD or <em>17OHP</em>. The molar ratio of ASD:cortisol was significantly lower (P < 0.05) in RA patients at base line, but did not differ during ACTH test. After ACTH bolus, the cortisol:<em>17OHP</em> ratio decreased significantly in the RA group (P < 0.001), whereas there was no change in the control group. The present results show decreased secretion of cortisol and DHEA in RA patients in response to ACTH, suggesting a subtle HPA hypofunction at the adrenocortical level.

BACKGROUND

3βHSD2 is a bifunctional microsomal NAD+-dependent enzyme crucial for adrenal and gonad steroid biosynthesis, converting Δ5-steroids to Δ4-steroids. 3βHSD2 deficiency is a rare cause of congenital adrenal hyperplasia caused by recessive loss-of-function HSD3B2 mutations.

OBJECTIVE

The aim was to define the pathogenic consequences of a novel missense mutation in the HSD3B2 gene.

METHODS

We report a 7-month-old 46,XX girl referred because of precocious pubarche and postnatal clitoromegaly. Hormonal profile showed inadequate glucocorticoid levels, increased <em>17OHP</em> and renin levels, and very high DHEAS levels, suggestive of compensated nonsalt-losing 3βHSD2 deficiency.

RESULTS

Direct sequencing revealed a novel, homozygous, pG250V HSD3B2 mutation. In vitro analysis in intact COS-7 cells showed impaired enzymatic activity for the conversion of pregnenolone to progesterone and dehydroepiandrosterone to androstenedione (20% and 27% of WT at 6 h, respectively). G250V-3βHSD2 decreased the Vmax for progesterone synthesis without affecting the Km for pregnenolone. Western blot and immunofluorescence suggested that p.G250V mutation has no effect on the expression and intracellular localization of the mutant protein. Molecular homology modeling predicted that mutant V250 affected an L239-Q251 loop next to a β-sheet structure in the NAD+-binding domain.

CONCLUSIONS

We identified a novel p.G250V mutation of HSD3B2 which causes an incomplete loss of enzymatic activity, explaining the compensated nonsalt loss phenotype. In vitro and in silico experiments provided insight into the structure-function relationship of the 3βHSD2 protein suggesting the importance of the L239-Q251 loop for the catalytic activity of the otherwise stable 3βHSD2 enzyme.

After both single (1500 IU) and daily repeated (1500 IU daily for 3 days) im administration of hCG, peak values of 17-hydroxyprogesterone (<em>17OHP</em>) were achieved 24 h after the single or first injection, whereas plasma testosterone (T) levels reached their maximum 48 h later. After the peak value of 17-OHP at 24 h, both steroids ran dissociated courses with the T levels rising and the 17-OHP levels falling. In both the single and repeated hCG experiments, the initial rise of 17-OHP was more pronounced than that of T, leading to a steep temporary increase of the 17-OHP to T ratio in the first 24 h. Repeated hCG administration for 3 days to the same subjects elicited T responses at 48 and 72 h quantitatively similar to those produced by single hCG loading, although the 17-OHP response appeared slightly higher in the multiple dose experiment. The data indicate that exogenous gonadotropins may influence testicular steroidogenesis not only quantitatively, but also qualitatively, possibly by altering enzyme activities.

Serum sulphates of 5-androstene-3 beta,17 beta-diol (5-ADIOL-S), 5 alpha-androstane-3 alpha,17 beta-diol (3 alpha-DIOL-S) and dehydroepiandrosterone (DHEA-S), as well as 5 alpha-androstane-3 alpha,17 beta-diol glucuronide (3 alpha-DIOL-G) and unconjugated androstenedione (AD) and testosterone (T), sex hormone binding globulin (SHBG), free androgen index (FAI) and 17 alpha-hydroxyprogester-one (<em>17OHP</em>) were measured by specific radioimmunoassays (RIA) in 14 women with late-onset 21-hydroxylase deficiency (LOCAH), and in normal women (n = 73). The diagnosis of LOCAH was made on the finding of a (<em>17OHP</em>) response level greater than 30 nmol/l following ACTH stimulation, and/or an elevation of urinary metabolites of <em>17OHP</em>. Mean values for serum concentrations of all steroids measured and the free androgen index (100 X T nmol/l divided by SHBG nmol/l) were significantly elevated, and SHBG levels depressed in patients with LOCAH. These studies show that in LOCAH, in addition to the unconjugated steroids AD and T, the sulphoconjugated steroids DHEA-S, 5-ADIOL-S and 3 alpha-DIOL-S are increased, as is the glucuronide conjugate 3 alpha-DIOL-G and the index of bioavailable testosterone (FAI), and that mean SHBG levels are depressed. These data suggest that as well as AD, 5-ADIOL-S and DHEA-S may act as pro-hormones for more potent steroids (T and 5 alpha-dihydrotestosterone) in peripheral tissues, while 3 alpha-DIOL-S and 3 alpha-DIOL-G may both reflect peripheral androgen metabolism in patients with LOCAH.

Congenital adrenal hyperplasia (CAH) is the most common cause of primary adrenal insufficiency in children and adolescents. It comprises several clinical entities associated with mutations in genes, encoding enzymes involved in cortisol biosynthesis. The mutations lead to considerable (non-classic form) to almost complete (classic form) inhibition of enzymatic activity, reflected by different phenotypes and relevant biochemical alterations. Up to 95% cases of CAH are due to mutations in <i>CYP21A2</i> gene and subsequent 21α-hydroxylase deficiency, characterized by impaired cortisol synthesis and adrenal androgen excess. In the past two decades an alternative ("backdoor") pathway of androgens' synthesis in which 5α-androstanediol, a precursor of the 5α-dihydrotestosterone, is produced from 17α-hydroxyprogesterone, with intermediate products 3α,5α-<em>17OHP</em> and androsterone, in the sequence and with roundabout of testosterone as an intermediate, was reported in some studies. This pathway is not always considered in the clinical assessment of patients with hyperandrogenism. The article describes the case of a 17-year-old female patient with menstrual disorders and androgenization (persistent acne, advanced hirsutism). Her serum dehydroepiandrosterone sulfate and testosterone were only slightly elevated, along with particularly high values for 5α-dihydrotestosterone. In 24 h urine collection, an increased excretion of 16α-OHDHEA-a dehydroepiandrosterone metabolite-and pregnanetriolone-a 17α-hydroxyprogesterone metabolite-were observed. The investigations that we undertook provided evidence that the girl suffered from non-classic 21α-hydroxylase deficiency with consequent enhancement of the androgen "backdoor" pathway in adrenals, peripheral tissues or both, using adrenal origin precursors. The paper presents diagnostic dilemmas and strategies to differentiate between various reasons for female hyperandrogenism, especially in childhood and adolescence.

Keywords: 16α-hydroxydehydroepiandrosterone (16α-OHDHEA); 21-hydroxylase deficiency; backdoor androgen pathway; non-classic congenital adrenal hyperplasia; pregnanetriolone (PTN).

Cytochrome P450 17A1 (CYP17A1) catalyses the 17α-hydroxylation and 17,20 lyase reactions to convert pregnenolone to 17α-hydroxypregnenolone (<em>17OHP</em>) and subsequently the androgen dehydroepiandrosterone (DHEA). In pigs and humans, CYP17A1 also catalyses the delta-16-synthase reaction to produce the 16-androstene steroid 5,16-androstadien-3β-ol (16A), which is then further metabolised to the sex pheromone androstenone. Cytochrome b5A (CYB5A) stimulates the 17,20 lyase reaction and is required for the delta 16-synthase reaction. We have identified and mutated residues in porcine CYP17A1 and CYB5A that may alter the synthesis of DHEA and 16A. This included residues in the steroid binding pocket of CYP17A1 and residues on the surface of CYP17A1 and CYB5A that are involved in binding of CYP17A1 to CYB5A. We then expressed the various mutations of CYB5A and CYP17A1 along with porcine cytochrome P450 oxidoreductase (POR) and cytochrome b5 reductase (CYB5R3) in HEK293 cells and measured the formation of metabolites 16A, <em>17OHP</em> and DHEA from radiolabelled pregnenolone by high performance liquid chromatography (HPLC). Mutations were identified in both CYP17A1 and CYB5A that affected the production of the different metabolites and also affected the overall production of metabolites. Several combinations of mutations decreased the production of both 16A and DHEA and increased production of <em>17OHP</em>, while the N62S mutation of CYB5A with wild type CYP17A1 increased production of both 16A and DHEA. The best combination of mutations to reduce the production of 16A, while maintaining the production of DHEA and the overall conversion similar to wild type are the N21K, L28V, N21K/L28V and the R52 M/N62S mutations of CYB5A with the D103S mutation of CYP17A1.

<AbstractText> To evaluate the offer, acceptance, uptake, and patient experience with 17-hydroxyprogesterone caproate (<em>17OHP</em>-C) over the course of 10 years.</AbstractText><AbstractText> This is a retrospective cohort study with a qualitative component. We identified all women with spontaneous preterm deliveries with subsequent births in our hospital between 2005 and 2015. We used linear regression to calculate unadjusted odds ratios for <em>17OHP</em>-C offer, acceptance, and doses received associated with predictors of interest, and multivariable modeling further adjusted for potential confounders. A grounded theory approach was used to glean recurrent themes surrounding the patient experience.</AbstractText><p><div><b>RESULTS</b></div> A total of 265 women fit the eligibility criteria; 39.6% were offered <em>17OHP</em>-C and 83.8% accepted <em>17OHP</em>-C. The mean number of documented <em>17OHP</em>-C doses was 15.7 ± 5.4. Women were less likely to be offered <em>17OHP</em>-C if they had public insurance or if their earliest preterm birth was of greater gestational age. Non-Hispanic black women were documented to have received four fewer doses than white women. We also identified recurrent themes that hindered acceptance and adherence to <em>17OHP</em>-C: insurance difficulties, unstable housing, lack of childcare, and job <i>inflexibility</i>.</p><AbstractText> Women at a risk of preterm birth are more likely to be offered and receive <em>17OHP</em>-C if they have private insurance and have had an earlier preterm birth. Non-Hispanic black women were documented to have received fewer doses of <em>17OHP</em>-C than white women. Further inquiry into the structural causes that lead to disparities in care for women at a risk for preterm birth is important.</AbstractText>

Purpose: Functional hypothalamic amenorrhea (FHA) occurs in response to exaggerated stressors with or without body weight loss. Various hormones, neurotransmitters, and neuromodulators are involved in the control of GnRH and kisspeptin is one of them. Our study aimed to evaluate the putative temporal coupling between kisspeptin and GnRH-induced LH pulsatile secretion.

<strong class="sub-title"> Methods: </strong> In total, 71 patients with FHA were selected for this study. All patients undergo to a pulsatility study for LH and kisspeptin evaluation (120 min, sampling every 10 min), and to an endocrine evaluation for prolactin (PRL), estradiol (E2), androstenedione (A), 17-hydroxy-progesterone (<em>17OHP</em>), TSH, fT3, fT4, insulin, cortisol and testosterone (T), glucose, total cholesterol, triglycerides.

Results: Our data demonstrated kisspeptin and LH pulsatile secretions and that both hormones are co-secreted and temporally coupled at time 0 (p < 0.05). When patients were subdivided in hypo-LH (≤3 mIU/ml, n = 58) and normo-LH (>3 mIU/ml, n = 13), more insights were observed on the specific correlations of metabolic and hormone profiles with pulsatility indexes of LH and kisspeptin.

Conclusions: Our study demonstrated the presence of a distinct kisspeptin episodic secretion in patients with FHA, and showed the temporally coupling of kisspeptin with LH secretory episodes thus supporting that though in amenorrhea, the reproductive axis is still relying on kisspeptin to drive GnRH discharge. In addition, correlations among hormonal data sustain the hypothesis that stress-induced compensatory events are the main direct and indirect promoters of the reproductive blockade in patients affected by FHA.

Keywords: Functional hypothalamic amenorrhea; Kisspeptin; LH; Pulses.

Background Testicular adrenal rest tumors (TARTs) leading to primary gonadal failure are the main etiology of infertility in congenital adrenal hyperplasia (CAH). We aimed at identifying the evolution of TART and related findings in young CAH patients. Methods Twelve male patients (3-23 years old) with 21-hydroxilase deficiency (11 with classic salt-wasting form) were included. Testicular ultrasonography (US) was performed in two moments, by a single blinded specialist in pediatric diagnostic imaging. Tumor progression was classified according to the Response Evaluation Criteria in Solid Tumors (RECIST). The clinical and laboratory data were retrieved from medical records. Serum 17-OH-progesterone (<em>17OHP</em>) and androstenedione concentrations were evaluated during the whole period of follow-up, from the CAH diagnosis. A logistic regression model with repeated measures was developed for the analysis. Results The prevalence of TART was 41.6% (n = 5) in the initial US evaluation and 66.6% (n = 8) after 6 years of follow-up. Tumor progression was detected in 4 of the 5 patients, and 1 presented with a stable tumor. Three patients presented with new tumors in the second evaluation. Most of the patients (n = 11) were pubertal, including a 7-year-old child with TART who presented with central precocious puberty. At regression analysis, it was observed that an inadequate hormonal control led to a 16 times greater chance of a patient to present with TART (OR = 16.08; confidence interval [CI] 95% = 2.38-108.81; p = 0.004). Conclusions We found a high prevalence of progressive TART in young pubertal subjects. US testicular screening should help in improving therapeutic optimization in CAH patients to reduce future impairment in fertility.

<AbstractText>The HIV drugs lopinavir and ritonavir have recently been reported to cause transient adrenal insufficiency in preterm newborns. We, therefore, considered HIV drugs as a cause of transiently elevated 17-hydroxyprogesterone (<em>17OHP</em>) levels in a neonatal screening test for congenital adrenal hyperplasia in a preterm girl exposed to zidovudine, efavirenz, tenofovir, and emtricitabine.</AbstractText><AbstractText>So far, HIV drugs have not been tested for their effect on steroidogenesis and the steroidogenic enzyme activity of CYP21A2 specifically in an in vitro system.</AbstractText><AbstractText>We tested the effect of efavirenz, tenofovir, emtricitabine, and zidovudine on steroidogenesis of human adrenal H295R cells. Cells were treated with the drugs at different concentrations including concentrations in therapeutic use. The effect on CYP21A2 activity was assessed by testing the conversion of radiolabeled <em>17OHP</em> to 11-deoxycortisol. Cell viability was tested by an MTT assay. In addition, recombinant human CYP21A2 protein was used to assess direct drug effects on CYP21A2 activity.</AbstractText><AbstractText>We observed significantly decreased CYP21A2 activity in both in vitro testing systems after treatment with efavirenz at therapeutic concentrations. Moreover, efavirenz affected cell viability. By contrast, the other test drugs did not affect steroidogenesis. Follow-up of our patient revealed elevated <em>17OHP</em> and androgen levels during the first weeks of life, but values normalized spontaneously. Genetic testing for CYP21A2 mutations was negative. Thus, it remains unsettled whether the transient <em>17OHP</em> elevation in this baby was due to a drug effect.</AbstractText><AbstractText>The HIV drug efavirenz inhibits CYP21A2 activity in vitro through direct interaction with enzyme catalysis at therapeutic concentrations. This may have clinical implications for HIV treatment in children and adults. However, so far, clinical data are scarce, and further studies are needed to be able to draw clinical conclusions.</AbstractText>

Natural and synthetic steroid hormones, excreted by humans and farmed animals, have been considered as important sources of environmental endocrine disruptors. A suite of estrogens, androgens and progestogens was measured in the wastewater treatment plant outfall (WWTPO) of Chascomús city (Buenos Aires province, Argentina), and receiving waters located downstream and upstream from the WWTPO, using solid phase extraction and high-performance liquid chromatography mass spectrometry. The following natural hormones were measured: 17β-estradiol (E₂), estrone (E₁), estriol (E₃), testosterone (T), 5α-dihydrotestosterone (DHT), progesterone (P), 17-hydroxyprogesterone (<em>17OHP</em>) and the synthetic estrogen 17α-ethinylestradiol (EE₂). Also, in order to complement the analytical method, the estrogenic activity in these surface water samples was evaluated using the in vitro transactivation bioassay that measures the estrogen receptor (ER) activity using mammalian cells. All-natural steroid hormones measured, except <em>17OHP</em>, were detected in all analyzed water samples. E₃, E₁, EE₂ and DHT were the most abundant and frequently detected. Downstream of the WWTPO, the concentration levels of all compounds decreased reaching low levels at 4500 m from the WWTPO. Upstream, 1500 m from the WWTPO, six out of eight steroid hormones analyzed were detected: DHT, T, P, <em>17OHP</em>, E₃ and E₂. Moreover, water samples from the WWTPO and 200 m downstream from it showed estrogenic activity exceeding that of the EC₅₀ of the E₂ standard curve. In sum, this work demonstrates the presence of sex steroid hormones and estrogenic activity, as measured by an in vitro assay, in superficial waters of the Pampas region. It also suggests the possibility of an unidentified source upstream of the wastewater outfall.

Keywords: Androgens; Aquatic pollution; Endocrine disruption; Estrogens; Municipal wastewater treatment; Progestogens.

OBJECTIVE

To investigate a possible relation between fibulin-1 plasma levels and PCOS.

METHODS

ELISA quantitative determination of human fibulin-1.

METHODS

50 women with PCOS and 40 control patients who attended the Unit of Human Reproductive Pathophysiology, Università Cattolica del Sacro Cuore, Rome, were enrolled. Ultrasonographic pelvic examinations, hormonal profile assays, oral tolerance test OGTT, lipid profile and ELISA quantitative determination of human fibulin-1 were performed.

RESULTS

Fibulin-1 levels were found to be statistically significantly higher in PCOS patients than in matched control women. No statistically significant positive correlation was found between fibulin-1 and AUCi, HOMA-IR, total cholesterol, LDL, AMH, androstenedione and FAI, whereas a statistically significant positive correlation was found between fibulin-1 and <em>17OHP</em> (p = 0.016) in the PCOS group. However, multivariable linear regression analysis showed that 17 OH P did not independently predict fibulin-1 levels (p = 0.089).

CONCLUSIONS

Our data could contribute to explain the hypothesized increased cardiovascular risk and vascular damage in patients with PCOS. A better understanding of the cellular and molecular mechanisms involved in cardiometabolic disorders associated with PCOS is mandatory to identify new therapeutic strategies to eventually prevent the progression of cardiovascular diseases in these patients.

Adrenal androgen excess is the hallmark of classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Recently, 11-oxygenated C19 steroids, a class of highly active adrenal-derived androgens, have been described in patients with CAH. The aim of our study was to elucidate the significance of 11-oxygenated androgens in children with CAH. We retrospectively analysed 190 daily urinary excretion rates of glucocorticoid-, 17α-hydroxyprogesterone (<em>17OHP</em>)-, and androgen metabolites determined by gas chromatography-mass spectrometry of 99 children aged 3.0-10.9 years with classic CAH on hydrocortisone and fludrocortisone treatment. Daily urinary steroid metabolite excretions were transformed into z-scores using references of healthy children. Androgen metabolite z-scores were separately calculated for androsterone (AN), the major urinary metabolite of androstenedione (A4), testosterone and 5α-dihydrotestosterone, for urinary metabolites of dehydroepiandrosterone (DHEA), and for 11β-hydroxyandrosterone (11OHAN), the major urinary metabolite of adrenal-derived 11-oxygenated androgens. Multivariate regression analysis was applied to analyse the precursors of 11OHAN synthesis. 11OHAN, cortisol-, and <em>17OHP</em> metabolite z-scores were elevated in treated children with CAH, whereas AN- and DHEA metabolite z-scores were normalized or suppressed. Multivariate regression analysis revealed that 11OHAN excretion was strongest associated with 21-deoxycortisol (β = 0.379; P =.0006), followed by A4 (β = 0.280; P = .0008)) and <em>17OHP</em> (β = 0.243; P = .04) metabolite excretion. Androgen excess in treated children with CAH is solely due to elevated 11-oxygenated androgens that derive in addition to the known conversion from A4 also by direct conversion from 21-deoxycortisol. 11-Oxygenated androgens may represent better biomarkers of adrenal androgen status and treatment response than conventional androgens.

OBJECTIVE

Gestational diabetes (GDM) and obesity portend a high risk for subsequent type 2 diabetes. We examined maternal factors influencing the development of gestational diabetes (GDM) in obese women receiving 17-alpha-hydroxyprogesterone caproate (<em>17OHP</em>C) for preterm delivery prevention.

METHODS

Retrospectively identified were 899 singleton pregnancies with maternal prepregnancy body mass indices of ≥30 kg/m(2) enrolled for either <em>17OHP</em>C weekly administration (study group) or daily uterine monitoring and nursing assessment (control group). Patients with history of diabetes type 1, 2, or GDM were excluded. Maternal characteristics were compared between groups and for women with and without development of GDM. A logistic regression model was performed on incidence of GDM, controlling for significant univariate factors.

RESULTS

The overall incidence of GDM in the 899 obese women studied was 11.9%. The incidence of GDM in the study group (n = 491) was 13.8% versus 9.6% in the control group (n = 408) (P = 0.048). Aside from earlier initiation of <em>17OHP</em> and advanced maternal age, other factors including African American race, differing degrees of obesity, and use of tocolysis were not significant risks for the development of GDM.

CONCLUSIONS

In obese women with age greater than 35 years, earlier initiation of <em>17OHP</em>C may increase the risk for GDM.

Congenital adrenal hyperplasia (CAH) was the fourth disorder added to the national Swedish neonatal screening program in 1986, and approximately 115,000 newborns are screened annually. Dried blood spot (DBS) screening with measurement of 17-hydroxyprogesterone (<em>17OHP</em>) is also offered to older children moving to Sweden from countries lacking a national DBS screening program. Here, we report an update on the CAH screening from January 2011 until December 2019. <i>Results</i>: During the study period, 1,030,409 newborns and 34,713 older children were screened. In total, 87 newborns were verified to have CAH, which gives an overall positive predictive value (PPV) of 11% and 21% for term infants. Including the five missed CAH cases identified during this period, this gives an incidence of 1:11,200 of CAH in Sweden. Among the older children, 12 of 14 recalled cases were found to be true positive for CAH. All patients were genotyped as part of the clinical follow-up and 70% of the newborns had salt wasting (SW) CAH and 92% had classic CAH (i.e., SW and simple virilizing (SV) CAH). In the group of 12 older children, none had SW CAH and two had SV CAH. <i>Conclusion</i>: The incidence of classic CAH is relatively high in Sweden. Early genetic confirmation with <i>CYP21A2</i> genotyping has been a valuable complement to the analysis of <em>17OHP</em> to predict disease severity, make treatment decisions and for the follow-up and evaluation of the screening program.

Keywords: 21-hydroxylase deficiency; CAH; CYP21A2; DBS; PPV; congenital adrenal hyperplasia; dried blood spots; neonatal screening; positive predictive value.

Context: Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice-daily, but there is debate about the optimal timing of highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening).

Objective: We aimed to compare two standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure, sleep and activity scores.

Design and setting: Six-week cross-over study.

Patients: Thirty-nine patients (4-19 years) with 21OHD.

<strong class="sub-title"> Interventions: </strong> Patients were treated for three weeks with highest hydrocortisone dose in the morning, followed by three weeks with highest dose in the evening (n=21), or vice-versa (n=18). Androstenedione (A4) and 17-hydroxyprogesterone (<em>17OHP</em>) levels were quantified in saliva collected at 5.00am; 7.00am; 3.00pm; and 11.00pm during the last two days of each treatment period.

<strong class="sub-title"> Main outcome measure: </strong> Comparison of saliva <em>17OHP</em> and A4 levels between two treatment strategies.

<strong class="sub-title"> Results: </strong> Administration of the highest dose in the evening resulted in significantly lower <em>17OHP</em> levels at 5.00am, whereas the highest dose in the morning resulted in significantly lower <em>17OHP</em> and A4 levels in the afternoon. The two treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal blood pressure, and activity- and sleep scores.

Conclusion: No clear benefit for either treatment schedule was established. Given the variation in individual responses we recommend to individually optimize dose distribution and monitoring disease control at multiple timepoints.

Keywords: 21-hydroxylase deficiency; CAH; Congenital Adrenal Hyperplasia; Dosing; Hydrocortisone.

Background: Nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency is caused by mutations in the active 21-hydroxylase gene (CYP21A2). The clinical symptoms can vary greatly. To date, no systematic studies have been undertaken in Germany.

<strong class="sub-title"> Aims: </strong> Description of the phenotype, evaluation of the diagnostics and genotype-phenotype correlation PATIENTS AND METHODOLOGY: Retrospective analysis of the data of 134 patients (age range 0.1-18.6 years) in a multicentre study covering 10 paediatric endocrinology centres in Bavaria and Baden-Württemberg. The data was gathered on site from the medical records. Two hundred and thirty-three alleles with a mutation of the CYP21A2 gene were identified in 126 patients. A genotype-phenotype correlation of the mutation findings was undertaken (C1, severe/mild; C2, mild/mild). Individuals with a heterozygous mutation of the CYP21A2 were also included (C3). The data was collected with the approval of the ethics committee of the University Hospital of Erlangen during the period of 2014 and 2015. RESULTS (MW ± SD): One hundred and seventeen out of 134 patients (115 f, 29 m) were symptomatic. The chronological age (CA) at diagnosis was 7.1 ± 4.4 years. The most frequent symptom (73.5%) was premature pubarche. The height-SDS on diagnosis was 0.8 ± 1.3 and the BMI-SDS was 0.8 ± 1.2. Bone age (BA) was ascertained in 82.9% of the symptomatic patients. The difference between BA and CA was 1.9 ± 1.4 years. Basal <em>17OHP</em> concentrations were 14.5 ± 19.1 ng/ml (18 patients < 2 ng/ml). In total, 58.1% mild and 34.7% severe mutations were found. The most common mutation was p.Val281Leu (39.1%); 65.8% of the patients could be allocated to group C1. No phenotypical differences were found between the 3 mutation groups. The <em>17OHP</em> levels (basal and after ACTH) in the standard ACTH stimulation test were highest in group C1 and also significantly higher in group C2 as in C3, the ACTH-stimulated cortisol levels (ng/ml) were significantly lower in groups C1 (192.1 ± 62.5) and C2 (218 ± 50) than in C3 (297.3 ± 98.7).

Conclusion: Most of the patients have symptoms of mild androgenisation. Male patients are underdiagnosed. Diagnostics are not standardised. Differences between the types of mutations are found in the hormone concentrations but not in phenotype. We speculate that further, as yet not clearly defined, factors are responsible for the development of the respective phenotypes.

<strong class="sub-title"> Keywords: </strong> <em>17OHP</em>; 21-Hydroxylase deficiency; ACTH stimulation test; Androgenisation; CYP21A2 mutations; Premature pubarche.

Background: Treatment of children with classic congenital adrenal hyperplasia (CAH) is a difficult balance between hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined.

Objective: Cluster analysis of the urinary steroid metabolome obtained by targeted gas chromatography-mass spectrometry (GC-MS) for treatment monitoring of children with CAH.

Methods: We evaluated 24-h urinary steroid metabolome analyses of 109 prepubertal children aged 7.0 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone. 24-h urinary steroid metabolite excretions were transformed into CAH-specific z-scores. Subjects were divided into groups (metabotypes) by k-means clustering algorithm. Urinary steroid metabolome and clinical data of patients of each metabotype were analyzed.

<strong class="sub-title"> Results: </strong> Four unique metabotypes were generated. Metabotype 1 (N = 21 (19%)) revealed adequate metabolic control with low cortisol metabolites (mean: -0.57z) and suppressed androgen and 17α-hydroxyprogesterone (<em>17OHP</em>) metabolites (-0.79z). Metabotype 2 (N = 23 (21%)) showed overtreatment consisting of a constellation of elevated urinary cortisol metabolites (0.62z) and low metabolites of androgens and <em>17OHP</em> (-0.75z). Metabotype 3 (N = 32 (29%)) demonstrated undertreated patients with low cortisol metabolites (-0.69z) and elevated metabolites of androgens and <em>17OHP</em> (0.50z). Metabotype 4 (N = 33 (30%)) presented patients with treatment failure reflected by unsuppressed androgen- and <em>17OHP</em> metabolites (0.71z) despite elevated urinary cortisol metabolites (0.39z).

Conclusion: Metabotyping, which means grouping metabolically similar individuals, helps to monitor treatment of children with CAH using GC-MS urinary steroid metabolome analysis. This method allows classification in adequately-, over-, or undertreated children as well as identification of patients with treatment failure.

Keywords: Congenital adrenal hyperplasia; GC–MS; Metabolic control; Metabotyping; Treatment monitoring; Urinary steroid metabolome.

In order to elucidate the mechanism of anovulation and luteal insufficiency that occur in hyperprolactinemia, the direct effect of prolactin (PRL) on luteal cells in vitro was investigated using human luteal cells in a monolayer cell culture. 1) The direct effect of PRL (that was kindly provided by the National Institute of Arthritis, Metabolism and Digestive Diseases) as seen in the production of P was such that when PRL concentrations were 1 through 100ng/ml the luteal stimulatory action was demonstrated, but in concentrations above 100ng/ml the stimulatory action was attenuated, and at 1 microgram/ml inhibitory effects were observed. 2) There was no significant difference between the PRL-added group and non-added group on the production of E2 and <em>17OHP</em>. 3) Production of P in the HCG 100ng group increased to about 4 times that of the non-added group. Production of P in the group with simultaneous addition of PRL 1 microgram-HCG 100ng also showed a similar degree of increase. From the above, it is concluded that PRL alone exerts a direct effect on luteal cells that is luteotropic and luteolytic, depending on the different concentrations of PRL. These facts suggested that the direct inhibitory effect of PRL on the ovary was one of the causes of anovulation and luteal insufficiency during hyperprolactinemia in vivo.

<AbstractText>An important goal in treating children with congenital adrenal hyperplasia (CAH) is to achieve a normal final adult height (FH). The aim of this study was to describe the clinical presentations and evaluate linear growth and possible factors affecting it in children with CAH.</AbstractText><AbstractText>This is a retrospective study of 56 patients with CAH followed up in a tertiary center for 11 years. Patient's data including demographics, clinical, anthropometric, and laboratory information at presentation and during follow-up period were collected from medical records.</AbstractText><AbstractText>Fifty-six children (31 females) with CAH were seen at KAMC-Jeddah over 11-year period and 91% were 21-hydroxylase deficient. Of these, 46.4% had hyponatremia and 28.6% had hyperkalemia (21.4% had hyponatremia and hyperkalemia) at presentation. Positive family history was documented in 53.6%. Ambiguous genitalia were present in 72% of females and the majority required corrective surgery. Males had significantly decreased HtSDS versus females and females had significantly higher body mass index. The HtSDS of children who had had higher <em>17OHP</em> or salt-losing crisis during treatment was significantly lower than those who had normal <em>17OHP</em> and those who did not have salt-losing crisis, respectively.</AbstractText><AbstractText>The final height outcome in our patients with CAH treated with glucocorticoids is lower than the population norm. Proper control of the disease clinically and biochemically through strict compliance to medical therapy as well as close clinical and laboratory monitoring is an important key to achieve normal final adult height in these patients. Side effects, including overweight, obesity, and hypertension are true risk associations and need timely diagnosis and early management.</AbstractText>

Determination of 17α-nyaroxyprogesterone (<em>17OHP</em>) is used for the diagnosis and monitoring of Congenital Adrenal Hyperplasia (CAH). Problems associated with the specificity of antibodies used in direct immunoassays can yield high false results.

OBJECTIVE

To analyze serum levels of direct <em>17OHP</em> (<em>17OHP</em>d) and previous extraction (<em>17OHP</em>e) in the neonatal period, in order to establish reference values. To relate levels of <em>17OHP</em>d and <em>17OHP</em>e with other androgens in CAH patients.

METHODS

Serum <em>17OHP</em>d and <em>17OHP</em>e were measured via RIA-DPC in 400 healthy newborns and infants (aged 2-365 days), and 100 treated CAH patients (aged 1-18 years). The extraction was performed with 3% isopropanol/heptane. The influence of age and gender was assessed by ANOVA.

RESULTS

The serum levels of <em>17OHP</em> were significantly correlated with chronological age, but not with gestational age, sex or birth weight. The difference between <em>17OHP</em>d and <em>17OHP</em>e decreased with age. The correlation index between <em>17OHP</em>d and <em>17OHP</em>e in CAH patients was 0.93 (p < 0.01).

CONCLUSIONS

The present results provide <em>17OHP</em> reference values for infants from birth up to one year of life. The extraction method is necessary in the neonatal period up to 6 months of life. Our data might be useful to make an early CAH diagnosis and follow-up newborns with high <em>17OHP</em> levels without adrenal pathology.

<strong class="sub-title"> Background: </strong> 17 alpha-hydroxyprogesterone caproate (<em>17OHP</em>) is used to reduce the recurrent risk of preterm delivery in women with a history of preterm delivery. Meis et al. conducted a double-blind placebo controlled trial to evaluate the effectiveness of <em>17OHP</em> and observed a significant reduction in the risk of recurrent preterm delivery. The FDA granted <em>17OHP</em> a conditional approval on 2011. A second study observed that <em>17OHP</em> did not decrease the risk of a recurrent preterm delivery. Criticism of the second study derived from a dissimilarity of the study population.

<strong class="sub-title"> Objective: </strong> Our investigation examined the effectiveness of <em>17OHP</em> in women with a prior preterm delivery in a rural US state with a patient population similar to the original Meis trial.

<strong class="sub-title"> Study design: </strong> <em>17OHP</em> became largely unavailable (due to cost and local pharmacies no longer compounding 17 OHP) and the University of Arkansas for Medical Sciences, Department of Health, and Arkansas Medicaid co-operated to make <em>17OHP</em> available to women with a prior PTB in our state. This study was a retrospective review of the <em>17OHP</em> that was offered to women with a prior preterm delivery. For our retrospective review, logistic regression was used on cases of prior preterm delivery between January 2014 and December of 2018 to examine the relationship between <em>17OHP</em> injections and preterm delivery.

<strong class="sub-title"> Results: </strong> A total of 268 women were analyzed for this review. They were divided into three groups: 0 injections, 1-10 injections, and > 10 injections. We found no relationship between <em>17OHP</em> injections with preterm delivery.

Conclusion: Although our patient population was similar to that of the original Meis trial, our results were more similar to the second study by Blackwell.

Keywords: 17 OHP; pregnancy; preterm birth; preterm prevention; recurrent preterm delivery.