Alternative pathway androgen biosynthesis and human fetal female virilization
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Abstract
Androgen biosynthesis in the human fetus proceeds through the adrenal sex steroid precursor dehydroepiandrosterone, which is converted to testosterone in the gonads, followed by further activation to 5α-dihydrotestosterone in genital skin, thereby facilitating male external genital differentiation. Congenital adrenal hyperplasia due to P450 oxidoreductase deficiency results in disrupted dehydroepiandrosterone biosynthesis, explaining undervirilization in affected boys. However, many affected girls are born virilized, despite low circulating androgens. We hypothesized that this is due to a prenatally active, alternative androgen biosynthesis pathway from 17α-hydroxyprogesterone to 5α-dihydrotestosterone, which bypasses dehydroepiandrosterone and testosterone, with increased activity in congenital adrenal hyperplasia variants associated with 17α-hydroxyprogesterone accumulation. Here we employ explant cultures of human fetal organs (adrenals, gonads, genital skin) from the major period of sexual differentiation and show that alternative pathway androgen biosynthesis is active in the fetus, as assessed by liquid chromatography-tandem mass spectrometry. We found androgen receptor expression in male and female genital skin using immunohistochemistry and demonstrated that both 5α-dihydrotestosterone and adrenal explant culture supernatant induce nuclear translocation of the androgen receptor in female genital skin primary cultures. Analyzing urinary steroid excretion by gas chromatography-mass spectrometry, we show that neonates with P450 oxidoreductase deficiency produce androgens through the alternative androgen pathway during the first weeks of life. We provide quantitative in vitro evidence that the corresponding P450 oxidoreductase mutations predominantly support alternative pathway androgen biosynthesis. These results indicate a key role of alternative pathway androgen biosynthesis in the prenatal virilization of girls affected by congenital adrenal hyperplasia due to P450 oxidoreductase deficiency.
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The backdoor pathway is active in the prenatal period of normal individuals and may play a role in male development during fetal life.
“This alternate path is active in the prenatal period of normal individuals and may play a role in male development during fetal life ( 12 , 23 ).”
From Classic and current concepts in adrenal steroidogenesis: a reappraisal (2022) · cites this paper as [12]
Recent evidence demonstrates involvement of the backdoor pathway in 21-hydroxylase deficiency consequent to 17OHP excess; this pathway likely contributes to androgen excess leading to virilization of the female external genitalia in 21-hydroxylase deficiency, and its activity appears to lessen after the first years of life.
“Recent evidence demonstrate involvement of the “ backdoor pathway ” in 21OHD, consequent to 17OHP excess. This pathway likely contribute to androgen excess leading to virilization of the female external genitalia in 21OHD; interestingly, activity of this androgen pathway appears to lessen after the first years of life.”
From Classic and current concepts in adrenal steroidogenesis: a reappraisal (2022) · cites this paper as [12]
Studies in Tammar wallaby demonstrated that DHT can be formed directly from 17-hydroxypregnenolone, without necessarily using DHEA, androstenedione or testosterone as intermediates.
“Studies in marsupials (Tammar wallaby) – whose sexual differentiation occurs after birth and inside the maternal abdominal pouch – demonstrated that DHT can be formed directly from 17-hydroxypregnenolone, without necessarily using DHEA, androstenedione or testosterone as intermediates ( 4 , 12 , 23 ).”
From Classic and current concepts in adrenal steroidogenesis: a reappraisal (2022) · cites this paper as [12]
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- Authors
- Reisch, N., Taylor, A. E., Nogueira, E. F., Asby, D. J., Dhir, V., Berry, A., Krone, N., Auchus, R. J., Shackleton, C. H. L., Hanley, N. A., & Arlt, W.
- Affiliations
- LMU Klinikum (DE)
- University of Birmingham (GB)
- Manchester Academic Health Science Centre (GB)
- University of Michigan (US)
- University of California, San Francisco (US)
- National Health Service (GB)
- University Hospitals Birmingham NHS Foundation Trust (GB)
- Corresponding author
- Arlt, Wiebke
- ORCID
- Venue
- Proceedings of the National Academy of Sciences
- Publisher
- National Academy of Sciences
- Published
- 2019-10-14
- Volume
- 116
- Issue
- 44
- Pages
- 22294-22299
- ISSN
- 0027-8424 (ISSN-L)
- 1091-6490
- PMC
- PMC6825302
- OpenAlex
- W2980338581
- Cited by
- 70
- References
- 44
- Citations by year
- 2026: 3 · 2025: 11 · 2024: 7 · 2023: 15 · 2022: 12 · 2021: 15 · 2020: 7
- FWCI
- 2.81
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Proceedings of the National Academy of Sciences (publishedVersion, cc-by)
- bioRxiv (Cold Spring Harbor Laboratory) (acceptedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion, cc-by)
- Explore Bristol Research (publishedVersion, cc-by)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Spiral (Imperial College London) (submittedVersion, cc-by)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion, cc-by)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion, other-oa)
- Bristol Research (University of Bristol) (submittedVersion, cc-by)
- Funders
- Wellcome (209492/Z/17/Z, WT088566)
- RCUK | Medical Research Council (0900567)
- European Commission (PIEF-GA-2008-221058)
- Deutsche Forschungsgemeinschaft (325768017, CRC 205/1)
- DH | National Institute for Health Research (BRC-1215-20009)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Sexual Differentiation and Disorders
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
- Keywords
- congenital adrenal hyperplasia, P450 oxidoreductase deficiency, 17-hydroxyprogesterone, dihydrotestosterone, dehydroepiandrosterone, androgen receptor nuclear translocation, gonads, urinary steroid excretion, neonates
- MeSH terms
- Adrenal Glands, Androgens, Cells, Cultured, Female, Fetus, Genitalia, Gonads, Humans, Male, Receptors, Androgen, Sex Differentiation, Virilism, 17-alpha-Hydroxyprogesterone, Antley-Bixler Syndrome Phenotype
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