[Gas chromatography-mass spectrometry determination of plasma 5 alpha-androstane-3 alpha,17 beta-diol and 5 alpha-androstane-3 alpha,17 beta-diol glucuronide in children with premature and normal puberty ]

Biomarkers in congenital adrenal hyperplasia

Monitoring of hormone replacement therapy represents a major challenge in the management of congenital adrenal hyperplasia (CAH). In the absence of clear guidance and standardised monitoring strategies, there is no consensus among clinicians regarding the relevance of various biochemical markers used in practice, leading to wide variability in their application and interpretation. In this review, we summarise the published evidence on biochemical monitoring of CAH. We discuss temporal variations of the most commonly measured biomarkers throughout the day, the interrelationship between different biomarkers, as well as their relationship with different glucocorticoid and mineralocorticoid treatment regimens and clinical outcomes. Our review highlights significant heterogeneity across studies in both aims and methodology. However, we identified key messages for the management of patients with CAH. The approach to hormone replacement therapy should be individualised, based on the individual hormonal profile throughout the day in relation to medication. There are limitations to using 17-hydroxyprogesterone, androstenedione and testosterone, and the role of additional biomarkers such 11-oxygenated androgens which are more disease specific should be further established. Noninvasive monitoring via salivary and urinary steroid measurements is becoming increasingly available and should be considered, especially in the management of children with CAH. Additionally, this review indicates the need for large scale longitudinal studies analysing the interrelation between different monitoring strategies used in clinical practice and health outcomes in children and adults with CAH.

Gonadal, adrenal, and neuroactive steroids' role in ictal activity

Of the many people that have epilepsy, only about 70% achieve seizure control with traditional pharmacotherapies. Steroids have long been known to influence ictal activity and may have a therapeutic role. This review summarizes recent investigations that have enhanced knowledge of the effects and mechanisms of gonadal, adrenal, and neuroactive steroids on seizure processes. Progesterone, which varies across reproductive cycles, pregnancy, and as a function of aging, has been shown to have anti-seizure effects among women with epilepsy and in animal models of epilepsy. Further, data suggest that progesterone's anti-seizure effects may involve its metabolism to the neuroactive steroid, 5 alpha-pregnan-3 alpha-ol-20-one (3 alpha,5 alpha-THP), and its subsequent actions at GABA(A) receptors. Androgens also have anti-seizure effects. Androgens' anti-seizure effects may be mediated, in part, through actions of the testosterone metabolite, and neuroactive steroid, 5 alpha-androstane-3 alpha,17 alpha-diol (3 alpha-diol) at GABA(A) receptors. Stress can alter seizure susceptibility, suggesting a role of adrenal steroids on seizure processes. In animal models of epilepsy, acute or chronic stress can increase ictal activity. Notably, stress and seizures can alter levels of gonadal, adrenal, and neuroactive steroids, which may then influence subsequent seizure activity. Thus, this review summarizes recent progress in the role of gonadal, adrenal, and/or neuroactive steroids in seizure processes which suggest that greater understanding of these steroids' effects and mechanisms may ultimately lead to improved seizure control for people with epilepsy.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency

More than 90% of cases of congenital adrenal hyperplasia (CAH, the inherited inability to synthesize cortisol) are caused by 21-hydroxylase deficiency. Females with severe, classic 21-hydroxylase deficiency are exposed to excess androgens prenatally and are born with virilized external genitalia. Most patients cannot synthesize sufficient aldosterone to maintain sodium balance and may develop potentially fatal "salt wasting" crises if not treated. The disease is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme. More than 90% of these mutations result from intergenic recombinations between CYP21 and the closely linked CYP21P pseudogene. Approximately 20% are gene deletions due to unequal crossing over during meiosis, whereas the remainder are gene conversions--transfers to CYP21 of deleterious mutations normally present in CYP21P. The degree to which each mutation compromises enzymatic activity is strongly correlated with the clinical severity of the disease in patients carrying it. Prenatal diagnosis by direct mutation detection permits prenatal treatment of affected females to minimize genital virilization. Neonatal screening by hormonal methods identifies affected children before salt wasting crises develop, reducing mortality from this condition. Glucocorticoid and mineralocorticoid replacement are the mainstays of treatment, but more rational dosing and additional therapies are being developed.