Normal and Premature Adrenarche

Adrenarche is the maturational increase in adrenal androgen production that normally begins in early childhood. It results from changes in the secretory response to ACTH that are best indexed by dehydroepiandrosterone sulfate (DHEAS) rise. These changes are related to the development of the zona reticularis (ZR) and its unique gene/enzyme expression pattern of low 3ß-hydroxysteroid dehydrogenase type 2 with high cytochrome b5A, sulfotransferase 2A1, and 17ß-hydroxysteroid dehydrogenase type 5. Recently 11-ketotestosterone was identified as an important bioactive adrenarchal androgen. Birth weight, body growth, obesity, and prolactin are related to ZR development. Adrenarchal androgens normally contribute to the onset of sexual pubic hair (pubarche) and sebaceous and apocrine gland development. Premature adrenarche causes ≥90% of premature pubarche. Its cause is unknown. Affected children have a significantly increased growth rate with proportionate bone age advancement that typically does not compromise growth potential. Serum DHEAS and testosterone levels increase to levels normal for early female puberty. It is associated with mildly increased risks for obesity, insulin resistance, and possibly mood disorder and polycystic ovary syndrome. Five-10% of premature pubarche is due to virilizing disorders, which are usually characterized by more rapid advancement of pubarche and compromise of adult height potential than premature adrenarche. Most cases are due to nonclassic congenital adrenal hyperplasia. Algorithms are presented for the differential diagnosis of premature pubarche.This review highlights recent advances in molecular genetic and developmental biologic understanding of ZR development and insights into adrenarche emanating from mass spectrometric steroid assays.

The Unique Role of 11-Oxygenated C19 Steroids in Both Premature Adrenarche and Premature Pubarche

<b><i>Introduction:</i></b> Recent studies have shown 11-oxygenated androgens (11oAs) are the dominant androgens in premature adrenarche (PA). Our objective was to compare 11oAs and conventional androgens in a well-defined cohort of children with PA or premature pubarche (PP) and correlate these androgens with metabolic markers. <b><i>Methods:</i></b> A prospective cross-sectional study was conducted at a university hospital. Fasting early morning serum steroids (including 11oAs) and metabolic biomarkers were compared and their correlations determined in children ages 3–8 years (F) or 3–9 years (M) with PA or PP (5 M and 15 F) and healthy controls (3 M and 8 F). <b><i>Results:</i></b> There were no differences between PA, PP, and controls or between PA and PP subgroups for sex, BMI z-score, or criteria for childhood metabolic syndrome. Dehydroepiandrosterone sulfate (DHEAS) was elevated only in the PA subgroup, as defined. 11oAs were elevated versus controls in PA and PP although no differences in 11oAs were noted between PA and PP. Within the case cohort, there was high correlation of T and A4 with 11-ketotestosterone and 11β-hydroxyandrostenedione. While lipids did not differ, median insulin and HOMA-IR were higher but not statistically different in PA and PP. <b><i>Conclusions:</i></b> PA and PP differ only by DHEAS and not by 11oAs or insulin sensitivity, consistent with 11oAs – rather than DHEAS – mediating the phenotypic changes of pubarche. Case correlations suggest association of 11oAs with T and A4. These data are the first to report the early morning steroid profiles including 11oAs in a well-defined group of PA, PP, and healthy children.

Role of Body Weight in the Onset and the Progression of Idiopathic Premature Pubarche

<b><i>Background:</i></b> The term premature pubarche (PP) refers to the appearance of pubic hair before age 8 in girls and before age 9 in boys. Although idiopathic PP (often associated with premature adrenarche) is considered an extreme variation from the norm, it may be an initial sign of persistent hyperandrogenism. Factors contributing to PP onset and progression have not been identified to date. <b><i>Aims:</i></b> The objectives of this study are to describe a group of Italian children with PP, to identify potential factors for its onset, and to define its clinical and biochemical progression. <b><i>Methods:</i></b> We retrospectively enrolled all infants born between 2001 and 2014 with PP. Children with advanced bone age (BA) underwent functional tests to determine the cause of PP. Hormonal analysis and BA determination were performed annually during a 4-year follow-up period. <b><i>Results:</i></b> A total of 334 children with PP were identified: idiopathic PP (92.5%, associated with premature adrenarche in some cases); related to precocious puberty (6.6%); late-onset 21-hydroxylase deficiency (0.9%). Low birth weight was associated with premature adrenal activation. Body mass index (BMI) was the only factor that influenced the progression of BA during follow-up. <b><i>Conclusions:</i></b> Low birth weight is a predisposing factor for premature adrenal activation. The increase in BMI in patients with idiopathic PP during the 4-years of follow-up was responsible for BA acceleration. We recommend prevention of excessive weight gain in children with PP and strict adherence to follow-up in order to prevent serious metabolic consequences.

p.Gln318X and p.Val281Leu as the Major Variants of CYP21A2 Gene in Children with Idiopathic Premature Pubarche

Premature pubarche (PP) is the appearance of sexual hair in children before puberty. The PP phenotype may attribute to nonclassic congenital adrenal hyperplasia (NC-CAH). In this study, we investigated the role of CYP21A2 gene variants in patients with PP in the Iranian population. Forty patients (13 males and 27 females), clinically diagnosed with PP, were analyzed for molecular testing of CYP21A2 gene variants. Direct sequencing was performed for the samples. Also, gene dosage analysis was performed for the cases. Fourteen patients (35%) had a mutation of p.Gln318X and p.Val281Leu, out of which 10% had regulatory variants. Approximately 10% of the patients were homozygous (NC-CAH). 78.5% (11/14) of patients had trimodular RCCX of which 5 patients had two copies of CYP21A1P pseudogene. The prevalence of p.Val281Leu was higher than p.Gln318X in PP patients. In conclusion, CYP21A2 variant detection has implications in the genetic diagnosis of PP phenotype. The genetic characterization of the CYP21A2 gene is important for characterizing the variable phenotype of carriers and genetic counseling of PP and NC-CAH patients.

OR27-06 11-Oxygenated C19 Steroids Are Alternative Markers of Androgen Excess in Children with Premature Adrenarche and Premature Pubarche

Premature adrenarche (PA), the early onset of pubic hair and/or axillary hair/odor in children, is associated with elevated adrenal androgens and precursors in the absence of gonadotropin-dependent puberty. Laboratory data in PA classically demonstrate increased DHEAS, T, and A4 levels that correlate with pubic hair development. In premature pubarche (PP), the clinical presentation occurs in the absence of elevated DHEAS, T, and A4. PA is associated with insulin resistance and progression to metabolic syndrome (MetS) and PCOS; it is unclear which of these children are at risk for metabolic abnormalities. Adrenally-derived 11-oxygenated C19 steroids (11oAs) have comparable androgenic potency to T and DHT and are elevated in disorders of androgen excess. We sought to characterize the 11oA profiles of children with PA/PP and controls and to correlate them with traditional androgens and metabolic markers, including criteria for childhood MetS. A prospective cross-sectional study was performed of subjects with PA or PP (5 M, 14 F) and controls (2 M, 6 F) ages 3 – 8 yrs (F) or 3 – 9 yrs (M). Children with precocious puberty, steroid use, or recent illness were excluded. Fasting early morning serum was collected, a complete physical exam was performed, and BP and waist circumference were measured; a bone age was obtained only in PA/PP subjects. 11oAs (11OHT, 11KT, 11OHA4, 11KA4) were analyzed by LC-MS. Subjects were divided into PA (DHEAS ≥ 50 µg/dL, n=10) or PP (DHEAS &lt; 50 µg/dL, n=9) for sub-analysis. There were no significant differences in sex, race/ethnicity, BMI z-score, preterm gestation, birth weight, family history, or clinical criteria for childhood MetS. T, A4, DHT, DHEAS, and all 11oAs were significantly higher in PA/PP subjects. While lipids did not differ, insulin and HOMA-IR were higher in PA/PP vs. controls {insulin Mdn = 8.2 (IQR 3.5 – 10.0) vs. 2.0 (2.0 – 3.3) µIU/mL, p &lt; 0.03; HOMA-IR Mdn = 1.8 (IQR 0.8 – 2.1) vs. 0.4 (0.4 – 0.8), p &lt; 0.03}. In a sub-analysis of PA vs. PP, there were no differences in baseline characteristics or metabolic markers. DHEAS was elevated in PA vs. PP {Mdn = 95 (IQR 73 – 111) vs. 42 (36 – 46) µg/dL, p &lt; 0.00003}, although no differences were noted in 11oA levels. Correlations of androgens and their precursors suggested best correlation of 11KT and 11OHA4 with T (ρ=0.87; ρ=0.87) and A4 (ρ=0.87; ρ=0.88). There was moderate correlation of 11KT and 11OHT with insulin (ρ=0.47; ρ=0.51) and HOMA-IR (ρ=0.43; ρ=0.47). We conclude that PA and PP differ only by DHEAS (by definition) and not by insulin sensitivity or 11oA, consistent with 11oA – rather than DHEAS – mediating the phenotypic changes of pubarche. These pilot data are the first to report the early morning steroid metabolite levels including 11oAs in a phenotypically and metabolically well-defined group of PA, PP, and age-matched male and female controls. The relationships between PA, PP, risk for MetS, and 11oA warrant further study.

Clinical, biochemical and gender characteristics of 97 prepubertal children with premature adrenarche

Background Premature adrenarche (PA) is defined as the appearance of clinical signs of androgen action associated with levels of dehydroepiandrosterone sulfate (DHEAS) ≥40 μg/dL, before age 8 years in girls and 9 years in boys, without breast or testicular enlargement. The aim of this study was to characterize a population of prepubertal Caucasian children with PA and to compare them with regard to gender and body mass index (BMI) (normal BMI vs. overweight/obesity). Methods We performed a cross-sectional study of Portuguese Caucasian prepubertal children followed, due to PA, in pediatric endocrinology clinics of a university hospital. Results Eighty-two girls and 15 boys were included (mean age at evaluation: 7.4 ± 1.3 years). The mean birth weight was 2990 ± 689 g; only two children were small for gestational age. Girls presented premature pubarche at a younger age (median [interquartile range (IQR)] 6 (5–6) years vs. 7 (7–8) years in boys; p < 0.001). No gender differences were found for gestational age, birth weight, maternal age at menarche, anthropometry, bone age advancement or androgen levels. The majority of the subjects were overweight or obese (59%). Overweight/obese PA children were taller and had a more advanced bone age than normal-BMI PA children. Overweight/obese children presented higher levels of DHEAS and androstenedione. Bone age advancement and DHEAS were correlated (r = 0.449; p = 0.05). Conclusions We found no evidence of reduced fetal growth. Girls presented premature pubarche at a younger age. No major gender differences in androgen levels were found in prepuberty. Obese and overweight PA children tend to be taller, have a more advanced bone age and higher levels of androgens than normal-BMI PA children.