CEDAM

School of Clinical & Experimental MedicineUniversity of Birmingham

Birmingham, United Kingdom

CEDAMCentre for Endocrinology, Diabetes and Metabolism

Wiebke Arlt

Adrenarche– nouveaux aspects de son

contrôle génétique

The Steroid Universe

DHEASDHEA

Oestradiol

Testosterone

Aldosterone

Androstenedione

Cortisol

Adrenarche

Seru

m D

HEA

-S (n

g/m

l)

1 10 20 30 40 50 60Age (yrs)

4000

2000

Serum DHEAS and Age

Age (years)

Korth-Schutz et al., JCE&M 1976

DHEAS Secretion during Adrenarche

Pubarche

Remer, Boye, Hartmann and Wudy , JCE&M 2005

Urinary Excretion of C19 Steroids from 3 to 19 years

Low birth weight

catch-upweight

gain

Premature adrenarche PCOS Metabolic

Syndrome

Early Onset Androgen Excess Premature Adrenarche and Adolescent PCOS

as a forerunner of adult metabolic disease

Idkowiak et al., Eur J Endocrinol 2011

Zona Glomerulosa

Aldosterone

Zona Fasciculata

DHEAZona Reticularis „Sex“

„Sugar“

„Salt“

Cortisol

CYP17A1

CYB5

HSD3B2

Pregnenolone

17Preg

Progesterone

17OHP

Cholesterol

Deoxycortico-sterone

11-Deoxycortisol

Cortisol

18OH-Cortico-sterone

AldosteroneCortico-sterone

DHEA Androstenedione Testosterone DHT

HSD3B2

HSD3B2 HSD17B3 SRD5A2

HSD3B2

CYP21A2

CYP21A2

CYP17A1

CYP17A1

CYP17A1

CYP17A1

CYP11A1

CYP11B1

CYP11B2 CYP11B2 CYP11B2

CortisoneHSD11B1

HSD11B2

Mineralocorticoids - SALTMineralocorticoid

precursors

Glucocorticoids- SUGAR

Androgens- SEX

Androgen precursors

Glucocorticoid precursors

CYP11B1

Adrenal Steroidogenesis

DHEA

DHEASSTSSULT

2A1

Estrone (E1)

17β-Estradiol (E2)

∆4-Andro-stenedione

Testosterone (T)

Dihydro-testosterone

(DHT)

Androstanediol glucuronide (ADG)

DHEA Metabolism and DHEA/DHEAS Interconversion

Adrenal Gland Peripheral target cell

17OH-Pregnenolone

CYP17A1

ACTH

Serum Hormones after 4 Months of DHEA 50 mg/d in Women with Adrenal Insufficiency (n=24)

DHEA

Andro-stene-dione

5α-Dihydro-

testo-sterone

ADG

Testo-sterone

DHEAS

Arlt et al., N Engl J Med

1999

DHEAS DHEA

STS

SULT2A1

Δ4-A‘dione

Testo

5α-DHT

E1

E2

Subjects• healthy young men (n=8, median age 25a)Protocol• frequent serum sampling 08:30 - 15:00 h• Day 1: Baseline• Day 2: 100 mg DHEA orally (09:00 h)• Day 3: 25 mg DHEAS i.v. (09:00 h)

Serum DHEA and DHEAS do not interconvert freely and continuously

Hammer F, Subtil S et al., JCE&M 2005

0

5

10

15

20

25

30

35

-60 0 60 120 180 240 300 360

Baseline25mg DHEAS i.v.

DH

EAS

(µm

ol/l)

Time (min)

25mg DHEAS i.v.

0

10

20

30

40

50

60

-60 0 60 120 180 240 300 360

25mg DHEAS i.v.

DH

EA(n

mol

/l)Time (min)

=> Circulating DHEAS does not necessarily reflect circulating DHEA

DHEAS DHEA

STS

SULT2A1

Androstenedione

Testosterone

E1

E2

5α-DHT

Hammer F, Subtil S et al., J Clin Endocrinol Metab 2005Arlt W et al., J Clin Endocrinol Metab 2006

DHEAS DHEASULT2A1

8-year old girl • Premature pubarche at 6 yrs• Tanner PH4, B2• Height 125 cm, Weight 36.2 kg• Advanced bone age (12 yrs)Follow-up:• Menarche at 11 yrs• At 12 yrs Tanner PH5, B4• Height 139 cm, Weight 58.3 kg• Advanced bone age (16.5 yrs)•Significant hirsutism and acne•At 13 yrs secondary amenorrhoea

The Case

From Premature Pubarche to PCOSHormone Age 8 yrs Age 12 yrsACTH (pmol/L) 10.0 (2.2-13.2) 3.6 (2.2-13.2)Cortisol (nmol/L) 280 (190-550) 440 (190-550)17OHP (nmol/L) 1.80 (1.0-3.4)DHEAS (µmol/L) <0.40 (0.4-4.6) <0.40 (1.6-10.4)DHEA (nmol/L) 15.0 (1.3-18.0) 20.0 (2.0-22.0)

Androstenedione (nmol/L) 4.1 (0.1-1.4) 27.0 (<12.0)Testosterone (nmol/L) 1.2 (0.03-0.65) 2.1 (0.51-1.26)Dihydrotestosterone (nmol/L) 0.36 (0.05-0.25)LH (U/L) <0.2 (<0.05-0.7) 3.2 (<0.05-20.2)FSH (U/L) 2.0 (0.3-4.8) 5.2 (0.14-8.78)

SST (12 yrs) Baseline 30 min 60 minDHEA (nmol/L) 20.0 38.0 43.0DHEAS (µmol/L) <0.40 <0.40 <0.40

DHEA

DHEAS

SULT2A1

From Bedside to Bench:The DHEA/DHEAS Shuttle

PAP

PAPS

PAPS Synthase

APSATP+ SO4

ATP Sulfurylase

APS Kinase

+ ATP

Compound heterozygous mutations in PAPSS286 kb

6321 2 3 4 5 6 10 11 127B

1,359 6002,00149,186 3,760 752 561 120 5,912 5,512 13,7447 98

N APS KINASE C

44 194 244 6071 614

F

M

P

T48R R329X

c.143C>G c.985C>T

A

ATP SULFURYLASE

• Defects in APSK2 (=PAPSS2) are the cause of autosomal recessive spondyloepimetaphyseal dysplasia Pakistani type (SEMD). ul-Haque et al, Nat Genet 1998, 20:157-162

Spondyloepimetaphyseal dysplasia (SEMD) Pakistani type (OMIM +603005)

Ahmad et al., Am J Med Genet 1998, 78:468-473S475X

A

C D

T48RR329X

B

APS kinase domain

ATP sulfurylase

domain S475X

From Bedside to Bench: Mutant Protein Analysis

PAPS

3H DHEA 3H DHEAS

ATPSO42-

In vitro assessment of DHEA sulfation: Coupled SULT2A1/PAPSS2 assay

WT/ Mutant PAPSS2

WT SULT2A1

PAP

TLC

Viv Dhir

0

20

40

60

80

100

WT T48R R329X S475X

DH

EA

S s

ynth

esis

by

SU

LT2A

1 co

-in

cuba

ted

with

wild

-type

and

mut

ant

PAP

SS

2a (

% w

ild-ty

pe a

ctiv

ity)

WT T48R R329X S475X

100

80

60

40

20

0

WT

T48R

R32

9X

S475

X

Western Blot

Co-Incubation of bacterially expressed hSULT2A1 and wild-type or mutant PAPSS2a

PAPSS2 and Androgen Excess• Inactivating mutations in PAPSS2 in a girl with

premature pubarche and early onset polycystic ovary syndrome – novel monogenic cause of androgen excess

• Critical role of DHEA sulfation as a gatekeeper of human androgen synthesis – Impaired DHEA sulfation results in increased conversion of DHEA to androgens

N Engl J Med 2009, 360: 2310-2318.

Premature adrenarche

Polycystic ovary syndrome

(PCOS)

Metabolic Syndrome

DHEA Sulfation and Childhood Androgen Excess

Virdis R, Zampolli M, Ibáñez L, Ghizzoni L, Street ME, Vicens- Calvet E. II pubarca prematuro. Riv Ital Pediatr (IJP) 1993;19:569–579

PAPSS

DHEA sulfation and Androgen

Synthesis

SULT2A1

PAPSS2

DHEA

DHEAS

Sulfation during chondrocyte and

bone development

Sulfation of drugs and xenobiotics

(Hepatic Phase 2 Drug Metabolism)

PAPS Synthase and Human Sulfation

Vivek Dhir

Jan IdkowiakNils Krone

Jo McNelis

Edson Nogueira

Florian Schlereth

CEDAM

Sex Steroid Group Nicole Reisch

Angela TaylorHannah Ivison

Pushpa PatelDonna HolmesSilvia ParajesIan Rose

Fred Sweep Hedi Claahsen Jan Smeitink Kees Noordam Ron Smeets

Kees Nordam Hedi Clahhsen van der GrintenBill Rainey Enzo Lalli