Increased Testosterone and

Dihydrotestosterone Ratio is not Necessarily

Diagnostic for 5 Alpha Reductase Deficiency

Firman Prathama Idris

Eijkman Institute for Molecular Biology
 5α-Reductase Enzyme (Azzouni, 2012)

• Membrane bound enzyme prevalent in

• Prostate, Testosterone Dihydrotestosterone
• Genital skin, 5αR2
• Seminal vesicle,
• Epididymis.
• Catalyze conversion of testosterone to
dihydrotestosterone.
• Important for the development of male external
genitalia. Testosterone Dihydrotestosterone
Development of Wolffian Ducts Prostate Development
Spermatogenesis External virilization
 5α-Reductase Enzyme (Fukami, 2013)

• T = Testosterone
• DHT = Dihydrotestosterone Zygote
• AR = Androgen receptor
• AMH = Anti Mullerian SRY (+) Indifferent SRY (-)
Hormone gonad
• AMHR = AMH Receptor
Fetal Fetal
• INSL3 = Insulin-like factor 3 testis ovary
• INSL3R = INSL3 receptor
Sertoli & Leydig Cell

INSL3 → INSL3R AMH → AMHR T → DHT → AR

Female sex
T → AR T → AR External genitalia
development
Testicular descent Wolffian duct masculinization
 5α-Reductase Enzyme Deficiency
(Chan, 2013)

• Autosomal recessive,
typically caused by
mutation in SRD5A2 gene.
• External phenotype :
• almost complete females to
males with micropenis or
hypospadia.
• Biochemical hallmarks:
• Normal to high concentration
of Testosterone
• Low concentration of DHT
• 97 mutations have been
reported so far (HGMD).
 46,XY DSD Cases & Results
Post-hCG test SRD5A2 gene
Patient Age Clinical Presentation
T DHT T/DHT mutation
Penoscrotal transposition,
hypospadia, shawl scrotum,
MZA 1 testes in scrotum, testicular 9.18 <5 9.18/<5 Het p.V89L
volume: 1 ml (right) & 0.5 ml
(left), phallus 1.2 cm
Micropenis, scrotum bifidum,
NA 6.5 366.1 27 13.56 N/A
hipospadia perineoscrotal
Unpalpable right testis,
palpable left testis, virilized at
AM 10 154 6 25.6 Het p.V89L
puberty, phallus: 3.5 cm,
perineal hypospadia

Micropenis, perineal
NU 17 hypospadia, unpalpable left 400.2 14 24.5 N/A
testis, virilized at puberty
 T/DHT Ratio ≠ SRD5A2 Mutation

• Four patients with characteristic phenotype for 5-

alpha reductase deficiency.
• Increased T/DHT ratio.
• No definite T/DHT cut-off for 5αR2 deficiency (Perry,
2011; Baldinotti, 2008).

• False negative T/DHT results were reported

previously (Perry, 2011):
• 5αR2 deficiency were detected in infants only in most
severely affected case.
• Previously suggested molecular testing can
confidently diagnose 5αR2 deficiency (Chan,2013).
 T/DHT Ratio ≠ SRD5A2 Mutation

• Two patients have Het p.V89L mutation.

• p.V89L: Common polymorphism in Asian population reported in
nearly 50% of Asian population (Makridakis, 1997).
• DNA of AM analyzed further using targeted massively parallel
sequencing:
• NR5A1/ SF1 mutation: p.R84H (Murdoch Children Research Institute,
Melbourne)
• Various factors could influence SRD5A2 expression and function:
• SREBP-2
AM (Sterol Regulatory
MZA Element Binding Proteins) (Seo,2009)
• BMI could affect SRD5A2 promoter methylation (Bechis, 2015)

V89L
Conclusions

• Increased T/DHT ratio does not necessarily

indicates mutation in the SRD5A2 gene.
• Molecular analysis is important to determine the
correct diagnosis.
References

• Azzouni, F., et al. (2012). "The 5 alpha-reductase isozyme family: a review of basic
biology and their role in human diseases." Adv Urol 2012: 530121.
• Baldinotti, F., et al. (2008). "Molecular Characterization of 6 Unrelated Italian Patients
With 5α-Reductase Type 2 Deficiency." Journal of Andrology 29(1): 20-28.
• Bechis, S. K., et al. (2015). "Age and Obesity Promote Methylation and Suppression of
5-Alpha Reductase 2–Implications for Personalized Therapy in Benign Prostatic
Hyperplasia." The Journal of urology 194(4): 1031-1037.
• Chan, A. O., et al. (2013). "Diagnosis of 5alpha-reductase 2 deficiency: is
measurement of dihydrotestosterone essential?" Clin Chem 59(5): 798-806.
• Seo, Y. K., et al. (2009). "Regulation of steroid 5-alpha reductase type 2 (Srd5a2) by
sterol regulatory element binding proteins and statin." Exp Cell Res 315(18): 3133-
3139.
• Makridakis, N., et al. (1997). "A prevalent missense substitution that modulates
activity of prostatic steroid 5alpha-reductase." Cancer Res 57(6): 1020-1022.
• Perry, R. J., et al. (2011). "Pitfalls in the Diagnosis of 5α-Reductase Type 2 Deficiency
during Early Infancy." Hormone Research in Paediatrics 75(5): 380-382.