Pathways and manipulation of testosterone biosynthesis and metabolism

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1 Pathways and manipulation of testosterone biosynthesis and metabolism

2 Dihydrotestosterone 8% Pregnenolone 3-βSD Progesterone 17- Pregnenolone 17a--lase 17-Progesterone 3-βSD 17a--lase Androstenedione DEA 3-βSD lyase lyase Testosterone Androstenediol 3-βSD SRD5A2 Estradiol 0.3% 17b-SD 17b-SD Cholesterol CYP11A1 Δ5 Δ4 Biosynthesis of Testosterone

3 Control of testosterone synthesis 1 GnR 2 GnR-R gonadotropes α-subunit FS β-subunit L β-subunit FS L Pregnenolone StAR CYP11A1 C Cholesterol side chain cleavage Cholesterol

4 Dihydrotestosterone 8% Pregnenolone 3-βSD Progesterone 17- Pregnenolone 17a--lase 17-Progesterone 3-βSD 17a--lase Androstenedione DEA 3-βSD lyase lyase Testosterone Androstenediol 3-βSD SRD5A2 Estradiol 0.3% 17b-SD 17b-SD Cholesterol CYP11A1 Δ4 Δ mg/day 300 to 1000 ng/dl Biosynthesis of Testosterone

5 Total Testosterone 2% 44% 54% Free testosterone Albumin-bound testosterone SBG-bound testosterone Bioavailable Testosterone (non SBG-bound T)

6 SBG nmol/l Mean SBG increases with age in adult 80 males 70 60, ,4 45,4 0 Age JCEM, 1996;86:1821

7 Factors Influencing SBG Levels Increased Estrogens Age yperthyroidism IV Cirrhosis Decreased Testosterone Insulin Resistance (besity, T2DM) ypothyroidism Progestins Nephrotic Syndrome

8 AR

9 Nuclear receptors

10 AR gene and protein

11 Androgen Receptor and Androgen Receptor Variants CE4 CE1 CE NTD/ AF- 1 DBD LBD/ AF2 CE3

12 Effects of T-AR on the human body Testosterone Bone AR Sexual function Body composition, strength, muscle

13 Androgen deficiency Androgen excess

14 Etiologies of Androgen Deficient States Primary testicular failure (low Testosterone, high L) Congenital Abnormalities Klinefelter's syndrome (1:1000 live male births) 46,XY/X karyotype, microdeletion long arm of the Y chromosome L or FS receptor mutations Cryptorchidism Myotonic dystrophy Disorders androgen biosynthesis (decreased in utero virilization) Acquired Conditions rchitis [infection (mumps), radiations (131I, XRT) Testicular trauma Autoimmune damage Chemotherapy (suramin, alkylating agents,) Drugs (Ketokenazole, Spironolactone, Abiraterone, alcohol) Chronic systemic diseases: [Liver (cirrhosis), CKD)]

15 Etiologies of Androgen Deficient States Secondary testicular deficiency (Low T and low or inappropriately normal L) Congenital: GnR, GnR receptor mutations, Kallman Syndrome (Kal1, FGFR1, PRK2, PRKR2), Dax1, GPR54, leptin, leptin receptor, L/FS b subunit mutations, LX3, LX4, ESX1, PRP-1 Acquired: Disease or suppression of hypothalamus Disease or suppression of the pituitary stalk (GnR does not reach the pituitary) Disease or suppression of the pituitary (impairment of L, FS secretion) Mixed primary and secondary: L?

16 Syndromes of Androgen Excess 21 -ase deficiency 11 b -ase deficiency PCS Castration resistant prostate cancer

17 Pregnenolone 3-βSD Progesterone Deoxy-corticosterone Corticosterone Aldosterone CYP21A2 CYP11B1 CYP11B2 17- Pregnenolone 17a--lase 17-Progesterone 11Deoxy Cortisol Cortisol 3-βSD CYP11B1 17a--lase Androstenedione DEA 3-βSD lyase lyase 21 ydroxylase Testosterone Testosterone 11 b ydroxylase 11 b ydroxylase

18 Syndrome of Androgen Excess: Castration resistant prostate cancer T-DT AR

19 17βSD AKR1C3 17βSD AKR1C3 17βSD AKR1C3 Pr egnenolone Progest erone CYP17A CYP17A CYP17A 3- βsd 3- βsd 17- Pregnenolone 17-0 Progest erone 3- βsd Alternative Pathway CYP17A SRD5A1 SRD5A1 Backdoor Pathway 5α- pregnane- 3, 20- dione CYP17A 5α- Pregnane- 17α- ol- 3, 20- dione CYP17A 3αSD AKR1C2 3αSD AKR1C2 5α- Pregnan- 3α- ol- 20- one CYP17A 5α- Pregnane- 3α, 17α- diol- 20- one CYP17A DEA Androst enedione SRD5A1 5α- Androstanedione 3αSD AKR1C2 3a- Androst erone A17βSD AKR1C3 Conventional 5- Androst enediol Pathway 3- βsd Test ost erone SRD5A2 DT RLSD 3αSD AKR1C2 5α- Androstane- 3α, 17β- diol Adiol

20 DT is formed mostly at the tissue level SRD5A1 Skin Liver SRD5A2 Dihydrotestosterone Dihydrotestosterone Prostate, skin, liver

21 Dihydrotestosterone 8% Pregnenolone 3-βSD Progesterone 17- Pregnenolone 17a--lase 17-Progesterone 3-βSD 17a--lase Androstenedione DEA 3-βSD lyase lyase Testosterone Androstenediol 3-βSD SRD5A2 Estradiol 0.3% 17b-SD 17b-SD Cholesterol CYP11A1 Δ4 Δ5 Inhibition of steroidogenesis 11-deoxycortisol to cortisol 11b-ydroxylase Ketoconaz ole Ketoconaz ole Ketoconaz ole Ketoconaz ole 11b-ydroxylase Metirapone Finasteride Dutasteride Anastrozole Letrozole

22 Antagonists of the AR AR Cyproterone Acetate Spironolactone Flutamide Bicalutamide Nilutamide Enzalutamide Endocrine Disruptors

23 GnR agonists Leuprolide Nafarelin Goserelin 1 GnR 1 GnR 2 GnR-R 2 GnR-R FS β-subunit α-subunit 3 3 L β-subunit FS β-subunit α-subunit 3 3 L β-subunit FS L FS L Pregnenolone CYP11A1 StAR C Cholesterol

24 Effect of 5α reductase inhibition Finasteride Dutasteride Prostate size ~ 20-25% ~ 20-25% Serum T 10% 17% Serum DT 78% 92% Prostate T 8x (RIA) 20 x (GC MS) Prostate DT 96% (RIA) 98% (GC MS) Number of cancers % Reduction 1147 Finasteride (n=4368) Placebo (n=4692) Total Cancer 2 to 4 5 to 6 7 to 10 Number of cancers % Reduction Total Cancer 617 Dutasteride (n=3299) 437 Placebo (n=3407) to 10 8 to 10 Gleason score Gleason score

25 TANKS

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