17 alpha-hydroxylase deficiency differential diagnosis: Difference between revisions

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{{CMG}}; {{AE}} {{MJ}}
{{CMG}}; {{AE}} {{MJ}}
==Overview==
==Overview==
17 alpha-hydroxylase deficiency must be differentiated from diseases with [[primary amenorrhea]] and female [[external genitalia]]. Some of these causes include [[Pregnancy]], [[androgen insensitivity syndrome]], 3beta-hydroxysteroid dehydrogenase type 2 deficiency, 17-alpha-hydroxylase deficiency,  gonadal dysgenesis, [[testicular regression syndrome]],  [[LH receptor|LH receptor defects]], [[5-alpha-reductase deficiency|5-alpha-reductase type 2 deficiency]], [[mullerian agenesis]], [[Ovarian insufficiency|primary ovarian insufficiency]], [[hypogonadotropic hypogonadism]] and [[turner syndrome]].
17 alpha-hydroxylase deficiency must be differentiated from diseases that present with [[primary amenorrhea]] and female [[external genitalia]] such as [[pregnancy]], [[androgen insensitivity syndrome]], 3beta-hydroxysteroid dehydrogenase type 2 deficiency, gonadal dysgenesis, [[testicular regression syndrome]],  [[LH receptor|LH receptor defects]], [[5-alpha-reductase deficiency|5-alpha-reductase type 2 deficiency]], [[mullerian agenesis]], [[Ovarian insufficiency|primary ovarian insufficiency]], [[hypogonadotropic hypogonadism]] and [[turner syndrome]].


==Differentiating 17 alpha-hydroxylase deficiency from other Diseases==
==Differentiating 17 alpha-hydroxylase deficiency from other Diseases==
17 alpha-hydroxylase deficiency must be differentiated from diseases with [[primary amenorrhea]]. Some of these causes include [[androgen insensitivity syndrome]], [[3 beta-hydroxysteroid dehydrogenase deficiency]], gonadal dysgenesis, [[testicular regression syndrome]], [[LH receptor|LH receptor defects]], [[5-alpha-reductase deficiency|5-alpha-reductase type 2 deficiency]], [[mullerian agenesis]], [[Ovarian insufficiency|primary ovarian insufficiency]], [[hypogonadotropic hypogonadism]] and [[turner syndrome]].<ref name="pmid21147889">{{cite journal |vauthors=Maimoun L, Philibert P, Cammas B, Audran F, Bouchard P, Fenichel P, Cartigny M, Pienkowski C, Polak M, Skordis N, Mazen I, Ocal G, Berberoglu M, Reynaud R, Baumann C, Cabrol S, Simon D, Kayemba-Kay's K, De Kerdanet M, Kurtz F, Leheup B, Heinrichs C, Tenoutasse S, Van Vliet G, Grüters A, Eunice M, Ammini AC, Hafez M, Hochberg Z, Einaudi S, Al Mawlawi H, Nuñez CJ, Servant N, Lumbroso S, Paris F, Sultan C |title=Phenotypical, biological, and molecular heterogeneity of 5α-reductase deficiency: an extensive international experience of 55 patients |journal=J. Clin. Endocrinol. Metab. |volume=96 |issue=2 |pages=296–307 |year=2011 |pmid=21147889 |doi=10.1210/jc.2010-1024 |url=}}</ref><ref name="pmid2164530">{{cite journal |vauthors=Moreira AC, Leal AM, Castro M |title=Characterization of adrenocorticotropin secretion in a patient with 17 alpha-hydroxylase deficiency |journal=J. Clin. Endocrinol. Metab. |volume=71 |issue=1 |pages=86–91 |year=1990 |pmid=2164530 |doi=10.1210/jcem-71-1-86 |url=}}</ref><ref name="pmid999330">{{cite journal |vauthors=Heremans GF, Moolenaar AJ, van Gelderen HH |title=Female phenotype in a male child due to 17-alpha-hydroxylase deficiency |journal=Arch. Dis. Child. |volume=51 |issue=9 |pages=721–3 |year=1976 |pmid=999330 |pmc=1546244 |doi= |url=}}</ref><ref name="pmid226795">{{cite journal |vauthors=Biglieri EG |title=Mechanisms establishing the mineralocorticoid hormone patterns in the 17 alpha-hydroxylase deficiency syndrome |journal=J. Steroid Biochem. |volume=11 |issue=1B |pages=653–7 |year=1979 |pmid=226795 |doi= |url=}}</ref><ref name="pmid8929268">{{cite journal |vauthors=Saenger P |title=Turner's syndrome |journal=N. Engl. J. Med. |volume=335 |issue=23 |pages=1749–54 |year=1996 |pmid=8929268 |doi=10.1056/NEJM199612053352307 |url=}}</ref><ref name="pmid25813279">{{cite journal |vauthors=Bastian C, Muller JB, Lortat-Jacob S, Nihoul-Fékété C, Bignon-Topalovic J, McElreavey K, Bashamboo A, Brauner R |title=Genetic mutations and somatic anomalies in association with 46,XY gonadal dysgenesis |journal=Fertil. Steril. |volume=103 |issue=5 |pages=1297–304 |year=2015 |pmid=25813279 |doi=10.1016/j.fertnstert.2015.01.043 |url=}}</ref><ref name="pmid4432067">{{cite journal |vauthors=Imperato-McGinley J, Guerrero L, Gautier T, Peterson RE |title=Steroid 5alpha-reductase deficiency in man: an inherited form of male pseudohermaphroditism |journal=Science |volume=186 |issue=4170 |pages=1213–5 |year=1974 |pmid=4432067 |doi= |url=}}</ref><ref name="pmid11344932">{{cite journal |vauthors=Schnitzer JJ, Donahoe PK |title=Surgical treatment of congenital adrenal hyperplasia |journal=Endocrinol. Metab. Clin. North Am. |volume=30 |issue=1 |pages=137–54 |year=2001 |pmid=11344932 |doi= |url=}}</ref>
17 alpha-hydroxylase deficiency must be differentiated from diseases that present with [[primary amenorrhea]] and female [[external genitalia]] such as [[pregnancy]], [[androgen insensitivity syndrome]], 3beta-hydroxysteroid dehydrogenase type 2 deficiency, gonadal dysgenesis, [[testicular regression syndrome]], [[LH receptor|LH receptor defects]], [[5-alpha-reductase deficiency|5-alpha-reductase type 2 deficiency]], [[mullerian agenesis]], [[Ovarian insufficiency|primary ovarian insufficiency]], [[hypogonadotropic hypogonadism]] and [[turner syndrome]].
.<ref name="pmid21147889">{{cite journal |vauthors=Maimoun L, Philibert P, Cammas B, Audran F, Bouchard P, Fenichel P, Cartigny M, Pienkowski C, Polak M, Skordis N, Mazen I, Ocal G, Berberoglu M, Reynaud R, Baumann C, Cabrol S, Simon D, Kayemba-Kay's K, De Kerdanet M, Kurtz F, Leheup B, Heinrichs C, Tenoutasse S, Van Vliet G, Grüters A, Eunice M, Ammini AC, Hafez M, Hochberg Z, Einaudi S, Al Mawlawi H, Nuñez CJ, Servant N, Lumbroso S, Paris F, Sultan C |title=Phenotypical, biological, and molecular heterogeneity of 5α-reductase deficiency: an extensive international experience of 55 patients |journal=J. Clin. Endocrinol. Metab. |volume=96 |issue=2 |pages=296–307 |year=2011 |pmid=21147889 |doi=10.1210/jc.2010-1024 |url=}}</ref><ref name="pmid2164530">{{cite journal |vauthors=Moreira AC, Leal AM, Castro M |title=Characterization of adrenocorticotropin secretion in a patient with 17 alpha-hydroxylase deficiency |journal=J. Clin. Endocrinol. Metab. |volume=71 |issue=1 |pages=86–91 |year=1990 |pmid=2164530 |doi=10.1210/jcem-71-1-86 |url=}}</ref><ref name="pmid999330">{{cite journal |vauthors=Heremans GF, Moolenaar AJ, van Gelderen HH |title=Female phenotype in a male child due to 17-alpha-hydroxylase deficiency |journal=Arch. Dis. Child. |volume=51 |issue=9 |pages=721–3 |year=1976 |pmid=999330 |pmc=1546244 |doi= |url=}}</ref><ref name="pmid226795">{{cite journal |vauthors=Biglieri EG |title=Mechanisms establishing the mineralocorticoid hormone patterns in the 17 alpha-hydroxylase deficiency syndrome |journal=J. Steroid Biochem. |volume=11 |issue=1B |pages=653–7 |year=1979 |pmid=226795 |doi= |url=}}</ref><ref name="pmid8929268">{{cite journal |vauthors=Saenger P |title=Turner's syndrome |journal=N. Engl. J. Med. |volume=335 |issue=23 |pages=1749–54 |year=1996 |pmid=8929268 |doi=10.1056/NEJM199612053352307 |url=}}</ref><ref name="pmid25813279">{{cite journal |vauthors=Bastian C, Muller JB, Lortat-Jacob S, Nihoul-Fékété C, Bignon-Topalovic J, McElreavey K, Bashamboo A, Brauner R |title=Genetic mutations and somatic anomalies in association with 46,XY gonadal dysgenesis |journal=Fertil. Steril. |volume=103 |issue=5 |pages=1297–304 |year=2015 |pmid=25813279 |doi=10.1016/j.fertnstert.2015.01.043 |url=}}</ref><ref name="pmid4432067">{{cite journal |vauthors=Imperato-McGinley J, Guerrero L, Gautier T, Peterson RE |title=Steroid 5alpha-reductase deficiency in man: an inherited form of male pseudohermaphroditism |journal=Science |volume=186 |issue=4170 |pages=1213–5 |year=1974 |pmid=4432067 |doi= |url=}}</ref><ref name="pmid11344932">{{cite journal |vauthors=Schnitzer JJ, Donahoe PK |title=Surgical treatment of congenital adrenal hyperplasia |journal=Endocrinol. Metab. Clin. North Am. |volume=30 |issue=1 |pages=137–54 |year=2001 |pmid=11344932 |doi= |url=}}</ref>


=== Differential diagnosis for [[primary amenorrhea]]: ===
=== Differential diagnosis for [[primary amenorrhea]]: ===
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! align="center" style="background:#4479BA; color: #FFFFFF;" + |Increased
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Increased
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Decreased
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Decreased
|-
![[17 alpha-hydroxylase deficiency|17-α hydroxylase deficiency]]
|
* [[Deoxycorticosterone]]
* [[Corticosterone]]
* [[Progesterone]]
|
* [[Cortisol]]
* [[Aldosterone]]
|
* [[Ambiguous genitalia]] in male
* [[Hypertension]]
* [[Primary amenorrhea]]
* Absence of [[secondary sexual characteristics]]
* Minimal [[body hair]]
|-
|-
![[21-hydroxylase deficiency|Classic type of 21-hydroxylase deficiency]]
![[21-hydroxylase deficiency|Classic type of 21-hydroxylase deficiency]]
Line 284: Line 303:
* [[Hypertension]] and [[hypokalemia]]
* [[Hypertension]] and [[hypokalemia]]
* [[Virilization]]
* [[Virilization]]
|-
![[17 alpha-hydroxylase deficiency|17-α hydroxylase deficiency]]
|
* [[Deoxycorticosterone]]
* [[Corticosterone]]
* [[Progesterone]]
|
* [[Cortisol]]
* [[Aldosterone]]
|
* [[Ambiguous genitalia]] in male
* [[Hypertension]]
* [[Primary amenorrhea]]
* Absence of [[secondary sexual characteristics]]
* Minimal [[body hair]]
|-
|-
![[3 beta-hydroxysteroid dehydrogenase deficiency]]
![[3 beta-hydroxysteroid dehydrogenase deficiency]]
Line 343: Line 344:
| rowspan="9" |Endogenous causes
| rowspan="9" |Endogenous causes
![[17 alpha-hydroxylase deficiency]]
![[17 alpha-hydroxylase deficiency]]
|Mutations in the [[CYP17A1]] gene
|
* Mutations in the [[CYP17A1]] gene
|
|
* [[Ambiguous genitalia]] in male
* [[Ambiguous genitalia]] in male
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|-
|-
![[11β-hydroxylase deficiency]]
![[11β-hydroxylase deficiency]]
|Mutations in the [[CYP11B1]] gene
|
* Mutations in the [[CYP11B1]] gene
|
|
* [[Ambiguous genitalia]] in female
* [[Ambiguous genitalia]] in female
Line 382: Line 385:
|-
|-
![[Liddle's syndrome|Liddle’s syndrome]] (Pseudohyperaldosteronism type 1)
![[Liddle's syndrome|Liddle’s syndrome]] (Pseudohyperaldosteronism type 1)
|Mutation of the epithelial [[sodium]] channels ([[ENaC]]) [[gene]] in the distal [[renal tubules]]
|
* Mutation of the epithelial [[sodium]] channels ([[ENaC]]) [[gene]] in the distal [[renal tubules]]
|
|
* [[Hypertension]]
* [[Hypertension]]
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|-
|-
!Insensitivity to [[glucocorticoids]] (Chrousos syndrome)
!Insensitivity to [[glucocorticoids]] (Chrousos syndrome)
|Mutations in [[glucocorticoid receptor]] (GR) gene
|
* Mutations in [[glucocorticoid receptor]] (GR) gene
|
|
* [[Hypertension]]
* [[Hypertension]]
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|-
|-
![[Cortisol]]-secreting adrenocortical [[carcinoma]]
![[Cortisol]]-secreting adrenocortical [[carcinoma]]
|Multifactorial
|
* Multifactorial
|
|
Rapid [[Obesity|weight gain]], particularly of the [[trunk]] and [[face]] with [[limbs]] sparing ([[central obesity]])
Rapid [[Obesity|weight gain]], particularly of the [[trunk]] and [[face]] with [[limbs]] sparing ([[central obesity]])
Line 444: Line 450:
|-
|-
!Geller’s syndrome
!Geller’s syndrome
|[[Mutation]] of [[mineralocorticoid]] (MR) receptor that alters its specificity and allows [[progesterone]] to bind MR
|
|Severe [[hypertension]] particularly during [[pregnancy]]
* [[Mutation]] of [[mineralocorticoid]] (MR) receptor that alters its specificity and allows [[progesterone]] to bind MR
|
* Severe [[hypertension]] particularly during [[pregnancy]]
|[[Progesterone]] has [[mineralocorticoid]] effects
|[[Progesterone]] has [[mineralocorticoid]] effects
|↓
|↓
|↓
|↓
| -
| -
|[[mineralocorticoid]] blockers
|[[Mineralocorticoid]] blockers
|-
|-
!Gordon’s syndrome (Pseudohypoaldosteronism type 2)
!Gordon’s syndrome (Pseudohypoaldosteronism type 2)
|Mutations of at least four genes have been identified, including WNK1 and WNK4
|
* Mutations of at least four genes have been identified, including WNK1 and WNK4
|
|
* [[Hypertension]]
* [[Hypertension]]
Line 468: Line 477:
| rowspan="4" |Exogenous causes
| rowspan="4" |Exogenous causes
!Corticosteroids with mineralocorticoid activity
!Corticosteroids with mineralocorticoid activity
|Fludrocortisone or fluoroprednisolone can mimic the action of aldosterone,
|
* Fludrocortisone or fluoroprednisolone can mimic the action of aldosterone
|
|
* [[Hypertension]]
* [[Hypertension]]
Line 480: Line 490:
|-
|-
!Licorice ingestion
!Licorice ingestion
|[[Glycyrrhetinic acid]] that binds [[mineralocorticoid]] receptor and blocks 11-HSD2 at the level of classical target tissues of [[aldosterone]]
|
* [[Glycyrrhetinic acid]] that binds [[mineralocorticoid]] receptor and blocks 11-HSD2 at the level of classical target tissues of [[aldosterone]]
|
|
* [[Hypertension]]
* [[Hypertension]]
Line 492: Line 503:
|-
|-
!Grapefruit
!Grapefruit
|High assumption of naringenin, a component of grapefruit, can also block 11-HSD (11β-Hydroxysteroid dehydrogenase)
|
* High assumption of naringenin, a component of grapefruit, can also block 11-HSD (11β-hydroxysteroid dehydrogenase)
|
|
* [[Hypertension]]
* [[Hypertension]]

Latest revision as of 11:52, 23 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Overview

17 alpha-hydroxylase deficiency must be differentiated from diseases that present with primary amenorrhea and female external genitalia such as pregnancy, androgen insensitivity syndrome, 3beta-hydroxysteroid dehydrogenase type 2 deficiency, gonadal dysgenesis, testicular regression syndrome, LH receptor defects, 5-alpha-reductase type 2 deficiency, mullerian agenesis, primary ovarian insufficiency, hypogonadotropic hypogonadism and turner syndrome.

Differentiating 17 alpha-hydroxylase deficiency from other Diseases

17 alpha-hydroxylase deficiency must be differentiated from diseases that present with primary amenorrhea and female external genitalia such as pregnancy, androgen insensitivity syndrome, 3beta-hydroxysteroid dehydrogenase type 2 deficiency, gonadal dysgenesis, testicular regression syndrome, LH receptor defects, 5-alpha-reductase type 2 deficiency, mullerian agenesis, primary ovarian insufficiency, hypogonadotropic hypogonadism and turner syndrome. .[1][2][3][4][5][6][7][8]

Differential diagnosis for primary amenorrhea:

Disease name Cause Differentiating
Findings Uterus Breast development Testosterone LH FSH Karyotyping
17-alpha-hydroxylase deficiency

No

No

Normal

Normal

XY

3 beta-hydroxysteroid dehydrogenase deficiency

Yes in female

Yes in female

Normal

Normal

XY and XX

Gonadal dysgenesis
  • Mutations in SRY, FOG2/ZFPM2, and WNT1

Yes

Yes

XY

Testicular regression syndrome
  • Loss of testicular function and tissue early in development

No

No

XY

LH receptor defects

No

No

XY

5-alpha-reductase type 2 deficiency

No

No

Normal male range

High to normal

High to normal

XY

Androgen insensitivity syndrome 

No

Yes

Normal male range

Normal

Normal

XY

Mullerian agenesis

No

Yes

Normal female range

Normal

Normal

XX

Primary ovarian insufficiency

Yes

Yes

Normal female range

XX

Hypogonadotropic hypogonadism
  • Functional, sellar masses

Yes

No

Normal female range

Low

Normal

XX

Turner syndrome

  • Chromosomal

Yes

Yes

Normal female range

45 XO

17 alpha-hydroxylase deficiency must be differentiated from diseases that cause ambiguous genitalia:[9][10]

Disease name Steroid status Important clinical findings
Increased Decreased
17-α hydroxylase deficiency
Classic type of 21-hydroxylase deficiency
11-β hydroxylase deficiency
3 beta-hydroxysteroid dehydrogenase deficiency
Gestational hyperandrogenism

17 alpha-hydroxylase deficiency can cause low reninemic hypertension and should be differentiate from other causes of pseudohyperaldosteronism (low renin):

Pseudohyperaldosteronism causes Disease Etiology Clinical features Labratory Treatment
Elevated mineralocorticoid Renin Aldosterone Other
Endogenous causes 17 alpha-hydroxylase deficiency Deoxycorticosterone (DOC) Cortisol Corticosteroids
11β-hydroxylase deficiency Cortisol
Apparent mineralocorticoid excess syndrome (AME) Genetic or acquired defect of 11-HSD gene Cortisol has mineralocorticoid effects Urinary free cortisone ↓↓ Dexamethasone and/or mineralocorticoid blockers
Liddle’s syndrome (Pseudohyperaldosteronism type 1) No extra mineralocorticoid presents, and mutations in Na channels mimic aldosterone mechanism Cortisol Amiloride or triamterene
Cushing’s syndrome Rapid weight gain, particularly of the trunk and face with limbs sparing (central obesity) Cortisol has mineralocorticoid effects
  • ↓ if excess cortisol saturates 11-HSD2 enzyme activity
Urinary free cortisol markedly ↑↑
  • Adrenalectomy
Insensitivity to glucocorticoids (Chrousos syndrome) Deoxycorticosterone (DOC) Cortisol Dexamethasone
Cortisol-secreting adrenocortical carcinoma
  • Multifactorial

Rapid weight gain, particularly of the trunk and face with limbs sparing (central obesity)

Cortisol has mineralocorticoid effects
  • ↓ if excess cortisol saturates 11-HSD2 enzyme activity
Urinary free cortisol markedly ↑↑ Surgery
Geller’s syndrome Progesterone has mineralocorticoid effects - Mineralocorticoid blockers
Gordon’s syndrome (Pseudohypoaldosteronism type 2)
  • Mutations of at least four genes have been identified, including WNK1 and WNK4
  • Normal renal function
No excess mineralocorticoid; an increased activity of the thiazide-sensitive Na–Cl co-transporter in the distal tubule Normal Hyperkalemia Thiazide diuretics and/or dietary sodium restriction
Exogenous causes Corticosteroids with mineralocorticoid activity
  • Fludrocortisone or fluoroprednisolone can mimic the action of aldosterone
Medications such as fludrocortisone - Change the treatment
Licorice ingestion - Moderate ↑ in urinary free cortisol Discontinue licorice
Grapefruit
  • High assumption of naringenin, a component of grapefruit, can also block 11-HSD (11β-hydroxysteroid dehydrogenase)
- - Discontinue grapefruit
Estrogens Estrogens can retain sodium and water by different mechanisms, causing: - - Discontinue estrogens

References

  1. Maimoun L, Philibert P, Cammas B, Audran F, Bouchard P, Fenichel P, Cartigny M, Pienkowski C, Polak M, Skordis N, Mazen I, Ocal G, Berberoglu M, Reynaud R, Baumann C, Cabrol S, Simon D, Kayemba-Kay's K, De Kerdanet M, Kurtz F, Leheup B, Heinrichs C, Tenoutasse S, Van Vliet G, Grüters A, Eunice M, Ammini AC, Hafez M, Hochberg Z, Einaudi S, Al Mawlawi H, Nuñez CJ, Servant N, Lumbroso S, Paris F, Sultan C (2011). "Phenotypical, biological, and molecular heterogeneity of 5α-reductase deficiency: an extensive international experience of 55 patients". J. Clin. Endocrinol. Metab. 96 (2): 296–307. doi:10.1210/jc.2010-1024. PMID 21147889.
  2. Moreira AC, Leal AM, Castro M (1990). "Characterization of adrenocorticotropin secretion in a patient with 17 alpha-hydroxylase deficiency". J. Clin. Endocrinol. Metab. 71 (1): 86–91. doi:10.1210/jcem-71-1-86. PMID 2164530.
  3. Heremans GF, Moolenaar AJ, van Gelderen HH (1976). "Female phenotype in a male child due to 17-alpha-hydroxylase deficiency". Arch. Dis. Child. 51 (9): 721–3. PMC 1546244. PMID 999330.
  4. Biglieri EG (1979). "Mechanisms establishing the mineralocorticoid hormone patterns in the 17 alpha-hydroxylase deficiency syndrome". J. Steroid Biochem. 11 (1B): 653–7. PMID 226795.
  5. Saenger P (1996). "Turner's syndrome". N. Engl. J. Med. 335 (23): 1749–54. doi:10.1056/NEJM199612053352307. PMID 8929268.
  6. Bastian C, Muller JB, Lortat-Jacob S, Nihoul-Fékété C, Bignon-Topalovic J, McElreavey K, Bashamboo A, Brauner R (2015). "Genetic mutations and somatic anomalies in association with 46,XY gonadal dysgenesis". Fertil. Steril. 103 (5): 1297–304. doi:10.1016/j.fertnstert.2015.01.043. PMID 25813279.
  7. Imperato-McGinley J, Guerrero L, Gautier T, Peterson RE (1974). "Steroid 5alpha-reductase deficiency in man: an inherited form of male pseudohermaphroditism". Science. 186 (4170): 1213–5. PMID 4432067.
  8. Schnitzer JJ, Donahoe PK (2001). "Surgical treatment of congenital adrenal hyperplasia". Endocrinol. Metab. Clin. North Am. 30 (1): 137–54. PMID 11344932.
  9. Hughes IA, Nihoul-Fékété C, Thomas B, Cohen-Kettenis PT (2007). "Consequences of the ESPE/LWPES guidelines for diagnosis and treatment of disorders of sex development". Best Pract. Res. Clin. Endocrinol. Metab. 21 (3): 351–65. doi:10.1016/j.beem.2007.06.003. PMID 17875484.
  10. White PC, Speiser PW (2000). "Congenital adrenal hyperplasia due to 21-hydroxylase deficiency". Endocr. Rev. 21 (3): 245–91. doi:10.1210/edrv.21.3.0398. PMID 10857554.