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Variable Phenotypes Associated with Aromatase (CYP19) Insufficiency in Humans

University College London Institute of Child Health (L.L., M.T.D., J.C.A.) and the Department of Medicine (L.L., J.C.A.) and Academic Department of Obstetrics and Gynaecology (S.M.C.), University College London, London WC1N 1EH, United Kingdom; Cerrahpasa Medical Faculty (O.E.), University of Istanbul, 34303 Istanbul, Turkey; Department of Endocrinology (J.R.), National Institute of Child Health, Karachi 75520, Pakistan; Bristol Royal Hospital for Children (C.P.B.), Bristol BS2 8BJ, United Kingdom; and Division of Endocrinology and Metabolism (R.J.A.), University of Texas Southwestern Medical Center, Dallas, Texas 75390-8857

Address all correspondence and requests for reprints to: Dr. John C. Achermann, Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, UCL Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, United Kingdom. E-mail: j.achermann{at}ich.ucl.ac.uk.

Context: The P450 enzyme aromatase (CYP19) plays a crucial role in the endocrine and paracrine biosynthesis of estrogens from androgens in many diverse estrogen-responsive tissues. Complete aromatase deficiency has been reported in a small number of 46,XX girls with genital ambiguity and absent pubertal development, but it is unknown whether nonclassic phenotypes exist.

Objective: The objective of this study was to determine whether variant forms of aromatase insufficiency can occur in humans.

Patients and Methods: Four patients (46,XX) from three kindreds with variable degrees of androgenization and pubertal failure were studied using mutational analysis of CYP19 and assay of enzyme activity.

Results: Aromatase insufficiency resulting in genital ambiguity at birth, but with variable breast development at puberty (B2–B4), occurred in 46,XX patients from two kindreds who harbored point mutations or single codon deletions (R435C, F234del). Absent puberty with minimal androgenization at birth was found in one girl with a deletion involving exon 5 of CYP19 (exon5del), which would be predicted to lead to an in-frame deletion of 59 amino acids from the enzyme. Functional studies revealed low residual aromatase activity in the cases in which breast development occurred.

Conclusions: These studies demonstrate that aromatase mutations can produce variable or "nonclassic" phenotypes in humans. Low residual aromatase activity may be sufficient for breast and uterine development to occur at puberty, despite significant androgenization in utero. Such phenotypic variability may be influenced further by modifying factors such as nonclassic pathways of estrogen synthesis, variability in coregulators, or differences in androgen responsiveness.