Salivary and plasma androstenedione and 17-hydroxyprogesterone levels in congenital adrenal hyperplasia

Diurnal salivary androstenedione and 17-hydroxyprogesterone levels in healthy volunteers for monitoring treatment efficacy of patients with congenital adrenal hyperplasia

OBJECTIVE

Treatment of congenital adrenal hyperplasia (CAH) patients with glucocorticoids is often challenging since there is a delicate balance between over- and undertreatment. Treatment can be monitored noninvasively by measuring salivary androstenedione (A4) and 17-hydroxyprogesterone (17-OHP). Optimal treatment monitoring requires the establishment of reference values in saliva.

DESIGN

A descriptive study.

PATIENTS

For this study saliva of 255 healthy paediatric and adult volunteers with an age range of 4-75 years old was used.

MEASUREMENTS

We developed a sensitive liquid chromatography-tandem mass spectrometry method, assessed salivary A4 and 17-OHP stability, and measured A4 and 17-OHP concentrations in saliva collected in the morning, afternoon, and evening.

RESULTS

We quantified A4 and 17-OHP concentrations in the morning, afternoon, and evening and demonstrated that there is a significant rhythm with the highest levels in the morning and decreasing levels over the day. A4 and 17-OHP concentrations display an age-dependent pattern. These steroids remain stable in saliva at ambient temperature for up to 5 days.

CONCLUSIONS

Good stability of the steroids in saliva enables saliva collection by the patient at home. Since salivary A4 and 17-OHP display a diurnal rhythm and age-dependent pattern, we established reference values for both children and adults at three time points during the day. These reference values support treatment monitoring of children and adults with CAH.

Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase Deficiency

CONTEXT

Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice daily, but there is debate about the optimal timing of the highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening).

OBJECTIVE

We aimed to compare 2 standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure (BP), and sleep and activity scores.

METHODS

This 6-week crossover study included 39 patients (aged 4-19 years) with 21OHD. Patients were treated for 3 weeks with the highest hydrocortisone dose in the morning, followed by 3 weeks with the highest dose in the evening (n = 21), or vice versa (n = 18). Androstenedione (A4) and 17-hydroxyprogesterone (17OHP) levels were quantified in saliva collected at 5 am; 7 am; 3 pm; and 11 pm during the last 2 days of each treatment period. The main outcome measure was comparison of saliva 17OHP and A4 levels between the 2 treatment strategies.

RESULTS

Administration of the highest dose in the evening resulted in significantly lower 17OHP levels at 5 am, whereas the highest dose in the morning resulted in significantly lower 17OHP and A4 levels in the afternoon. The 2 treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal BP, and activity and sleep scores.

CONCLUSION

No clear benefit for either treatment schedule was established. Given the variation in individual responses, we recommend individually optimizing dose distribution and monitoring disease control at multiple time points.

Measurement of Salivary Adrenal-Specific Androgens as Biomarkers of Therapy Control in 21-Hydroxylase Deficiency

BACKGROUND

Monitoring of hormonal control represents a key part of the management of congenital adrenal hyperplasia (CAH). Monitoring strategies remain suboptimal because they rely on frequent blood tests and are not specific for adrenal-derived hormones. Recent evidence suggests the crucial role of adrenal-specific 11-oxygenated-C19 androgens in the pathogenesis of CAH.

OBJECTIVE

To establish a correlation between plasma and salivary adrenal-specific androgens in CAH as a noninvasive monitoring strategy.

DESIGN

This prospective cross-sectional study recruited patients between 2015 and 2018.

SETTING

Multicenter study including 13 tertiary centers in the United Kingdom.

PARTICIPANTS

Seventy-eight children with CAH and 62 matched healthy controls.

METHODS

Using liquid chromatography-tandem mass spectrometry, plasma and salivary concentrations of five steroids were measured: 17-hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11-hydroxyandrostenedione (11OHA4), and 11-ketotestosterone (11KT). The correlation between plasma and salivary steroids was analyzed to assess their use in clinical practice.

RESULTS

Strong correlations between plasma and salivary steroid concentrations in patients with CAH were detected: 17OHP (rs = 0.871; P < 0.001), A4 (rs = 0.931; P < 0.001), T (rs = 0.867; P < 0.001), 11OH4A (rs = 0.876; P < 0.001), and 11KT (rs = 0.944; P < 0.001). These results were consistent for patient subgroups based on sex and age. Analysis of patient subgroups based on 17OHP concentrations established clear correlations between plasma and salivary concentrations of the adrenal-specific androgen 11KT.

CONCLUSIONS

The current study identified tight correlations between plasma and saliva for the adrenal-derived 11-oxygenated C19 androgen 11KT, as well as 17OHP and A4, which are widely used for monitoring treatment in CAH. This combination of steroid hormones will serve as an improved noninvasive salivary test for disease monitoring in patients with CAH.

Long-term follow-up of children with classic congenital adrenal hyperplasia: suggestions for age dependent treatment in childhood and puberty

Background In congenital adrenal hyperplasia (CAH), achieving the balance between overtreatment and undertreatment remains challenging. Final height (FH) can serve as a long-term outcome measure. We aimed to identify age-dependent factors that influence FH in CAH patients, resulting in age-specific treatment goals. Methods We retrospectively evaluated longitudinal data of 39 pediatric CAH patients born between 1980 and 1997 from the Radboudumc CAH database. We analyzed height and bone age (BA) at diagnosis or 4 years of age, at the start of puberty and at FH. Height data were corrected for parental height and secular trend. Hydrocortisone (HC) use and salivary steroid concentrations were studied longitudinally throughout childhood and puberty. Results Median FH standard deviation scores (SDSs) corrected for target height SDSs (THSDSs) was -1.63. Median height SDS corrected for THSDS (HSDS-THSDS) decreased from diagnosis/age 4 years to FH in both salt wasting (SW) CAH and simple virilizing (SV) CAH, and in both male and female patients. However, when height was corrected for BA, no height loss occurred from diagnosis/age 4 years to FH in any of the subgroups, while a height gain was seen in SV males. In the combined model analyzing both HC dose and salivary steroid concentrations, in childhood the androstenedione (A) concentration was negatively associated with FH, while in puberty the HC dose was negatively associated with FH. Conclusions In CAH, loss of growth potential already occurs in early childhood. In prepubertal children, exposure to elevated androgens is associated with decreased FH. In puberty, the growth suppressing effects of HC outweigh the negative effects of elevated androgens. Therefore, we suggest different treatment approaches in prepubertal and pubertal patients.

Parallel diurnal fluctuation of testosterone, androstenedione, dehydroepiandrosterone and 17OHprogesterone as assessed in serum and saliva: validation of a novel liquid chromatography-tandem mass spectrometry method for salivary steroid profiling

Background:

Salivary androgen testing represents a valuable source of biological information. However, the proper measurement of such low levels is challenging for direct immunoassays, lacking adequate accuracy. In the last few years, many conflicting findings reporting low correlation with the serum counterparts have hampered the clinical application of salivary androgen testing. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) makes it possible to overcome previous analytical limits, providing new insights in endocrinology practice.

Methods:

Salivary testosterone (T), androstenedione (A), dehydroepiandrosterone (DHEA) and 17OHprogesterone (17OHP) were extracted from 500µL of saliva, separated in 9.5 min LC-gradient and detected by positive electrospray ionization – multiple reaction monitoring. The diurnal variation of salivary and serum androgens was described by a four paired collection protocol (8 am, 12 am, 4 pm and 8 pm) in 19 healthy subjects.

Results:

The assay allowed the quantitation of T, A, DHEA and 17OHP down to 3.40, 6.81, 271.0 and 23.7 pmol/L, respectively, with accuracy between 83.0 and 106.1% for all analytes. A parallel diurnal rhythm in saliva and serum was observed for all androgens, with values decreasing from the morning to the evening time points. Salivary androgen levels revealed a high linear correlation with serum counterparts in both sexes (T: R>0.85; A: R>0.90; DHEA: R>0.73 and 17OHP: R>0.89; p<0.0001 for all).

Conclusions:

Our LC-MS/MS method allowed a sensitive evaluation of androgen salivary levels and represents an optimal technique to explore the relevance of a comprehensive androgen profile as measured in saliva for the study of androgen secretion modulation and activity in physiologic and pathologic states.

Increased prevalence of testicular adrenal rest tumours during adolescence in congenital adrenal hyperplasia

Testicular adrenal rest tumours (TART) are one of the most important causes of infertility in adult male patients with congenital adrenal hyperplasia (CAH). These benign tumours are already detected in children, but screening of TART is not routinely performed.

OBJECTIVE

To define retrospectively the prevalence of TART in 41 paediatric male CAH patients aged 0-19 years regularly followed by high-frequency (Fcentral 12-MHz) ultrasound techniques.

RESULTS

Above the age of 10 years, there was a clear increase in the prevalence of TART: 10-12 years, 28% (2 of 7 patients), 13-14 years, 50% (4/8), and 15-16 years, 75% (3/4). Above the age of 16 years, TART were detected in 100% of the patients (7/7). The tumours were not detectable by palpation.

CONCLUSION

TART is already present in childhood with an increasing prevalence after onset of puberty. We recommend regular ultrasound from the onset of puberty in all boys with classic CAH.

Monitoring of therapy in congenital adrenal hyperplasia

BACKGROUND

Congenital adrenal hyperplasia is a group of disorders caused by defects in the adrenal steroidogenic pathways. In its most common form, 21-hydroxylase deficiency, patients develop varying degrees of glucocorticoid and mineralocorticoid deficiency as well as androgen excess. Therapy is guided by monitoring clinical parameters as well as adrenal hormone and metabolite concentrations.

CONTENT

We review the evidence for clinical and biochemical parameters used in monitoring therapy for congenital adrenal hyperplasia. We discuss the utility of 24-h urine collections for pregnanetriol and 17-ketosteroids as well as serum measurements of 17-hydroxyprogesterone, androstenedione, and testosterone. In addition, we examine the added value of daily hormonal profiles obtained from salivary or blood-spot samples and discuss the limitations of the various assays.

SUMMARY

Clinical parameters such as growth velocity and bone age remain the gold standard for monitoring the adequacy of therapy in congenital adrenal hyperplasia. The use of 24-h urine collections for pregnanetriol and 17-ketosteroid may offer an integrated view of adrenal hormone production but target concentrations must be better defined. Random serum hormone measurements are of little value and fluctuate with time of day and timing relative to glucocorticoid administration. Assays of daily hormonal profiles from saliva or blood spots offer a more detailed assessment of therapeutic control, although salivary assays have variable quality.

Salivary steroid assays – research or routine?

Salivary concentrations of unconjugated steroids reflect those for free steroids in serum although concentrations may differ because of salivary gland metabolism. Samples for salivary steroid analysis are stable for up to 7 days at room temperature, one month or more at 4°C and three months or more at −20°C. When assessed against strict criteria, the evidence shows that salivary cortisol in evening samples or following dexamethasone suppression provides a reliable and effective screen for Cushing's syndrome. Sequential salivary cortisol measurements are also extremely helpful for the investigation of suspected cyclical Cushing's syndrome. There is potential for the identification of adrenal insufficiency when used with Synacthen stimulation. Salivary 17-hydroxyprogesterone and androstenedione assays are valued as non-invasive tests for the home-monitoring of hydrocortisone replacement therapy in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. The diagnostic value of salivary oestradiol, progesterone, testosterone, dehydroepiandrosterone and aldosterone testing is compromised by rapid fluctuations in salivary concentrations of these steroids. Multiple samples are required to obtain reliable information, and at present the introduction of these assays into routine laboratory testing is not justified.

Influence of commercial collection devices for saliva on the reliability of salivary steroids analysis

Saliva analysis is an accepted non-invasive alternative to plasma in pediatric endocrinology. Although commercial saliva collectors are available, the reliability of these devices for the analysis of salivary hormones has not been proved. We investigated the recovery and linearity of salivary steroids (cortisol, cortisone, 17-hyroxyprogesterone, testosterone, androstenedione) being relevant in endocrine research and therapy control. Pooled saliva was spiked with ascending concentrations of the steroids and applied onto a variety of absorbents, such as the cotton and the polyester (PE) Salivette (Sarstedt), the foam-tip applicator (Whatman) and strips of blood-spot collection paper (Whatman). Analysis was performed by LC-MS/MS. Best results were achieved using the PE Salivette, yielding recoveries (%) of 99.8 (cortisol), 98.7 (cortisone), 91.8 (17OHP), 96.3 (testosterone), 98.9 (androstendione) with a volume recovery of 98+/-1%. Using the blood-spot paper, recoveries (%) were 92.0 (cortisol), 89.1 (cortisone), 72.0 (17OHP), 70.3 (testosterone) and 77.1 (androstendione). The recovery of glucocorticoids was significantly higher compared to androgens (p<0.001). The recovery of liquid volume was 95+/-2%. The cotton Salivette yielded weak recoveries of 88.7 (cortisol), 86.2 (cortisone), 60.9 (17OHP), 62.0 (testosterone) and 72.4 (androstendione). The recovery of the glucocorticoids differed significantly from the androgens (p<0.001). Liquid recovery was most variable with 89+/-8%. The weakest recoveries were found in the foam-tips being 76.2 for cortisol, only 41.8 for cortisone, 31.1 for 17OHP, 38.5 for testosterone and 36.1 for androstendione. The volume recovery here was 97+/-1%. We assume only the PE version of the Salivette suitable for salivary steroid analysis. The weak recovery from the cotton version is a severe problem due to lacking comparability with values obtained with the polyester wads and the weak homogeneity as observed over a physiological concentration range.

Aggression, dominance, and affiliation: Their relationships with androgen levels and intelligence in 5-year-old children

This study explores the potential relationship between social behavior (aggression, dominance, and affiliation) and testosterone, androstenedione, and DHEA measurements in 5-year-old children while also analyzing the moderating effect of IQ on the hormone-behavior relationship. 129 healthy normal Iberian children (60 boys and 69 girls) were videotaped in free play interactions in the school playground. Their behavior was then evaluated with particular emphasis on aggression, government, and affiliation. Testosterone, androstenedione, and DHEA levels were measured using an enzyme immunoassay technique in saliva samples. A test (K-BIT) which provides an IQ measurement for children was also administered to subjects. The correlation analysis revealed a positive relationship between the behavioral factor of Provocation and androstenedione in boys, and a regression analysis indicated that this relationship was moderated in a positive direction by the subject's intelligence. In girls, we observed a positive relationship between testosterone and Affectivity, with this relationship being moderated in a negative direction by intelligence.

Cognitive abilities, androgen levels, and body mass index in 5-year-old children

This study explores the potential relationship between a series of cognitive abilities and testosterone, dehydroepiandrosterone (DHEA), androstenedione, and body mass index (BMI) measurements in 5-year-old children. 60 boys and 69 girls were administered a test (K-BIT) which provided measurements of fluid intelligence (Matrices subtest), crystallized intelligence (Vocabulary subtest), and IQ composite (the combination of the two subtests); a sub-sample of 48 boys and 61 girls was also subjected to diverse tests related to theory of mind (affective labeling, appearance-reality distinction, display rules, and false belief). Testosterone, DHEA, and androstenedione levels were measured using an enzyme immunoassay technique in saliva samples. An analysis of variance failed to reveal any significant differences between boys and girls in any of the cognitive abilities assessed. The correlation analysis revealed a positive relationship between fluid intelligence and testosterone levels in boys, a negative relationship between crystallized intelligence and androstenedione levels in girls, and between affective labeling and androstenedione levels in boys. A multiple regression analysis indicated that androstenedione and BMI were the best predictors for some of the cognitive abilities assessed.

Monitoring of menstrual cycles, ovulation, and adrenal suppression by saliva sampling in female patients with 21-hydroxylase deficiency

OBJECTIVE

To investigate the correlation between menstrual cycles, ovulation, and adrenal suppression in congenital adrenal hyperplasia.

DESIGN

Prospective observational study.

SETTING

An academic outpatient clinic.

PATIENT(S)

Five females with salt-wasting 21-hydroxylase deficiency, aged 15.5 to 22.9 years; one had amenorrhea, one had irregular bleeding, and three had regular bleeding.

INTERVENTION(S)

Daily morning saliva sampling for 40 to 280 days.

MAIN OUTCOME MEASURE(S)

Salivary levels of progesterone (P), 17-hydroxyprogesterone (17-OHP), and androstenedione.

RESULT(S)

In the amenorrheic patient, the elevated P and 17-OHP levels decreased when the glucocorticoid dose was increased, and subsequently menarche occurred. The androstenedione levels were normal. The correlations between P and 17-OHP levels before and after menarche suggest that adrenal progesterone had prevented menarche. The patient with irregular bleeding showed slightly elevated androstenedione levels and increased levels of 17-OHP and P in an irregular pattern, without correlation in time with vaginal bleeding. Three patients with regular cycles showed a biphasic pattern of P levels, indicating ovulation.

CONCLUSION(S)

These longitudinal data support the hypothesis that menstrual cycling in females with 21-hydroxylase deficiency can be prevented or disturbed by elevated progesterone levels of adrenal origin, in the absence of androgen excess. Increasing glucocorticoid dose could suppress adrenal progesterone production, resulting in menarche.

Normal bone mineral density and lean body mass, but increased fat mass, in young adult patients with congenital adrenal hyperplasia

Patients with congenital adrenal hyperplasia attributable to 21-hydroxylase deficiency are treated with glucocorticoids. Glucocorticoid administration, even in substitution doses, may cause decreased bone mineral density (BMD) and obesity. The purpose of this study was to determine BMD, lean mass, and fat mass in young adult male (M, n = 15) and female (F, n = 15) patients with 21-hydroxylase deficiency, who had been treated with currently recommended low doses of glucocorticoids. Measurements were performed with dual-x-ray absorptiometry. In addition, calcaneal ultrasound measurements were performed (broadband ultrasound attenuation and speed of sound). Results were compared with those in age- and sex-matched controls; to adjust for height, lean and fat mass were divided by (height)(2). M and F patients [M, 21.7 +/- 2.4; F, 20.6 +/- 2.9 yr old (mean +/- SD)] were shorter than the controls (M, P < 0.001; F, P < 0.003) and their body mass indices were higher [M patients (25.0 +/- 3.6) vs. controls (22.3 +/- 1.9 kg/m(2)) (P < 0.02); F patients (25.5 +/- 4.5) vs. controls (21.9 +/- 2.3 kg/m(2)) (P < 0.02)]. BMD values (lumbar spine L1-L4, femoral neck, and total body) were not different from controls. Calcaneal ultrasound measurements showed that M patients had higher speed of sound values [M patients (1564 +/- 38) vs. controls (1529 +/- 29 m/sec) (P < 0.01)]. Lean mass in M and F patients was not different from controls when adjusted for height. Fat mass was higher in M and F patients when adjusted for height [M patients 5.6 +/- 2.9 vs. controls 2.7 median (1.7-7.0 min-max) kg/m(2) (P < 0.04); F patients 8.7 +/- 2.8 vs. controls 5.8 (4.3-10.7) kg/m(2) (P < 0.02)]. Relative fat mass (fat mass as a percentage of the total body mass) was higher in patients, compared with controls [M patients 22.0 +/- 9.1 vs. controls 12.8 (8.5-27.0)% (P < 0.04); F patients 34.1 +/- 5.0 vs. controls 29.0 +/- 5.1% (P < 0.02)]; this resulted from increased fat mass, not from decreased lean mass. Fat distribution over the body was not different in patients and controls. No significant correlations were found between cumulative glucocorticoid doses in the last 0.5, 2, or 5 yr or mean salivary morning levels of 17-hydroxyprogesterone and androstenedione in the last 5 yr on one hand and bone parameters, lean mass, or fat mass on the other hand. We conclude that, at prevailing low-dose glucocorticoid regimens, young adult patients with 21-hydroxylase deficiency have normal BMD. Their lean mass is in accordance with height, but fat mass is increased, with a normal distribution over the body. This results in a higher fat percentage of the total body and a higher body mass index than in healthy peers. Because overweight and increased fat mass are associated with the metabolic syndrome and increased cardiovascular risk, weight management should have appropriate attention in the follow-up of congenital adrenal hyperplasia patients, to prevent overweight-associated morbidity.

Serum cortisol and 17-hydroxyprogesterone interrelation in classic 21-hydroxylase deficiency: is current replacement therapy satisfactory?

One of the main aims in the management of patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency is to achieve adequate suppression of the adrenal cortex with the smallest possible dose of glucocorticoid substitution. To evaluate the administration schedule of current replacement therapy regimens, we investigated the cortisol-17-hydroxyprogesterone interrelation in 36 patients (13 males and 23 females; median age, 12.3 yr; range, 6.1-18.8 yr) with salt-wasting congenital adrenal hyperplasia. As sufficient variation in 17-hydroxyprogesterone concentrations was required to allow analysis of the cortisol-17-hydroxyprogesterone interrelation, patients were divided into 2 groups depending on the adequacy of hypothalamic-pituitary-adrenal axis suppression. The first group consisted of 17 patients with suppressed 17-hydroxyprogesterone concentrations (group 1), and the second group consisted of 19 patients with nonsuppressed 17-hydroxyprogesterone concentrations (group 2). We determined serum cortisol and 17-hydroxyprogesterone concentrations at 20-min intervals for a total of 24 h while patients were receiving their usual replacement treatment with hydrocortisone and 9alpha-fludrocortisone. We also determined the lowest dose of dexamethasone required to suppress the 0800 h serum ACTH concentrations when administered as a single dose (0.3 or 0.5 mg/m(2)) the night before. Mean 24-h cortisol and 17-hydroxyprogesterone concentrations were 3.9 microg/dl (SD = 2.1) and 66.2 ng/dl (SD = 92.7), respectively, in group 1 and 4.1 microg/dl (SD = 2.5) and 4865.7 ng/dl (SD = 6951) in group 2. The 24-h 17-hydroxyprogesterone concentrations demonstrated circadian variation, with peak values observed between 0400-0900 h. In group 2, 17-hydroxyprogesterone concentrations decreased gradually in response to the rise in cortisol concentrations during the day, but remained low during the night despite the almost undetectable cortisol concentrations between 1600-2000 h. Mean 0800 h androstenedione concentrations correlated strongly with integrated 17-hydroxyprogesterone concentrations (r = 0.81; P < 0.0001), but not with integrated cortisol concentrations. There was a significant negative correlation between cortisol and 17-hydroxyprogesterone at lag time 0 min (r = -0.187; P < 0.0001), peaking at lag time 60 min (r = -0.302; P < 0.0001), with cortisol leading 17-hydroxyprogesterone by these time intervals. Finally, 0800 h serum ACTH concentrations were sufficiently suppressed after a dexamethasone dose of 0.3 mg/m(2) in all but three patients. These findings indicate that in classic 21-hydroxylase deficiency, hydrocortisone should be administered during the period of increased hypothalamic-pituitary-adrenal axis activity, between 0400-1600 h, with the biggest dose given in the morning. Blood investigations performed as part of monitoring of congenital adrenal hyperplasia patients should include androstenedione and 17-hydroxyprogesterone concentrations determined in the morning before the administration of hydrocortisone. It should also be emphasized that blood investigations are only complementary to the overall assessment of these patients, which is primarily based on the evaluation of growth and pubertal progress.

Development of a highly sensitive nonisotopic immunoassay for the determination of salivary 17-hydroxyprogesterone: reference ranges throughout childhood and adolescence

A sensitive nonisotopic immunoassay for the determination of 17-hydroxyprogesterone (17-OHP) levels in saliva was developed. The new time-resolved fluorometric immunoassay employs a specific polyclonal anti-17-OHP antiserum immobilized onto microtiter plates, a 17-OHP-biotin conjugate as a tracer, and streptavidin-europium a as secondary probe. The lower detection limit of the assay is 23.6 pmol/L (mean -3 s of a 22-fold zero determination) corresponding to 0.39 pg/well. The coefficients of intraassay variation are 8.8, 5.3, and 8.3% at the respective concentrations of 90.9, 454.5, and 1363.5 pmol/L. The coefficients of interassay variation are 8.8, 5.3, and 8.3% at the respective concentrations. Saliva was collected in commercially available devices. Reference ranges were established using 394 saliva samples from 132 healthy children, adolescents, and adults. Morning, midday, and evening levels of 17-OHP levels in saliva varied significantly in all age groups with morning levels being higher than midday and evening levels. Saliva samples (n = 57) were also obtained from 18 children with congenital adrenal hyperplasia (CAH). Salivary 17-OHP levels in the limited number of CAH patients studied ranged from 121 to 106,050 pmol/L. In conclusion 1) a new, sensitive nonisotopic immunoassay for measurement of 17-OHP in saliva has been developed; 2) reference ranges for healthy children, adolescents, and adults have been established; 3) there is a circadian pattern of 17-OHP levels in saliva at all ages; and 4) measurement of 17-OHP in saliva should be further evaluated over a longer period of time as a potentially reliable and powerful technique to monitor metabolic control in patients with CAH. As 17-OHP levels in saliva are stable for > 10 wk at 4 degrees C, the technique is ideally suited for outpatient sampling.

Relationship of smoking cessation and nicotine gum use to salivary androstenedione and testosterone in middle-aged men

Cross-sectional studies have associated cigarette smoking in men with elevated androstenedione and little net effect on other sex steroids. However, it is not clear if such findings reflect the impact of nicotine exposure or if sex hormone levels change following smoking cessation. The relationship of the reported number of cigarettes smoked per day and salivary cotinine to salivary testosterone and androstenedione was examined in 221 men aged 35 to 59 years at baseline and 1 year following randomization into a clinical trial including a smoking-cessation intervention. At baseline, salivary cotinine was related to increased salivary androstenedione and testosterone following control for age, body mass, alcohol intake, and time of day of specimen collection (partial r = +.14 and +.30 P < .05 and .01, respectively). The reported number of cigarettes smoked per day was unrelated to either hormone. At the first annual visit, there was a significant decrease in the salivary androstenedione of men who had quite smoking and were currently using nicotine gum (94 v 60 pg/mL, P < .05, n = 34) and of men who had quit smoking and were not exposed to nicotine (86 v 56 pg/mL, P < .05, n = 48), whereas the salivary androstenedione of men who remained smokers at the first annual visit was unchanged (83 v 85 pg/mL, n = 139). Salivary testosterone levels were not significantly affected by a change in smoking status.(ABSTRACT TRUNCATED AT 250 WORDS)

Steroid assays in saliva: a method to detect plasmatic contaminations

Plasmatic and salivary levels of six steroid hormones in adult males and females are given and compared to the data of the literature. These steroids are: cortisol (F), dehydroepiandrosterone (DHA) and its sulphate (DHAS), androstenedione (A), testosterone (T) and 11 beta OH androstenedione (OHA). The salivary assay of the last compound is an original. The correlations between salivary and plasmatic values are presented and confirm that this method is a reliable alternative for hormonal investigations. From these data and from those of the literature, the salivary versus plasmatic ratio are calculated. From the fact that high concentrations of DHAS in saliva generally stem from blood contamination, we derive a method to estimate the amount of this contamination and its impact on other steroids measured on the same saliva sample.

Effects of inhibition of cholesterol synthesis by simvastatin on the production of adrenocortical steroid hormones and ACTH

Simvastatin, a derivative of lovastatin, is a potent inhibitor of cholesterol biosynthesis and may interfere with steroid hormone production, for which cholesterol is required. In a single-blind, placebo-controlled study, 24 patients with severe primary hypercholesterolaemia (mean serum cholesterol +/- SD = 10.74 +/- 1.59 mmol/l) were treated with simvastatin 40 mg per day for 8 weeks. Before and after treatment, the following parameters were evaluated: basal levels of ACTH, cortisol, androstenedione, dehydroepiandrosterone and 17-hydroxyprogesterone; urinary excretion of free cortisol; the cortisol response after short-term infusion of ACTH; the ACTH and cortisol response during insulin-induced hypoglycaemia. Total serum cholesterol decreased by 35.0 +/- 8.1% (P less than 0.001) and low-density lipoprotein (LDL) cholesterol by 39.8 +/- 9.8% (P less than 0.001); high-density lipoprotein (HDL) increased by 9.2 +/- 11.1% (P less than 0.001). Basal levels of ACTH were higher after simvastatin (2.9 +/- 1.9 pmol/l vs 4.1 +/- 2.9 pmol/l; P less than 0.05) whereas basal levels of steroid hormones were not significantly changed. The excretion of free cortisol was unaltered. The peak cortisol after ACTH infusion was lower after treatment (0.87 +/- 0.23 mumol/l vs 0.78 +/- 0.10 mumol/l; P less than 0.05), but was unaltered during insulin-induced hypoglycaemia. We conclude that simvastatin lowers serum cholesterol without clinically relevant effects on the adrenocortical steroid hormone secretion and the hypothalamic-pituitary-adrenal axis.

Comparison of saliva and plasma 17-hydroxyprogesterone time-course response to hCG administration in normal men

17-Hydroxyprogesterone (17-OHP) time-course response to hCG (5000 IU) was studied simultaneously in the saliva and the plasma of 12 adult healthy men. Baseline levels in plasma and saliva were: 1.0 +/- 0.1 ng/ml (mean +/- SEM) and 24 +/- 2 pg/ml respectively. After hCG, a biphasic pattern was observed in both fluids with a similar early response but the peak elicited at 33 h in plasma was not observed in saliva where the levels were lower than those recorded at 24 h. Since saliva steroids are believed to reflect the plasma non-protein bound fraction, this difference was assumed to be due to the decrease of the unbound fraction of plasma 17-OHP in the late afternoon as a consequence of the increase of CBG-bound fraction since at that time cortisol levels are low. The ratio of saliva to plasma 17-OHP levels was significantly correlated with plasma cortisol levels: r = 0.44 (P less than 0.01; n = 140). However the similar response in saliva at 24 and at 48 h after hCG allows the evaluation of the endocrine testicular function using saliva instead of plasma.

The measurement of hormones in saliva: possibilities and pitfalls

The easy stress-free, non-invasive nature of saliva collection makes it one of the most accessible body fluids and it is potentially of value in studying normal human physiology as well as pathology. Measurements of salivary hormone levels will usually only be of value if they reflect the plasma level of the hormone and the relationship between the saliva and plasma levels of many hormones have been studied by a number of groups. The measurement of the salivary level is a valuable clinical tool for some hormones (e.g. cortisol, oestriol, progesterone), is of little value for others (e.g. cortisone, dehydroepiandrosterone sulphate, thyroxine, pituitary hormones) and for many others the saliva/plasma relationship is not yet sufficiently understood to assess the value of the salivary measurement. As well as reviewing the state of our knowledge of the salivary concentration of many hormones this review outlines a number of "rules of thumb" concerning the presence of hormones in saliva, their saliva/plasma relationship and the potential usefulness of assays of their salivary concentration.

Hormones in saliva

Since the collection of saliva is noninvasive, nonstressful and usually very convenient there have been many recent studies examining the clinical relevance of measuring various hormones in saliva. It now appears that the measurement of most unconjugated steroids in saliva will provide clinically useful data whereas the measurement of conjugated steroids, thyroid hormones, and protein hormones is unlikely to be clinically relevant. The key factors determining whether the salivary concentration of a hormone or drug is likely to be clinically relevant are the mechanisms by which the material enters the saliva; the "free to protein bound" ratio for the material; and the structure of the material, i.e., its molecular weight, polarity and the presence of ionizable groups.