Clinical Manifestations and Challenges in Adolescent and Adult Females With Classic Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency

Abstract

Classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is a rare genetic condition that results in cortisol deficiency and excess production of adrenal androgens. While the introduction of newborn screening for CAH has reduced morbidity and mortality, management of CAH remains challenging. Lifelong treatment with glucocorticoids is required to replace the endogenous cortisol deficiency and reduce excess adrenal androgens. Undertreatment or overtreatment with glucocorticoids can lead to multiple disease- and treatment-related comorbidities, including impaired growth and compromised final height, menstrual irregularities and reduced fertility in females, and long-term cardiometabolic complications. In addition to avoiding adrenal crisis and sudden death, treatment goals in adolescent females with CAH are to obtain normal growth and bone maturation and normal timing of puberty. Management of adolescents is particularly challenging due to changes in growth and sex hormone levels that can lead to inadequate suppression of adrenal androgens and increasing independence that can affect treatment adherence. During the transition to adult care, treatment goals focus on preventing symptoms of hyperandrogenism, preserving menstrual regularity and fertility, and providing education and support for issues related to sexuality, atypical genitalia, and/or complications from previous surgical treatment. In addition, patients must be monitored continuously to prevent long-term complications such as decreased bone mineral density, obesity, diabetes, and hypertension. In this review, we discuss the challenges faced by adolescent and adult females with CAH and provide guidance to health-care professionals to help patients to navigate these challenges.

Keywords: adolescence; congenital adrenal hyperplasia; females; long-term complications; treatment.

Figure 1.

Prader staging of the degree of virilization of the female genitalia in CAH. Stage 0, normal vulva; stage 1, mildly enlarged clitoris and slightly reduced vaginal opening size; stage 2, intermediate sized phallus and a small vaginal opening with separate urethral opening, posterior labial fusion will be present; stage 3, further enlarged phallus, with a single urogenital sinus and almost complete fusion of the labia; stage 4, phallus of the size of a normal penis, a single small urogenital sinus at the base or shaft of the phallus, and an empty scrotum; stage 5, complete male virilization, with a normally formed penis with the urethral opening at or near the tip and a normally formed scrotum but empty; stage 6 indicates a normal penis and scrotum, with no hypospadias present and normal testicles. Adapted from Claahsen-van der Grinten 2022.

Figure 2.

The genotype phenotype correlation is depicted in a schematic overview showing the reciprocal relationship between the severity of the disease, that is, the cortisol deficiency, and the androgen excess. Some examples of the more common null variants are listed.

Figure 3.

Clinical manifestations and treatment challenges in females with classic CAH. BMD, bone mineral density; CAH, congenital adrenal hyperplasia; IGF-1, insulin-like growth factor 1.