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  • Endocrinologie
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La puberté surrénalienne

Adrenal puberty or adrenarche

Andrologie volume 7, pages 165–186 (1997)Cite this article

Resume

La surrénale produit surtout des stéroïdes de la voie Δ5, la déhydroépiandrostérone (DHA) et son sulfate (DHAS). Leurs taux très élvés à la naissance, décroissent rapidement les premiers mois de vie, et sont très bas de 1 à 6 ans. Ils augmentent abruptement vers 7–8 ans dans les deux sexes, et vers 9–11 ans, avant tout signe de puberté gonadique, DHA et DHAS ont augmenté d'un facteur 10 et 20 respectivement, alors que la sécrétion du cortisol ne change pas. C'est la période pré- et parapubertaire des changements de biosynthèse des androgènes surrénaliens que l'on individualise commepuberté surrénalienne ouadrénarche. Elle est contemporaine du développement progressif de la zone réticulée du cortex surrénal et de l'activation du complexe enzymatique 17α-hydroxylase/17,20-lyase (P450c17) au détriment de la 3β-hydroxystéroïde déshydrogénase. L'adrénarche est un phénomène caractéristique de l'espèce humaine. A l'exception du chimpanzé, elle ne s'observe chez aucun autre mammifère. Les facteurs responsables de l'adrénarche sont toujours mal connus. L'existence d'une régulation propre de la biosynthèse des androgènes a été postulée. Plusieurs hypothèses ont été invoquées (inhibition de la 3ß-ol par les œstrogènes ovariens, effet stimulant des gonadotrophines, de la GH ou de la prolactine) et réfutées à mesure que l'ontogénie des sécrétions pubertaires se précisait. L'ACTH est un facteur trophique indispensable à une sécrétion normale d'androgènes. La dissociation entre la réponse des sécrétions androgéniques et celle du cortisol à l'ACTH a fait suggérer l'existence d'un facteur additionnel à l'ACTH. L'hypothèse que le CASH (cortical androgen-stimulating hormone) soit un segment de la pro-opiomélanocortine attend confirmation. On a aussi invoqué l'effet des variations de gradient du cortisol intra-surrénalien. Les facteurs génétiques joueraient un certain rôle.

En terme de développement le rôle de l'adrénarche apparaît bien modeste. L'administration prolongée de DHAS ou de DHA chez des enfants présentant un retard d'adrénarche a montré qu'ils n'avaient pas de rôle déterminant sur la croissance somatique prépubertaire et le déclenchement de la puberté, et fait remettre en cause le concept classique qu'ils soient par eux-mêmes responsables de la pousse des poils sexuels. L'adrénarche peut être vue comme un index de maturation corporelle. En effet, la DHA est une pro-hormone, accessible au métabolisme périphérique dans un grand nombre de tissus, dont le cerveau. Un certain nombre de ses actions pourraient en dériver, en particulier celles qui sont liées à la lutte contre le vieillissement.

Enfin, des études épidémiologiques récentes suggèrent que des taux circulants bas de DHAS sont corrélés avec une augmentation du taux de morbidité cardio-vasculaire chez l'homme ou de cancer du sein chez la femme. Il n'est pas encore possible de conclure sur l'importance biologique de ces associations, et que les androgènes surrénaliens soient une fontaine de jouvence, d'autant que la DHA peut avoir un rôle tout à fait indirect sur ces effets anti-vieillisement en particulier par son métabolisme en estrogènes ou autres métabolites.

Abstract

The androgens produced by the adrenal glands are mainly Δ5 steroids, first dehydroepiandrosterone (DHA) and its sulfate (DHAS). Adrenal androgens, very high at birth, decrease rapidly the first few months of life, remaining very low from 1 to 6 years of life. Adrenarche is defined as the changes in the pattern of adrenal secretions which occur several years before the onset of gonadal puberty (gonadarche). Developmental patterns of adrenal androgens differ markedly among species and only the chimpanzee exhibits an adrenarche comparable to that of man. Adrenarche starts in both sexes around age 7. The increase in DHA/DHAS has a rather abrupt onset and is thereafter progressive. Before the onset of gonadarche mean levels of DHA and DHAS have increased by about 10 and 20 fold respectively. The prepubertal rise in plasma Δ5-androgens is accompanied by that of Δ4-androstenedione and 11β-hydroxy-Δ4-androstenedione occurring likely at about the same time but being very progressive and more modest are only significant after age 8 in both sexes. Adrenal androgens continue to rise during puberty. Plasma levels of DHA and DHAS continue to rise from pubertal stages 1 to 5 and remain similar in both sexes until age 15. At pubertal stage P5, plasma DHA levels are similar to that seen in young adults with no sex difference while that of DHAS continue to rise in boys and become significantly higher than in girls.

Developmental changes in adrenal androgen secretions are also observed in the response to ACTH stimulation. Whether estimated as absolute levels or Δ of response, the rise in all unconjugated adrenal androgens to a short or prolonged ACTH stimulation, is greater with increasing age, with no sex difference, and is somewhat correlated to basal levels. Plasma levels of DHAS do not vary significantly the 2 hours following a bolus injection of ACTH (21, 34) but its response to longterm (3-days) ACTH stimulation is also increasing with age. Morphological and functional changes in the adrenal cortex also occur during development. Focal development of aZona reticularis starts at 5 years of age, and progressively becomes continuous. The development of the zona reticularis is parallel to the increase in adrenal androgen secretions, and is completed only by age 15. This is accompanied by a rise in 17-hydroxylase and 17,20-desmolase activity in the adrenals.

In a normal timing of physiological events, the onset of adrenarche occurs several years before the onset of gonadarche, 2–3 years in girls and 3–4 years in boys. This relation does not preclude that the processes are independent events. Indeed, the onset of adrenarche and gonadarche are dissociated in a variety of disorders of sexual maturation

Adrenal androgen secretions are under the control of ACTH, as shown by a series of observations. However, the specific increase of adrenal androgen secretions during development without any detectable change in ACTH stimulation, the dissociation between adrenarche and gonadarche in several conditions, have led to postulate that the biochemical differentiation of the zona reticularis may require the action of an «adrenal factor» in addition to ACTH. Among the proposed «trophic» factors of adrenal androgen secretion, LH/FSH and estrogens are no longer believed to be involved. The evidences for the existence of a separate and specific pituitary cortical androgen-stimulating hormone (CASH) are not yet convincing. Prolactin, linked to nutritional status, may stimulate the activity of the adrenal hydroxysteroid sulfotransferase. The functional zonal theory» is attractive, but it does not explain why changes in adrenal androgens occur at a given age. Finally, the occurrence of familial cases of premature pubarche, the study of the changes in adrenal androgens in monozygotic or dizygotic twins and the observation that in idiopathic delayed puberty the delay in adrenarche is only one part of a generalized growth and developmental delay, strongly suggests that maturation of the adrenal cortex is regulated, at least in part, by genetic factors.

The physiological importance of adrenal androgens remains a matter of controversy. Classical “dogma” dictates that adrenal androgens are responsible for pubic hair development. It has also been suggested that they contribute to somatic growth or epiphyseal advancement in childhood.

This is mainly based on the observation that premature adrenarche is accompanied by premature pubarche, tall stature and advanced bone age. However, adequate androgen secretion alone does not ensure normal sexual hair development in many patients with gonadal dysgenesis. Moreover, in children with a lack or delayed adrenarche long-term treatment with DHAS at dosages such as to restore normal levels for age, failed to induce growth of sexual hair or any change in growth rate, bone maturation velocity, or to advance puberty. Although new hypotheses favour the view that Δ5-androgens, particularly Δ5-androstenediol, have some characteristic properties of estrogens, the physiological role of adrenal androgens, if any, remains to be established.

DHAS may well be only a prohormone. There are ample evidences that all tissues possess active sulfatases which transform it into DHA, a steroid with high turn-over. Administration of DHA to experimental animals has shown beneficial effects on various endocrine-metabolic parameters, enhanced immunoprotective functions and reduced carcinogenesis. DHA prevents diabetes in genetically diabetic and obese mice. The importance ofin vivo andin vitro experimental findings is underscored by epidemiological data showing that low DHA levels are correlated with increased cardiovascular morbidity in men, breast cancer in women and a decline in immune competence. Human studies are at the moment controversial. It remains possible that DHAS influence breast cancer risk earlier in life, and/or that there are more complex interactions with other hormones or the intracellular metabolism of DHA/DHAS. Indeed, the tissue concentrations of DHAS may be important since it may act indirectly via its metabolism into estradiol or other steroids. Further long-term studies are needed to conclude whether DHA/DHAS are a youth fountain.

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    M. G. Forest

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Forest, M.G. La puberté surrénalienne. Androl. 7, 165–186 (1997). https://doi.org/10.1007/BF03034931

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