There's a slight change in the order. Our first speaker will be Deborah Merck, and we will introduce Deborah as a wonderful pediatric endocrinologist, senior investigator, and chief of pediatric service at the NIH Clinical Center in Bethesda, Maryland. Her research focuses on the pathophysiology and genetics of CAH, including the study of a contiguous gene deletion syndrome affecting approximately 10% of CAH patients, called CAH-X. Dr. Merck is currently conducting a natural history study of CAH with over 450 patients to date enrolled. Central to her work is the study of new treatments, including circadian cortisol replacement and the use of adjuvant therapies to allow for lower-dose glucocorticoid replacements. I thank Debbie. As I said, my first presentation, I was told by Dr. Mel Grumbach, be careful not to fall off the podium. There you go. Thank you, Sharon, and I'll try not to fall off as I speak. Well, it's really, really wonderful to be here today presenting in person. It feels good after two years of remote meetings. So I'll be discussing novel therapies for patients with CAH. Before I begin, I do have a few disclosures. So this is a timeline of important discoveries, a historical perspective of CAH, and really a landmark was in the early 1950s when cortisone was found to be effective for the treatment in CAH. And this was really simultaneously reported by Wilkins and Barter. And the next few decades were identification of the rarer forms of CAH. And then we had the first neonatal screening. Now we have neonatal screening in all 50 U.S. states, as well as over 45 countries, and the identification of the CYP21A2 gene. And now in the 21st century, we've made lots of genetic advances, biomarker discovery, and of course, novel treatments, which I'll be discussing today. At the NIH, I have a natural history study that began in 2006. I actually was able to start this due to a CARES Foundation grant, and it's continued over the years. And to date, we have 490 patients. Shown here is age at last visit. And really in the past, like two years is the first time we have more adults than children. So my patients are aging with me. We have an awful lot of young adults. And we do comprehensive clinical and genetic evaluations, and we also refer to treatment studies. Now, classic CAH, or classic 21-hydroxylase deficiency, has multiple hormonal imbalances. The decrease in cortisol results in lack of negative feedback with an increase in CRF and an increase in ACTH. And this leads to nodular hyperplasia of the adrenals, overstimulation, and the excess androgens. Years ago, we also described that patients with the most severe form have epinephrine or adrenaline deficiency due to abnormal adrenal formation. There's also an impairment in aldosterone production. Sometimes I feel like this is kind of the forgotten child, but it's very, very important. And when you have salt wasting and volume depletion, this indirectly leads to difficulty suppressing ACTH and an increase in ACTH production and even more stimulation to the adrenals. So when we think about the management of CAH, you need to consider all these multiple hormonal imbalances. And the overarching goals in the management of CAH are to replace the deficient cortisol and aldosterone and to control the adrenal androgens. The clinical management is really a very difficult balancing act between too much androgen and too much cortisol. The too much cortisol is iatrogenic. We can always give more glucocorticoid to suppress the androgens, but then patients become mildly cushionoid. And when we decrease the glucocorticoid, we then have too much androgen. And often patients really experience both of these undesirable states. Another important unresolved issue is how best to treat. Pediatricians in general agree that hydrocortisone is best. The longer acting glucocorticoids tend to be more growth suppressive. For adults, there is no standardized approach. So adult endocrinologists use long acting, short acting, any of the glucocorticoids that are available. So these multiple comorbidities and adverse outcomes are combinations of disease-related and treatment-related outcomes. And really almost every organ system is affected in CAH. And we also see this throughout the lifespan. So in childhood, pediatric endocrinologists are managing adrenal crises, abnormal growth and development, some metabolic issues. And in adulthood, the adult endocrinologists are managing adrenal crises. The patients already have short stature, metabolic syndrome, tumor formation, and infertility are issues, as well as low bone mineral density and poor quality of life. So clearly new treatments are needed. An overarching goal is to try to decrease the daily glucocorticoid. And I'll be covering four different areas, adrenal stroidogenesis inhibitors, novel glucocorticoid approaches, HPA axis suppressors, and cell-based and gene-based therapies. So first, adrenal stroidogenesis inhibitors. Next. So at the NIH, I actually started this study as a fellow under Gordon Cutler. And this was the first use of sex hormone blockade in the treatment of CAH. We used an antiandrogen aromatase inhibitor and lower dose hydrocortisone to treat patients. So patients were put on six to eight milligrams per meter squared per day, a physiologic daily dose. And after two years, children who were receiving the experimental treatment regimen, so they were on four drugs. They were on flutamide, the antiandrogen aromatase inhibitor, lower dose glucocorticoid, and flugercortisone. They had normalization of growth rate and bone maturation despite having elevated androgens because these androgens were being blocked at the androgen receptor. So since that time, there's better drugs available and advancements made in antiandrogens. And specifically, abiraterone, a 17-hydroxylase inhibitor, is being studied in CAH. So when you think about the 21-hydroxylase enzyme deficiency in the pathway, right, this is what happens. And if you add a 17-hydroxylase inhibitor, then dokes should not accumulate and we shouldn't need to worry about hypertension, right, just because of where the block in the pathway is. And so we know that we worry about hypertension in our 17-hydroxylase deficient patients. We saw it in men with prostate cancer treated with abiraterone. And then Rich Aukes at University of Michigan did a study using abiraterone in six women with classic CAH who were treated for six days. And they had elevated androstenedione at baseline. After the six days, 80% had normal androstenedione. And remarkably, that androstenedione stayed low for the following two days, even though they were off the medication. And I think this study showed that we don't need to worry about the doke accumulation and the hypertension in our CAH patients because that didn't happen. So because of these positive results, there is a phase one, two multicenter study in prepubertal children. The PI is Perrin White in Texas. It was delayed due to pediatric formulation issues, but is now active. I'd like to make a comment about the 17-hydroxylase inhibitors. They are blocking gonadal sex hormone production as well. So they're really best given in prepubertal children or if adults were to use abiraterone, then the women would need to be on birth control pills or men potentially on testosterone replacement. Okay, next, novel glucocorticoid formulations or more specifically circadian replacement. So this is a reminder of what normal circadian cortisol secretion looks like. This is a study where 28 healthy subjects had 24-hour sampling. So cortisol is low at night. It peaks in the morning with a gradual decline throughout the day. In a separate study, we did 24-hour sampling of CAH patients receiving three times a day hydrocortisone. So you can see not very physiologic at all. And this is what children are on. In this case, we were giving the higher dose at night, therefore the higher peak. So one way in which we studied circadian cortisol replacement was in a pump study where we used a Medtronic pump usually used to deliver insulin. And we had eight adult patients with classic CAH. They were all very difficult to control with multiple comorbidities. And we specifically chose this group to see what would happen if we put them on the pump and also because it is a work-intensive kind of way to treat patients. We were able to achieve physiologic cortisol profile with multiple rates throughout the day. This was done through 24-hour sampling. And we found improved quality of life. That was actually our most significant finding. All the patients had poor quality of life at baseline. And shown here is the androstenedione and the 17-hydroxyprogesterone. So the gray is the conventional. Pump at six months in blue, 18 months in green. And you can see that the androstenedione and 17-hydroxyprogesterone were much flatter and closer to normal. And we did see some improvement in comorbidities, shrinkage of testicular adrenal rest, resumption of menses, and some improvement of liver fat. We did not see any improvement in obesity. Now, recently, Adena Turcu at University of Michigan measured 11-oxyandrogens in our patients receiving pump therapy. And we saw decreased 11-oxyandrogens with pump. And interestingly, the 11-oxyandrogens remained elevated for a longer period of time than the 17-hydroxyprogesterone in patients with poor control. Now, we've also studied for years, in collaboration with Richard Ross and Dyer et al, a modified release form of hydrocortisone called Kronocort, now being marketed as FMODE. So this shows the phase two results. Now, Kronocort, or FMODE, is a capsule. This is hydrocortisone. You can see to the left, there's a hydrocortisone layer and then a delayed-release coat, which has a pH trigger. And it is designed to mimic circadian rhythm. So you take the highest dose at night, peak in the morning. We found that the cortisol profile did approximate the norm with a maximum of 17.3 at approximately 7 AM. We found improved control on similar or lower glucocorticoid dose. The average hydrocortisone dose equivalency decreased from 28 to about 26. And we also did 24-hour urinary steroid metabolome profiling in collaboration with WebKey Alt and showed reduced 11 oxygenated androgens in those receiving the modified-release hydrocortisone. So once again, the alternative pathways of androgens are being reduced. This led to a phase three randomized parallel arm study with modified-release hydrocortisone compared to standard glucocorticoid therapy. This was a multicenter, 10-country study. So in six months, 122 adult patients with classic CAH were studied. And there was blinded dose titration. The primary outcome was a change in a 24-hour 70-hydroxy progesterone standard deviation score. Now, the study did fail its primary outcome. But importantly, we saw differences in the early morning and early afternoon compared to standard treatments. And that's what's shown on the left with 70-hydroxy progesterone and androstenedione. And then there was an extension study. And we found sustained benefits at lower doses. So in the 18-month extension study, the median dose that patients were on went from 30 to 20 milligrams per day. Here, the management was being done by the local physician. But we continued to have good control and see improved menstruation, patient or partner pregnancies, and improved attention in the patients. And because of these positive results, FMODI was licensed in Europe and the UK for CAH patients 12 years and older. And a US study has just begun for patients greater than 16. And this is a randomized double-blind controlled study comparing chronocort to standard hydrocortisone. Okay, next are HPA-axis suppressors. So there are two CRF1 receptor antagonists in development. So first is Crineserfant, sponsored as Neurocrin. And a Phase II open-label dose-finding study was completed of four dosing regimens for 14 days. Patients had poorly controlled CAH. And you can see on the left is percent fall from baseline. And the Crineserfant did attenuate the morning ACTH rise, resulting in reductions in 17-OHP and a dose-related decrease in androstenedione. So because of the dose-related decrease in androstenedione, the 100-milligram BID was chosen. There's currently a Phase III randomized double-blind placebo-controlled trial in adults using this dose. And there is also an active randomized trial in children. Now, the other CRF1 receptor antagonist that's currently in clinical trials is Tildaserfant. The sponsor is Spruce. There's two Phase II studies were completed. Study one, patients are in poor disease control, defined as androstenedione greater than two times the upper limit of normal. Different doses were given. There was no dose response. But reductions in ACTH, 17-hydroxyprogesterone, and androstenedione were observed. Now, study two is what's shown on the left. 400 milligrams were given once daily for 12 weeks. And mean reductions were seen in ACTH, 74%, 17-hydroxyprogesterone, 82%, androstenedione, 55%. And one thing that's interesting is, you know, you do see greater reduction with time. So similar to what we saw with Cronochort, I think in general in the CH patients, you need to treat for long, or with longer treatment, we're seeing more of an impact. And there are two active studies with Tildastrifont. One is a randomized double-blind placebo-controlled study in adults. The other is adults with CAH who are in good control in an attempt to reduce their glucocorticoid dose. Now, there also is an agent targeting ACTH and its receptor MC2R. And this is developed by Cronetics a little earlier in development than the CRF antagonists. To the left is animal data. So this is rats. And you can see that the experimental medication is dosed. Then one hour later, an ACTH bolus. And there was a dose-dependent suppression of corticosterone observed in the rats. To the right is human data. And this actually was presented in another session earlier at Endo. It was dose-dependent suppression of cortisol observed following an ACTH challenge. And shown here is the 250 micrograms. They also did one microgram and showed suppression. And because of these positive results, a phase 2 study is being planned. And they actually plan on using this in Cushing's as well. OK, so last is cell-based and gene-based therapies. So there now is gene therapy for CAH. It's an AAV5 vector called BBP631. It encodes the human CYP21A2 gene. And it provides a functional copy of the gene. Shown here is animal data. To the left, these are mice that are affected by CAH, treated. And there's a dose-dependent increase in their body weight. And also not shown here were changes in renin and progesterone. On the right is the non-human primate data. There's a dose-dependent increase in the human 21-hydroxylase enzyme in the adrenals. And the human 21-hydroxylase protein expression remained at 24 weeks when the animals were sacrificed. So there currently is a phase 1, 2, first in human study of gene therapy in CAH. The way it's designed is there's dose escalation with three patients per level. Because ideally, you would want to treat at the lowest dose possible. And after each dose is given, the DSMC will review safety data before dose escalation or before expansion to a larger population. Patients can receive only one dose of the gene therapy. And there are several endpoints being evaluated. And of course, the most important would be levels of endogenous cortisol. Now, cell-based therapy is something that has been huge in medicine, especially in cancer. And there are now advances in CAH. Researchers in London and Dresden reprogrammed mature cells to generate human-induced stratogenic cells. These cells were able to secrete cortisol. They were viable when transplanted into the adrenals in mice. And then they took mature cells obtained from urine of patients with CAH and transformed and rescued them. There's still the unanswered questions, how do we get this into human use? But I think it's very exciting preliminary research that's being done. Ultimately, maybe one day we'd be able to have a bioartificial adrenal. And there is development of novel encapsulation devices underway. So just to summarize, it's a very exciting time to be doing CAH research. There's so many novel investigational products in the pipeline. Shown here is all of them. The ones in green are current clinical trials that I've discussed today. The FMODI, or the modified release hydrocortisone, is the one that's furthest along. It's the first drug since the early 1950s that's specifically designed for CAH and that's approved at least in Europe. All of the hypothalamic pituitary adrenal axis suppressors, I think, have the potential to reduce glucocorticoid doses even further and also potential use in tumor formation, which is a big issue in our adult population. And of course, gene therapy is the only approach that actually tries to correct the underlying defect. So in conclusion, in CAH, there are many unresolved clinical issues that are common reflecting both disease and treatment related factors. New treatments in the pipeline hold promise to improve patient outcomes with neurophysiologic cortisol replacement, adjunct therapies, and therapies to genetically correct the underlying defect. Pediatric studies are greatly needed to determine long-term outcome and prevent the development of comorbidities. I also wanted to extend special thanks to our patients. This photo is actually from 2007, which reflects how long it takes to develop drugs sometimes also. So this was early stages of the development of modified-release hydrocortisone. And to the right are all the tubes of blood we were drawing on this patient. So on the top is day one and two, the bottom, day three and four. And if it weren't for patients, we wouldn't be able to do all these clinical trials and develop new treatments. And last, I'd like to acknowledge my lab in the section on congenital disorders. It's been quite challenging during the pandemic to continue our clinical research. I'd like to thank everyone at NIH and collaborators for their support of the Natural History Study. Thank Rich and Dina for their collaboration looking at new biomarkers in our Natural History Study. And also thank Richard Ross and all of the phase three investigators for making the studies in the modified release hydrocortisone possible. Thank you. We have a few moments for questions. This was an incredible, incredible talk and relevant journey. So please come to the microphone, state where you're from, and we have time for about three questions. Hi, Sajitha Nagella from Northern Virginia. So using abiraterone, you are actually creating 17-hydroxylase deficiency in someone with 21-hydroxylase, correct? Okay, so when you give them abiraterone, what happens to aldosterone levels in these patients? And do you see any problems with potassium? Even though there's no hypertension, do you see hyperkalemia or? No, so there's... So in the 17-hydroxylase deficient patients, the problem is the doke and other metabolites that accumulate. And because of where the block is in the pathway with the 21-hydroxylase patients, we wouldn't expect that to happen. So no problems with potassium, correct? Yeah, so if I might add, we didn't have any hypokalemia in the trial. And then we actually were able to go back and measure progesterone and doke. And as we expected, progesterone did go up. Doke actually didn't change much in the trial. You can get some extra adrenal doke formation from plasma-borne progesterone through CYP3A4 and a few other enzymes, but it wasn't very much. And they can't make aldosterone. So that didn't change. Yeah, these were classic patients. It was short-term therapy, but there shouldn't be mineralocorticoid effects. Okay, okay. So I have another, I have a quick patient case. So I have a patient with 17-hydroxylase deficiency who had the classic hypertension, hypokalemia. And then she saw her primary care. He just looked at the low cortisol and kept giving her higher and higher, higher doses of dexamethasone. She became cushioned guide, et cetera. And then she decided to come back and see me. So to make a long story short, she actually now has no doke. After that, whatever happened with the dexamethasone, she's hyperkalemic. So I had to put her on flutocortisone, and she requires nothing much for hypertension now. And sometimes her diet is low in potassium. Otherwise she becomes hyperkalemic. Do you know what happened to her? No, no, I mean, she had some adrenal atrophy. If people are on dex for a long time, it'll take a long time to recover, just like anybody put on prednisone for arthritis or lupus for a long time. It's been five years. It can be a long time, yeah. Debbie, you didn't talk about non-classic disease. Do you think any of these treatments might be useful in non-classic disease? Those people are also very unhappy. Yes, so some of the treatments might be good for non-classic. Like I think the modified release hydrocortisone could potentially be used. Something like gene therapy, obviously, wouldn't do for the non-classic patients. So it's all a spectrum in terms of the severity of disease and what kind of treatment. My impression is the classic patients, or the non-classic rather, don't really have tumor formation. So the CRF antagonists are probably, I would say, more specific to a classic patient. Thank you. Okay, well, thank you, Debbie. Thank you. And I didn't fall off. Okay, so it's my pleasure to introduce our second speaker, Philippe Touraine. Philippe is the head of the Department of Endocrinology and Reproductive Medicine at a hospital in Paris whose name I can't pronounce, so I'm not gonna try, but I can say that he's a full professor at the Cervon. And he is also a leader of two groups dedicated to rare endocrine and gynecological disorders. And finally, he leads one of the groups belonging to the European Rare Network and the sex differentiation disorders. His major research interests include the pathogenesis and the genetics of premature ovarian failure, the management of patients with congenital adrenal hyperplasia, and finally, management of patients with rare endocrine and gynecological conditions in the transition period to adults. So he is a perfect person to talk to us today about starting a family, eggs and sperm and CAH families. Philippe. Thank you, Richard. Thank you to the Endocrine Society for the invitation, and specifically to Selma Wichel. It's a great pleasure for me to be here. I have no disclosure concerning the topic of fertility and CAH. As you may know, we have to challenge two main topics when we are in front of a patient with CAH. The first one is adrenal insufficiency. Deborah developed all the approaches concerning such deficiency. And beside that, due to an overproduction of androgens leading to potentially reproductive disorders, we have to discuss what should be as the best management of this patient with CAH. The second point you have to keep in mind, because Richard asked a question about non-classical forms, is that infertility is not just a topic concerning classical forms, even if I will develop essentially this kind of problem, this kind of situation. But non-classical forms, when you are an adult endocrinologist, is a very common situation to be in front of a patient with either acnea, hyperandrogenism, or infertility. And I will tell you a few words about such situation. So if we refer to old studies, I mean, which have been published 10 years ago, and I'm happy to see that now Deborah has twice the number, which was the number of patients published in the 2010, but it's very interesting because in the UK, they performed a multicentric study with VIPTRA, in the NIH with a large study with a pediatric case and other cases. And in my department, we had a monocentric study with 100 patients. But the key point is the fact that you can observe that you have almost in all studies, the same kind of problems you have to challenge and to manage. I mean, you have the metabolic consequences and probably due to an overtreatment with glutaral proteic rates, with overweight and obesity, or abnormal bone mineral density, osteopenia, osteoporosis in either, in about 50% of the population. And the second topic, which is my topic today, is the question of fertility and reproductive disorders. I mean, you can observe that in front of male patients, you have almost 40% of them who can develop testis adrenal rest tumors and around 50% of the population who has irregular menstrual cycles, meaning that the other 50% has not. So I will just remind you something which is very basic. I mean, we know that if you want to have another lattice, which works perfectly well, you need an hypothalamus leading to the secretion of GnRH inducing the secretion of LH and FSH at the pituitary level. It's everybody knows that. And these pituitary hormones have an action on the ovary, but it could be the testis. It's exactly the same thing. When you have the CAH situation, you will observe an over secretion of androgens with aromatization into estrogens leading to a negative feedback in the pituitary level. And besides such over secretion of androgens, you have an over secretion of progesterone too, progesterone which has a negative impact on the LH and on ovulation. And besides the central consequence, progesterone will induce a very thin endometrium leading to the implantation, which will be really impossible and impermeability of the cervical mutus. So which leads to the infertility too. So you have to keep in mind that both androgen over secretion and progesterone over secretion may have consequences on the genital axis. And finally, the discovery, the most recent discovery of the different 11-oxosteric pathway may have some consequences too. So if we focus first on fertility in a woman with the classical form of CAH, for many, many years, the dogma was these women have very low chances to become pregnant. And if you observe this slide, you can see in some studies, you have here studies with specian and a few control studies. You have a very low rate in terms of pregnancy, especially in sole-wasting forms. And it was very exceptional to observe some live births among this population. So by the beginning of this century, the trend was to say that the fertility was decreased in CAH women and especially in sole-wasting form. This is an important point, and you have to keep in mind that it's not wrong. More recently, the Swedish group from Anna Nordenström published a very later study, because first of all, it's always very exciting to see that you can have almost 30,000 patients as a control, thanks to the registry. And Anna and her group published data concerning CAH patient in general, sole-wasting, simple virilizing, and some of them with non-classical forms. And of course, if you compare the patients, so the CAH patient with the control, you observe that you have a low number of biological children in these women, and who are a little bit older compared to the control population. So we don't have to forget this kind of dogma about fertility in the fact that the number of patients who have children is relatively low. However, we don't have to do a confusion between the fertility rate, which is very low, and the pregnancy rate. I mean, in a study by Conway's group in 2009, it was compared the fertility rate in the CAH women and the UK population. And obviously, it was very low, the fertility rate. But if you observe the situation concerning the 81 patients with sole-wasting form, when you ask them, do you want, do you have any desire of pregnancy, 72 patients will tell, no, I don't have, I never tried to conceive. So when you study the nine remaining patients, you observe that the pregnancy rate, if you really focus on the hormonal control of this woman, is perfectly normal, around 90%. So we have multiple causes to explain subfertility in CAH adult patients. First one is insufficient glucoprotein replacement therapy, which leads to anovulation and potentially PCOS syndrome-like in those patients, in which is quite important because it leads to the question about which treatment should we propose to those patients who have a desire of pregnancy, since most of them are under hydrocortisone, for example, and should we replace such treatment for another one? We'll discuss that. Sexual activity may be reduced also in those women because of genital malformation, which have been poorly reconstructed. And as a third point is the fact that progesterone, when it's increased, may decrease the implantation, which is a key point to permit to the development of the embryo. And finally, we can discuss a lot about the psychological factors, the psychosexual factors, sexual orientation of this woman, we can explain the subfertility. In our group, we started with our patients studying much more the situation concerning pregnancies of this woman. And what we observed is that among first 70 patients with CH, only 30 expressed the desire of pregnancy. And women who have been pregnant, more than 30% were because they received dexamethasone, which wasn't the first treatment. But in our practice in general, once they decide to become pregnant and because we want to obtain a very low level of progesterone during the fertility phase, lower than two minimum per liter, we propose to add to hydrocortisone dexamethasone. So far, we obtained pregnancy most often spontaneously, but sometimes with different treatment in terms of stimulation. And if we observed what happens during pregnancy, at the Swedish group, we observed a higher number of gestational diabetes among the population, sometimes also with high blood pressure and no specific preeclampsia or adrenal crisis. It's very important to underline that in all studies, most of these babies are born after cesarean. So far in our hands, we can say that the percentage of women with pregnancy was 24%, with beside that, a very low prevalence of desire of pregnancy. But if we focus on these women, you don't have to tell them it will be impossible. You have to keep in mind that if a woman is in front of you with a CH, classical form, and if she expressed the desire of pregnancy, you have to tell her that it will be possible if we are able to obtain a good hormonal control, which is a key goal. Based on androgen over secretion, we were interested to understand the real mechanism leading to infertility. And we perform a study comparing 16 CH women and CH control women, and we perform an LH pulsatility study during eight hours. And it was interesting because we had the first group of patient with almost all the control patient, 15 on 16, and seven CH who had a perfect LH pulsatility. At the contrary, we had another group with one control patient with a poor LH pulsatility, and nine CH women with an absence, a complete absence of pulsatility, of LH pulsatility. And when we compare both groups, you can observe that in the first one, which is with a normal LH pulsatility, they are really controlled in terms of hormonal levels compared with a second group. But among the different parameters, we observe that progesterone is probably a key factor to as a good marker for control of LH pulsatility and therefore of ovulation. That's why I always say that progesterone measure is quite important in the practice life and in all clinical trials, because it's quite important to have a very low progesterone level, which could be a more significant marker than Anderson-Diagne. But the question is, what will be the therapeutic approach? And where maybe the frontier between the traditional treatments, and now we'll see maybe in the future, if new approaches will improve such hormonal control and potentially fertility of this woman. And finally, concerning the classical forms, it's typical to speak about testosterone arrest tumors, but Eddie Klassen presented the figure of ovarian arrest tumors. And most people say it's not so obvious to observe such situation because ovaries are not observed such as testes. It's easier to perform ultrasonography, a precise ultrasonography of the testes than the ovaries. But it's a rare condition, which is associated with a poor control also. And recently, a Turkish group has presented 20 cases of ovarian arrest tumors within the gonads, which is a very high number, but essentially associated with 11 adverse deficiency. But we have to keep in mind that these tumors may also participate to infertility. The topic, if now we move on to the non-classical form, you will see that the situation is completely different. Two large studies have been performed, one from Moran in the US in 2006, and our study from our group concerning almost 200 patients. Patients were without any specific problem. They were referred to our department essentially because of esthetism, menstrual cycle disorders, and in few cases of hyperfertility, but they were very young, I mean, around the 20s. And these women presented in 60% the menstrual disorder, leading to the suggestion initially sometimes that they had a PCO syndrome and not a 21 deficiency. So you have to search for such deficiency in front of any patient who presents with an aspect of PCO. And the only question which is quite important for this woman is to know if they will become pregnant easily. And you have to answer yes. You won't have any problem to conceive. In our experience, 66% of one year, and finally 90%. So in general, you can observe that after six months, they conceive, except if you do have some computation in the partner, et cetera. But in the normal situation, a woman was in a non-classical form because she will ask you immediately the question, what about my fertility? You have to be very quiet and reassure the patient saying, you won't have any problem to become pregnant. The question which remains open is, what should we do concerning the treatment? Because traditionally, in the non-classical form, it has been discussed, but we had the volunteer, we had to try to give the ibuprofen with very small doses, 10 to 15 milligrams in this woman, maybe because we had the impression that it could lower the androgen levels in this patient. And so most of these women, either in our study than the modern study, when they became pregnant, they were under hydrocortisone or sometimes under dexamethasone in the US with the largest use of dexamethasone compared with our approach. But the fact is that these women under hydrocortisone have a lower rate of miscarriage compared with patient who didn't receive hydrocortisone. But it was an observational study, a retrospective study. We don't have any prospective study comparing population under and without hydrocortisone. So the suggestion is to maintain hydrocortisone during the first trimester, but they don't need hydrocortisone during the pregnancy because they don't have adrenal insufficiency. So let's move to male fertility with two main goals, the challenge of hypodermatism and the development of testis adrenal rescuers. In a large survey in France a few years ago, you can observe that the patient have been measured for different parameters, progesterone, 17-hydroxyprogesterone, endostendione, ACTH and renin. And you can observe this is a normal range for the population and you can observe that you have, for example, very high progesterone level in men. If in case of you observe one day in one patient, a male patient, a high progesterone level, you have to focus immediately on an adrenal disease. Of course, 17-hydroxyprogesterone was increased because they have CAH and endostendione was very heterogeneous with some patients with normal levels. But normally a normal male patient has very low levels of endostendione. At the contrary, in CAH patients, you have a very high level of endostendione. And if you focus now on the consequences in terms of LH and FSH, you observe different patterns, but most often you can observe the relative hypogonadism, which is an overproduction of androgens by the adrenal glands and secondary testis hypogonadism potentially with testosterone level in young male patients, which are at the lower range. Testosterone is variable, but we observe most often such levels, which are insufficient in young male patients. And finally, it's an important point, inibin-B is very heterogeneous, but it's a good marker for spermatogenesis. So what about testis adrenal rest tumors? Every man has in the testis some adrenal rest cells, which are very microscopic, so it has absolutely no consequences. But due to the over secretion of SETH, you can observe a stimulation in an hypertrophy of adrenal cells, the growth of testis adrenal rest tumors leading to fibrosis, and finally, excuse me, to a complete damage of testis. So TARV is a main challenge in terms of clinics because it's painful. Sometimes it's not acceptable for the men who ask for surgery, and with the consequences we'll see in terms of fertility. And so far, it's a challenge for the new approach in terms of treatment to permit a decrease of TARV volume. Recently, a German group published data concerning sperm concentration depending on TARV volume. You have here the sperm concentration in the CAH male patient, which is lower compared to control population. If you compare their sperm concentration depending on the control of the disease, you observe that you have a trend towards a better concentration in case of good control compared to moderate or poor control. Even if you have a non-significant difference between control population, it's a lower concentration. There is a real association between TARV volume and sperm concentration, and surprisingly, inibin B appear not higher in the group which is considered as well controlled compared with the moderate one. And this group decided to distinguish control of the disease before puberty and after puberty. And so you could have two possibilities, either good-good, medium-good, good-medium, medium-medium, bad-medium, and bad-bad, the first one before puberty, the second one after puberty. And what you can observe is that if you are really poorly controlled since childhood, you can observe the presence of TARV. And in terms of sperm concentration, of course, you will have a better concentration in case of good control since childhood. To conclude, in a few minutes, I would like to present our study, which is a little bit particular because we decided in some cases who were completely unable to control the disease with male patients who wanted to father with azoospermia. So we decided to give them mitotan, which is a typical treatment, which is given in Cushing's syndrome. And you can observe that after 60 months, five years, those patients who had testes, adrenal rest tumors, decreed 17-hydroxyprogesterone, progesterone, and androstenedione levels. In general, we observed a natural crisis in this patient. And after that, in two of the five patients with azoospermia, we obtained an improvement of sperm concentration, leading potentially to fertility. And one of them fathered a few months after. So to finish and to conclude, I would like just to focus just on fertility. I'm not speaking about the other aspects. In classical forms, you have woman and male. One point, don't forget, genetic counseling is absolutely mandatory, and specifically in non-classical form, because you know that a severe and a non-severe mutation can lead to a non-classical form. But if the partner presents just one single severe mutation, you can obtain an embryo fetus with a severe, severe, so a classical form. So in woman, you have to manage the embryo genitalia. And in terms of measurements, it's not so complicated. LHFSH, 17-hydroxyprogesterone, androstenedione, and progesterone. And with a question for the future, what will be the future of fertility in this woman, which is considered as poor, except if you control perfectly well the hormonal situation and the impact of new formulation should be probably interesting. Concerning male patient, it's very interesting, because traditionally, it was the adult endocrinologist who was the referent for reproduction. And so now we can observe a switch that's perfect towards a pediatrician who propose when the young adult is 14 or 15, if we can have a test-issue personography just to observe the presence or not of a TARP. And we really recommend a sperm cryoconservation. And once again, what about the new treatment, specifically in case of testis adrenal rest tumors? The only question for non-classical form is, what should we do during the first trimester? Should we maintain hydrocortisone or given hydrocortisone? Or should we just leave the patient without any treatment? And male with non-classical form, this is a real question, because nobody knows them, because they won't complain about eustachism or irregular menstruation. So far, it's a unknown situation. And finally, the fact is that if you want to manage priority your patient during adulthood, we have to work with pediatrician. The transition period, I'm really involved in such a period. It's quite important. On Saturday, I saw a poster that more than 90% of CH patients were treated by pediatrician endocrinologist, and that less than 70% in adulthood. So we have a lot of lost of you. And so we have to manage this population during transition. Thank you so much for your attention. Great overview. Maggie Wehrman from the University of Colorado. In your discussion of classic CH women trying to induce ovulation and maintain a pregnancy, you seem to suggest that you didn't tell us the doses of hydrocortisone and or dex that you used, and your patients had a pretty abnormal metabolic phenotype. So can you give us more specifics about what is the protocol you use, and then do you back off on those steroids as soon as they're pregnant? So traditionally, in France, we don't use first prednisone and prednisone. So I don't have experience with such molecules. We use hydrocortisone. When they are uncontrolled, which is the most common situation, I add 0.25 or 0.5 milligram a day of dexamethasone on the evening. What hydrocortisone doses are you using? Now, hydrocortisone in general, they are over-treated, and they receive more than 25, 30, 35 milligrams a day, which is probably the first step because we believe that increasing the dose will improve the situation. I'm not convinced about that. OK, so you will need some side effects without any benefits. But if we consider a patient with 30 milligrams a day of hydrocortisone with uncontrolled situation, and she wants to become pregnant, I add dexamethasone by the evening, 0.5 or 0.25 milligram a day. But this dexamethasone, you have to stop it when she's pregnant. And so you have to come back to hydrocortisone because dexamethasone will cause the placenta. And in case, except if you know that probably she has a baby with a two-stage mutation, but it's another topic, you have to stop it. OK, thank you. And just to add that in Jerry Conway's study that he always said that the key was a bedtime dose of prednisolone, usually less than 2.5 milligrams was the trick. So I think that's the point. It's not just going up on the hydrocortisone. They need a nighttime dose of a long-acting glucocorticoid of some sort. Dr. Ross. Richard Ross, University of Sheffield, UK. Philip, very nice presentation. I just want to reinforce this message about progesterone suppression. When a woman with salt wasting wants to get pregnant. And I feel guilty in the past that I haven't done that and referred people for IVF. And they haven't been successful in IVF because their progesterone's still been there. And I can remember these patients from the past. Jerry Conway's protocol, which we used, is actually prednisolone, 2.5 milligrams, eight hourly. And I think that's pretty good. That sort of switches things off. It's obviously a high dose. In our modified release hydrocortisone trials, actually, what we've seen is that we are controlling the androgens throughout the 24 hours. And what we've seen is restoration of menses. And an anecdotal case, which has just been reported to us, is of a woman who had tried lots of different steroid regimens. She'd had three cycles of IVF. And she came along, and the investigator said, we'll try you on a modified release hydrocortisone. I'm not promising it will help. She got pregnant in the first month and with twins. Congratulations. Good comment. I do agree about the potential benefit of coronacortisone in the future. But we need more data. OK. The second point, I don't have any experience. And I think that in France, we don't have experience. Maybe with prednisone and prednisone. And so far, that's why we use data made in the evening. But it's true that probably you can obtain the same results or even better results with prednisone. Philippe, actually, part of Maggie's question was about what do you do once they get pregnant? Besides stopping the dexamethasone. So in others, do you titrate during pregnancy? Do you just leave them on their hydrocortisone, whatever dose they got pregnant in? Because this is a question I get all the time. I don't do specifically something when she becomes pregnant. If she's pregnant, I maintain the same dose of hydrocortisone. And just stop the dexamethasone. Absolutely. I don't perform any hormonal study. I don't either. Maybe should I? But the most important, especially if you use a stimulation IVF or intrauterine stimulation, you need a neutrosinography with a measure of the endometrium. Because if it's very thin, you know that it will have failure for implantation. So this is a challenge. With the new treatments or with the old treatments, whatever you want, you need a low progesterone level and a thick endometrium. Dr. Merck? Yeah. Debbie Merck, NIH. That was a wonderful overview of infertility. So we found in the non-classic patients that have difficulty getting pregnant, prednisone, low dose, like two milligrams twice a day, actually works in the majority of patients. In the literature, there's a lot about suppressing progesterone. And obviously, that's very important. But I have a very practical question for you. Is it necessary to suppress the progesterone as suggested by many? And do you actually aim to suppress it? No, to suppress completely. In the non-classics you're talking about. You're speaking about non-classical forms. Now, in non-classical forms, we're not wondering about progesterone level really to be treated. And if we suppose that ovulation and pregnancy occurs after a few months, it means that progesterone was not so high. Because in case of high progesterone level during the follicular phase, you will induce an ovulation if the contraception precepts. So we don't measure progesterone in non-classical forms. In the classic, do you try to suppress it totally? Well, we try to observe the lowest level. And we perform beside an ultrasonography. If we do have a very low level, suppress meaning zero, it's quite impossible. But you don't have to, in most of the publication, it's considered that below two nanomoles per liter, it's a challenge you should obtain. Yeah, which is about 0.6 nanograms per mil. One more quick question from Dr. Cutler. I was fascinated with a mitotane experiment. And I wondered what dose you used for mitotane, just out of curiosity. And I think it's a very interesting, because we've had nothing for the azoospermia. What? Thank you. It has been helpful. I won't say I would recommend systematically to use mitotane in these patients. It was because we were in front of patients. We didn't know what to do. Because they received a high dose of hydrocortisone. They received dexamethasone. Of course, I didn't use prednisone or prednisone. But in this patient, we decided to test mitotane. And with an effect, because two of these male patients fathered, with a question of, will we remain in spermatozoa and blood? What will be the consequences? So it's not so obvious. So I will say, I would say, you can discuss it in case by case, if there is absolutely no other solution. But we don't have any authorization in France to use it. So did you push it to like, you know, six or the highest grams a day, or the highest they would tolerate? The dose, and did you titrate blood levels? I didn't, I didn't show precisely the dose. The dose was highly variable. And the concentration of mitotane was around 4 to 6 nanograms a minute, which is lower than the concentration obtained in Crescent disease, for example. I just mentioned this. But all of them had adrenal crisis. I had, I had a patient who was a bad, bad, and 60 ml testes bilaterally that were cosmetically and a big problem. Azospermia and no suppression to them up to 4 milligrams a day of dex. And we did an orchiectomy and put in silastic press. He was very happy with that, but never occurred to me to give mitotane. Thank you. All right. Thank you so much, Dr. Trey. All right. And we have not one but two European speakers. And it's my pleasure to now introduce Dr. Anna Nordestrom. Professor Nordestrom is a senior consultant and team leader of pediatric endocrinology at the Astrid Lindgren Children's Hospital at the Karolinska Institute in Stockholm. She's responsible for the National Neonatal Screening Program, which is a job all in and to itself for CAH. And she represents the Karolinska Institute University Hospital and is the chair of the quality care and patient view work package in the European Reference Network for Rare Endocrine Consortium. She is also active in the IDSD and ICAH registries and in the European registries for rare endocrine conditions. And her research is focused on CH and other disorders of sex development. Today, she's going to talk to us about a somewhat different topic, which is the advantage for heterozygote carriers for the CYP21A2 mutations. Thank you. Thank you, Richard, for the kind introduction. And thank you for the organizers for inviting me. And this is, as Richard said, a slightly different topic. And here is the Q&A link. Just to remind you all that CYP21A2 deficiency or 21-hydroxylase deficiency is an autosomal recessive disease. And more than 300 mutations have been reported so far. But with 11 common mutations and deletion, more than 90% of cases are made up. The severity is determined by the milder allele. And there is an excellent genotype-phenotype correlation with clinical symptoms with salt wasters, simple virulisers, and non-classics, but also with the level of 17-OHP. So the incidence and the carrier frequency. For classic CAH, the incidence varies between 1 in 10,000 and 1 in 40,000. And it's usually stated to be around 1 in 15,000 globally. So that means that the carrier frequency is 1 in 50 or 1 in 100. Which is a rather high number. For non-classics, there has been a larger variation between populations reported. And the carrier frequency as assessed in newborn screening has been 1 in 10 or 1 in 25. Maria News Group reported in the mid-80s, using HLA linkage, that the carrier frequency among the Ashkenazi Jews in New York was above 30%. Now, there has been new reports on the carrier frequency based on genotyping. And then it was shown that the Ashkenazi Jewish population had a lower frequency of carriers, of about 15%. And the Caucasians higher than was expected, almost 10%. And with mostly, or almost always, V281 mutations. And for other reported populations, it varies between a couple of percentages, up to 10%. So what is the phenotype of CYP21A2 carriers? Well, we usually think that they have no symptoms or androgen excess. Males are rarely identified. In children, we have premature adrenarche, growth acceleration, and accelerated bone age and acne. And in adults, hirsutism, oligomenorrhea, PCOS, and overweight, fertility issues are reported, and hyperinsulinemia. But if we try to look at this from the other perspective, if we have an individual with clinical androgen excess, how common is it that we find that the person is a carrier or has CAH? This is results from an Indian study where 205 females, 64 girls with premature adrenarche, and 141 women with hyperandrogenism were genotyped. And it ended up that 34 had non-classical CAH, 66 were heterozygous carriers, and 50%, 105 had no mutation identified. In this particular study, they found that apolimorphis, not thought to be pathogenic, was more common among those that were negative for another CYP21A2 variant, which may have made for more symptoms. Here's another study from Portugal with 32 girls and 99 women, and the genotype showed that there are about equal numbers of non-classic CAH carriers and individuals where no mutation could be identified. When looking at the basal 17-OHP level, there was a huge overlap between the three different groups and on stimulation the non-classics had increased levels but there was still a large overlap. In this study from Israel, symptomatic carriers had higher 17-OHP on stimulation and it was even higher compared to the asymptomatic family members with the same genotype which most often was V281L. But in this study they also reported that there were more symptoms among carriers with classic mutations as growth acceleration, early puberty, advanced bone age and PCOS and only three out of 14 individuals carriers for V281L had growth acceleration. There has recently been published a meta-analysis where they looked at the 17-OHP on synaptic stimulation tests. In 16 studies, all in all 1,215 individuals were included. They were heterozygous carriers or had no mutation with and without symptoms and they report a considerable overlap in 17-OHP. And the symptomatic individuals always had higher levels than the asymptomatic individuals regardless of carrier status. The authors wonder if the finding of a carrier is actually incidental. Here is a study from 1998 but it shows that also individuals that are carriers for more severe mutations have large individual differences in the response. And the 17-OHP level in individuals with premature probarche or hyperandrogenism with and without CYP21A2 mutations show a considerable overlap. What was very interesting in this study here on the right hand side is that there was a significant difference in cortisol response between carriers and controls and the carriers had higher cortisol levels already after 10 minutes. So then there was this discussion if an upregulated primed HPA axis with a brisk response and triggered ACTH due to the relative unrecognizable deficiency was actually an advantage. It could activate the phenylethanol amine and methyl transferase in the medulla to differentiate and produce more adrenaline. So it could be possible that the cortisol acts to maintain a state of readiness. So if carriers of CAH have a more pronounced cortisol response to ACTH stimulation and a more activated HPA axis this could be an advantage in stressful situations. But it is also possible that it could be the opposite that a chronic CRH stimulation could have negative psychological effects involving the amygdala and leukocereus to result in increased vulnerability to anxiety and depression. And it has been known or it is known that chronic anxiety and depression is associated with increased CRH. So Sharmandari and her group was interested to see if the decreased cortisol production and the stimulated CRH to compensate and increase ACTH could actually have psychological consequences. They looked at 42 parents of patients with CAH and as controlled they had 23 parents of patients with other diseases and they found that carriers actually had lower 24-hour urinary free cortisol. And on CRH stimulation the ACTH increased considerably more in the carriers and there was a higher 17 OHP response. In this study though the cortisol did not increase more in the carriers than in the controls. But they saw no differences in the psychometric assessment in the anxiety, depression, mood states or the symptom checklist 90R or temperament and character. But they saw a possible correlation with the cortisol deficiency in that individuals with lower 24-hour cortisol and higher ACTH response had more obsessive compulsive behavior and novelty seeking reward dependence and harm avoidance. So we were in Sweden then interested in seeing if there was an increased or decreased stress vulnerability among CAH carriers. So we took advantage of the national CAH registry in Sweden with almost 600 patients born between 1910 and 2009 and for more than 80 percent of these patients the CYP21A2 genotype is known and for all we know the severity of CAH. And so then we also identified parents of the patients through the multi-generation registry. So we wanted to compare the risk of receiving a psychiatric diagnosis if you were a carrier and compare that to controls. And as a stressor we used the birth of a child with CAH and we then calculated risk as odds ratio. All in all we identified 610 carriers both parents of patients with classic CAH that are then obligate carriers of the classical mutations and also parents of patients with non-classic CAH who are obligate carriers but of a mixture of mutations. And for control groups we had three different controls. Parents matched for sex and age from the general population and parents that have recently had a child yet got the diagnosis of type 1 diabetes. There was 35 000 individuals in both of those control groups and also parents who just had a child of hypospadias and that was 13 452 individuals in that control group. And so we through the diagnosis registry we looked at the psychiatric diagnosis of affective disorders, substance and alcohol misuse and stress diagnosis. And we saw no significant difference overall in the psychiatric morbidity between the groups prior to the birth of the child or the diagnosis of the child but there was a tendency for less diagnosis in some of the aspects for carriers with classic CYP21A2 mutations. But the interesting thing was after the diagnosis of the child there was a considerably lower risk among the CYP21A2 carriers to receive a psychiatric diagnosis compared to all the other three control groups. For any psychiatric diagnosis that the compass all of these combined the odds ratio was 0.6 for all the three control groups. For mood disorders it was 0.5 or 0.4. Substance misuse was also considerably lower and stress diagnosis was 0.3. So in conclusion then the CYP21A2 carriers were less likely to receive a psychiatric diagnosis after the birth or diagnosis of the child with an odds ratio of 0.6 or 0.3. For mood disorders stress and substance misuse and CYP21A2 carriers seem then to be less vulnerable to psychological stressful events. And could this be a survival advantage explaining the relatively high carrier rate? Well it is difficult to see what the pathogenesis would be but it could be due to a more pronounced cortisol response or other mechanisms at the level of the pituitary or hypothalamus or an adrenaline effect. Another group from Greece has studied the metabolic and atherogenic effects and they studied 45 adolescent girls with premature adrenergy. 16 were carriers and 21 non-carriers. They studied young individuals to minimize age-related changes and both groups had similar age, pubertal stage, BMI and waist-hip ratios. And they did biochemical and hormonal profiles, oral glucose stimulation tests, GNRA stimulation tests and they looked at endothelial dysfunction. And for most parameters assessed they saw no differences. But all individuals had normal glucose tolerance and the insulin resistance was assessed and they computed a beta cell function using insulinogenic index divided by the HOMA index and they found a marginally more favorable beta cell function. The mechanism involved may be related to insulin secretion action, HPA axis responsiveness or other factors. For coagulation they also found possibly favorable effects with the tissue plasminogen activator TPA on the far upper right there that was higher and the PA inhibitory clotting factor on the upper left was lower and endothelin 1 was lower, it's an osseoconstrictor factor. And on the lower right hand side you see that the insulinogenic or the beta cell function was higher. Interestingly the opposite is seen in the metabolic syndrome and the PCOS and premature pubarca in general. So if there is a survival advantage then we need to look at the mortality. So then in the Swedish national registries we took advantage of the CH registry and all the registries that we have in Sweden we have the multi-generation registry again and we identified the parents of the patients and in all in all we had 1143 parents and we identified 100 controls per parent from the national population registry that was matched for sex and age. And we also divided them into groups of carriers for salt wasting, simple virulizing or other mutations. The mortality differs between men and women in the general population so we calculated this separately and the incidence in Sweden is about 1 in 70 for classic CH and for in total is 1 in 50. And interestingly we found that carriers of classic mutations actually had a lower mortality with a hazard rate of 1.6 to 1.8. And you can see that I've listed here that first it's all men and women and then salt wasters and simple virulizers together and then salt wasters and simple virulizers separate and the hazard ratio is between 0.6 and 0.8. But for the other the mixture where also the non-classic mutations are included there was no significant difference. So then we of course wondered what is the cause of death that is lower in the carriers and it turned out that it's infections. The infections was significantly lower as the cause of death among the carriers and it was more specifically pneumonia that was very rare among the carriers. Only two carriers had pneumonia as the cause of death. We didn't see a significant difference for cerebrovascular disease or stroke. So in conclusion the CYP21A2 carriers have lower mortality in infectious diseases. More severe mutations seem to have even lower mortality. Pneumonia was the cause of death as it was very uncommon. A higher and more prompt cortisol response could be an explanation for an evolutionary advantage of being a carrier. For example the anti-inflammatory effect for anti-TNF alpha interferon interleukins that we have seen also for COVID-19 has been very important. But the timing may also be important and it has been controversial for several decades I think of how you should treat bacterial meningitis and how important it is to give glucocorticoids as soon as the patient enters the hospital. It may be that even giving it within 30 minutes or an hour after the patient comes to the hospital may be too late. In most studies where they looked at TNF alpha and glucocorticoids in relation to mortality of the mice it was clear that inhibition needs to come early before the release of TNF alpha and that is essential since TNF alpha down regulates the glucocorticoid response. So in conclusion then we see that there are advantages for carriers. Carriers of classic mutations have a brisk cortisol response and a lower mortality due to infections, less psychological stress vulnerability and lower risk of thrombosis. But there is really no obvious explanation for the preponderance of the V281L mutation or the non-classicals. It may even be that it doesn't have to do with carriers or non-classical CAH but it may be that it is survival fitness to have an increased androgen exposure, that it may have beneficial effects with muscle strength, bone mineral density and insulin resistance or beta cell function. And thank you for your attention. Questions? While we're waiting for people to come up I was going to ask this. This issue of carriers overlapping for 17-OHP and even 21-deoxycortisol from the studies from Brazil with people that are affected with non-classic bothers me. Do you have any insight into either a biochemical or genetic explanation for those carriers who have unusually elevated 17-OHPs or other metabolites? Well I think the interesting thing that we have seen in these studies is that also the patients with hyperandrogenism that weren't carriers, they also had as elevated 17-OHP levels. So that must come from somewhere else. Mitchell, Pittsburgh, that was wonderful. In fact the whole session has been wonderful. So coming to the V281L, it's probably a carrier mutation that's been around for a long time. Is that sort of a natural form of birth control to space out births from a long time ago? One speculation. It should be. But I think the other question that I didn't have time to really investigate is cortisol goes up faster, does it come down faster? Is it a way to modulate cortisol to prevent longer periods of increased cortisol exposure? It could. I mean, the fact that the Sharmandari group actually saw that the cortisol excretion over 24 hours is lower, it speaks in that direction. But I must admit that I was a bit surprised that carriers had less vulnerability to stressful events because my impression was that parents of children with CAH were actually more stressed than the parents of children with other forms of genital deformities. But it could be that they're reacting more strongly in the acute phase and then can handle the situation in the longer run. I don't know. Thank you. Okay. Hi. We heard a fascinating talk this morning about Olympic transgender athletes. And, you know, is there an advantage to performance in sports because of the higher androgen levels or the muscle memory, etc.? So would that apply to these women who have higher testosterone? It is possible. I think there was actually an abstract when Esper was in Helsinki that showed that there was a higher carrier frequency among the individuals that made it to the final in the Olympics. But when I looked into that abstract again now before preparing for this talk, I realized that the carrier frequency was only 14% in that. And it has never made it to be published as a manuscript. So I didn't include that in my talk. But I think it's very possible that this could be one survival advantage, of course, if you're looking in a longer perspective than the life we are living today. How about women with PCOS and higher testosterone levels? I do not think they, I mean, they have the metabolic syndrome, etc. So would that be a concern? You mean for women with PCOS? Yeah. Well, it could be, as you mentioned, that it is possible to have a little bit more of androgens and you're stronger. But I cannot really speculate on that. Thank you. My genetics is probably not good enough to ask this, but I wondered if the carriers could be in linkage disequilibrium with another variant of some other gene that would be, would be really conferring the advantages. If you look carefully at the surrounding genes around the 21 lupus to see if it might just be linkage disequilibrium in the carriers to some other variant that's co-linked with it. Yeah, well, I don't think I really understand your question. Yeah, so the heterozygote carriers, the advantage of that allele, could it be because that allele is in this linkage disequilibrium with another gene that is actually conferring the advantage? It could be, but I think that the numbers that we find for the, for the classic mutations for, for both the psychological vulnerability and the mortality rate are pretty convincing. Yes, but yes, yes, I wasn't doubting the association strength. I was just questioning the interpretation because the DNA right around there has other genes. I just wondered how carefully you've looked at the other genes, what's known about them. I know Debbie's looked carefully at a number of them in the region. Just to see if there might be another logical explanation for this that didn't relate to the very subtle, pretty really subtle, whether it's cortisol or everything, these were pretty subtle differences. And also about the differences, and I only say this, I think they all need to be verified in another cohort because I doubt that you corrected for multiple comparisons. It looks like you looked at a lot of different things and you just, it'd be nice to have the same thing looked at in Italy or somebody, or UK, somewhere where there's another registry, just to confirm because it ought to occur in any country. Okay, we're out of time. We've gone a little over. I appreciate, I really want to thank the speakers for this excellent session and for your questions and thank you for attending.

novel therapies

Congenital Adrenal Hyperplasia

hormone imbalances

deficient cortisol

aldosterone

adrenal steroidogenesis inhibitors

glucocorticoid formulations

gene-based therapies

fertility

reproductive disorders

low fertility rate

CYP21A2 deficiency

autosomal recessive disease