5-alpha reductase deficiency is a condition that affects sexual development before birth and during puberty. People with this condition are genetically male, with one X and one Y chromosome in each cell, and they have male gonads (testes). Their bodies, however, do not produce enough of a hormone called dihydrotestosterone (DHT). DHT has a critical role in male sexual development, and a shortage of this hormone disrupts the formation of the external sex organs before birth.

Many people with 5-alpha reductase deficiency are assigned female at birth based on their external genitalia. In other cases, affected infants are assigned male at birth based on their external genitalia, often an unusually small penis (micropenis) and the urethra opening on the underside of the penis (hypospadias). Still other affected infants may be assigned either female or male at birth as their external genitalia do not look clearly male or clearly female.

During puberty, an increase in the levels of male sex hormones leads to the development of some secondary sex characteristics, such as increased muscle mass, deepening of the voice, development of pubic hair, and a growth spurt. The penis and scrotum (the sac of skin that holds the testes) may grow larger. People with 5-alpha reductase deficiency do not develop much facial or body hair. Most affected individuals are unable to have biological children (infertile) without assisted reproduction.

Variants (also called mutations) in the SRD5A2 gene cause 5-alpha reductase deficiency. The SRD5A2 gene provides instructions for making an enzyme called steroid 5-alpha reductase 2. This enzyme is involved in processing androgens, which are hormones that direct male sexual development. Specifically, the steroid 5-alpha reductase 2 enzyme is responsible for a chemical reaction that converts the hormone testosterone to DHT. DHT is essential for the normal development of male sex characteristics before birth, particularly the formation of the external genitalia.

Variants in the SRD5A2 gene prevent steroid 5-alpha reductase 2 from effectively converting testosterone to DHT in the developing reproductive tissues. These hormonal factors underlie the changes in sexual development seen in infants with 5-alpha reductase deficiency.

During puberty, the testes produce more testosterone. Researchers believe that people with 5-alpha reductase deficiency develop secondary male sex characteristics in response to higher levels of this hormone. Some affected people also retain a small amount of 5-alpha reductase 2 activity, which may produce DHT and contribute to the development of secondary sex characteristics during puberty.

Normal Function

The SRD5A2 gene provides instructions for making an enzyme called steroid 5-alpha reductase 2. This enzyme is involved in processing androgens, which are hormones that direct male sexual development. Specifically, the enzyme is responsible for a chemical reaction that converts the hormone testosterone to a more potent androgen, dihydrotestosterone (DHT), in male reproductive tissues.

Testosterone and DHT are essential for the normal development of male sex characteristics. Before birth, testosterone is responsible for the formation of internal male genitalia, including the tubes that collect sperm and carry it out of the testes (the epididymis and vas deferens) and glands that help produce semen (the seminal vesicles). DHT directs the development of the external genitalia, including the penis and scrotum, and the prostate gland. During puberty, these two hormones also play an important role in the development of male secondary sex characteristics such as the growth of facial and body hair, increased muscle mass, and deepening of the voice.

Health Conditions Related to Genetic Changes

5-alpha reductase deficiency

About 50 mutations in the SRD5A2 gene have been identified in people with 5-alpha reductase deficiency. Most of these mutations change single protein building blocks (amino acids) in steroid 5-alpha reductase 2. Some of these genetic changes render the enzyme completely inactive. Other mutations reduce but do not eliminate the enzyme's function.

As a result of SRD5A2 mutations, the body cannot effectively convert testosterone to DHT in reproductive tissues. A shortage of DHT disrupts the formation of external genitalia before birth. People with 5-alpha reductase deficiency are genetically male, with one X and one Y chromosome in each cell, but they may be born with external genitalia that look female-typical, or that are not clearly male or clearly female. Other affected infants have external genitalia that appear male-typical, but they often have an unusually small penis (micropenis) and the urethra opening on the underside of the penis (hypospadias).

During puberty, the testes produce more testosterone. Researchers believe that people with 5-alpha reductase deficiency develop secondary male sex characteristics in response to higher levels of this hormone. Some affected people also retain a small amount of 5-alpha reductase 2 activity, which may produce DHT and contribute to the development of secondary sex characteristics during puberty.

Prostate cancer

Certain normal variations (polymorphisms) in the SRD5A2 gene may be associated with prostate cancer. Two of these polymorphisms have been studied extensively. The most common variation replaces the amino acid valine with the amino acid leucine at position 89 in steroid 5-alpha reductase 2 (written as Val89Leu or V89L). The other variation replaces the amino acid alanine with the amino acid threonine at position 49 in the enzyme (written as Ala49Thr or A49T). Some studies have suggested that these variations are associated with an increased risk of developing prostate cancer or having a more aggressive form of the disease. Other studies, however, have not shown these associations. It remains unclear what role SRD5A2 polymorphisms play in prostate cancer risk.

Some gene mutations are acquired during a person's lifetime and are present only in certain cells. These changes, which are called somatic mutations, are not inherited. Studies have shown that somatic SRD5A2 mutations in prostate cancer cells may be associated with the progression of prostate cancer. These mutations may increase the activity of steroid 5-alpha reductase 2, which would raise the levels of DHT in prostate tissue. Research has shown that androgens such as DHT can stimulate prostate cancer growth.

Other disorders

In women, certain polymorphisms in the SRD5A2 gene may affect the risk of developing a condition called polycystic ovary syndrome (PCOS). PCOS is characterized by a hormonal imbalance that can lead to irregular menstruation, acne, excess body hair (hirsutism), and weight gain. Some genetic variations increase the activity of steroid 5-alpha reductase 2 in the ovaries, which could contribute to the signs and symptoms of this condition. Other variations, including the common polymorphism Val89Leu, reduce the activity of steroid 5-alpha reductase 2 and are associated with a reduced risk of developing PCOS.

Other Names for This Gene

• 3-oxo-5 alpha-steroid 4-dehydrogenase 2
• 5 alpha-SR2
• MGC138457
• S5A2_HUMAN
• SR type 2
• steroid 5-alpha-reductase 2
• steroid-5-alpha-reductase, alpha polypeptide 2 (3-oxo-5 alpha-steroid delta 4-dehydrogenase alpha 2)
• Type II 5-alpha reductase

Genomic Location

5-alpha reductase deficiency is a rare condition; the exact incidence is unknown. Large families with affected members have been found in several countries, including the Dominican Republic, Papua New Guinea, Turkey, and Egypt.

This condition is inherited in an autosomal recessive pattern, which means both copies of the SRD5A2 gene in each cell must have a variant to cause the disorder. The parents of an individual with an autosomal recessive condition each carry one copy of the altered gene, but they typically do not show signs and symptoms of the condition.

Although people who are genetically female (with two X chromosomes in each cell) may inherit variants in both copies of the SRD5A2 gene, their sexual development is not affected. The development of female sex characteristics does not require DHT, so a lack of steroid 5-alpha reductase 2 activity does not cause physical changes in these individuals. Only people who have variants in both copies of the SRD5A2 gene and are genetically male (with one X and one Y chromosome in each cell) will have the characteristic signs of 5-alpha reductase deficiency.