Androgen backdoor pathway

The androgen backdoor pathway is responsible for the synthesis of physiologically relevant androgens. This process starts with 21-carbon (C
₂₁) steroids, also known as pregnanes, and involves a step called "5α-reduction". Notably, this pathway does not require the intermediate formation of testosterone, hence the term "bypassing testosterone" is sometimes used in medical literature as the hallmark feature of this way of androgen biosynthesis. This feature is a key distinction from the conventional, canonical androgenic pathway, which necessitates the involvement of testosterone as an intermediate in the synthesis of androgens.

These alternate androgen pathways play a crucial role in early male sexual development. In individuals with congenital adrenal hyperplasia due to enzyme deficiencies like 21-hydroxylase or cytochrome P450 oxidoreductase deficiency, these pathways can activate at any age with increased levels of precursors like progesterone or 17α-hydroxyprogesterone. This activation can lead to symptoms of hyperandrogenism such as acne, hirsutism, polycystic ovarian syndrome, or prostate enlargement.

In the canonical pathway, dihydrotestosterone is directly synthesized from testosterone by the enzyme 5α-reductase, primarily in tissues like the prostate gland, hair follicles, and skin. Both pathways rely on 5α-reductase, but in the androgen backdoor pathway, this enzyme acts on C
₂₁ steroids (pregnanes), initiating a series of chemical reactions that eventually lead to dihydrotestosterone production. In contrast, in the canonical pathway, 5α-reductase targets the 4,5-double bond in testosterone, producing dihydrotestosterone directly.

The backdoor pathway was initially described as a biosynthetic route where 5α-reduction of 17α-hydroxyprogesterone ultimately leads to dihydrotestosterone. Since then, several other pathways have been discovered that lead to 11-oxygenated androgens which are also physiologically significant.