46,XX aromatase deficiency: A single-center experience with the varied spectrum and recurrent variants, and a systematic review of hormonal parameters

Ann Endocrinol (Paris). 2024 Feb;85(1):48-55. doi: 10.1016/j.ando.2023.05.010. Epub 2023 Jun 20.


Background: Aromatase deficiency is a rare disorder, with only a few cases reported in India. We describe a single-center experience in western India, with a systematic review of genetically proven 46,XX aromatase deficiency patients to evaluate hormonal parameters.

Methods: Retrospective review of case records, collating phenotypic and genotypic data and molecular modeling. Systematic review of 46,XX aromatase deficiency, analyzing data on gonadotropins, estrogen and androgens.

Results: In the seven patients from our center, presentation was frequent in childhood or adolescence (4/7: delayed puberty or hyperandrogenism), with maternal virilization (4/7), predominance of Prader III/IV (5/7), and initial rearing as females (6/7). Three patients had hypoplastic ovaries. One patient had spontaneous regular menses. We report three novel (p.Arg115Pro, p.Arg192Pro, and c.145+1_145+4delins) and two recurrent variants (p.Val370Met, and c.145+1_145+4delins) in western and northern India, respectively. On systematic review (n=43), gonadotropins were elevated (FSH>LH) across ages (except preterm infants), androgens were elevated in about one-third of cases during childhood and puberty, and estradiol was lower than in controls in mini-puberty and puberty. Spontaneous thelarche and streak ovaries were significantly more frequent in patients with non-truncating and truncating variants, respectively.

Conclusion: We report uncommon presentations with possible founder variants, and highlight hormonal parameters across ages. Serum FSH levels were elevated except in preterms, and can be used as a diagnostic marker.

Keywords: 46,XX; Aromatase deficiency; Hormonal parameters; Novel mutation; Varied presentation.

Publication types

  • Systematic Review

MeSH terms

  • 46, XX Disorders of Sex Development*
  • Adolescent
  • Androgens
  • Aromatase / deficiency*
  • Female
  • Follicle Stimulating Hormone
  • Gonadotropins
  • Gynecomastia*
  • Humans
  • Infant
  • Infant, Newborn
  • Infant, Premature*
  • Infertility, Male*
  • Male
  • Metabolism, Inborn Errors*


  • Androgens
  • Follicle Stimulating Hormone
  • Gonadotropins
  • Aromatase

Supplementary concepts

  • Aromatase deficiency