DHT plays a critical function in the sexual development of males, beginning early in prenatal life. The role of DHT differs as males progress through the different stages of development. It has various impacts on their physiology during childhood, puberty, and even throughout adult life.

Prenatal:

During sexual development, various embryological structures develop under the influence of a variety of genes and hormones. A specific and unique environment of hormones results in male or female differentiation of structures. In males, testosterone, anti-mullerian hormone (AMH), and DHT act in concert to inhibit female differentiation and promote the development of the male phenotype. DHT is essential for the formation of the male external genitalia. The testicular Leydig cells produce testosterone under the influence of placental human chorionic gonadotropin by around day 60 of prenatal development. The luteinizing hormone (LH) from the fetal pituitary takes over the production of testosterone by roughly week 16. The peripheral 5-alpha-reductase type 2 converts circulating fetal testosterone to DHT, which is responsible for proper male differentiation of the urogenital sinus, the genital tubercle, urogenital fold, and labio-scrotal folds. This activity leads to the formation of the penis, scrotum, and prostate. DHT, along with insulin-like factor 3 (INSL3), helps stimulate gubernacular growth required for testicular descent. The absence of DHT may lead to ambiguous male external genitalia and undescended testis. Sex steroids accumulate from testicular production of testosterone in the male fetus and placental production of estrogen in both sexes, causing negative feedback on fetal pituitary, which helps control gonadotropin levels in the womb.

Childhood:

The loss of placental estrogen after birth removes negative feedback on the hypothalamic-pituitary-gonadal (HPG) axis, which results in a transient increase in its activity in both sexes for the first few months of life. In males, this promotes a rise in testosterone levels and, therefore, DHT. The negative feedback on the HPG axis recovers by six months of age, and the levels of sex hormones remain low until adrenarche.

Adrenarche typically occurs around six years of age in both sexes. The adrenal gland develops a new layer, the zona reticularis. This layer of the adrenal gland produces androgens, including testosterone, which increases systemic testosterone, leading to the development of sebaceous and apocrine glands, contributing to the development of minor acne and body odor. Testosterone production continues to increase as the zona reticularis continues to mature. There is enough peripheral conversion of testosterone into DHT by age 10 to result in pubic hair development. These events of adrenarche are distinct from puberty though they often coincide.

Puberty:

An increase in the activity of the HPG axis characterizes the onset of puberty. Hypothalamic secretion of gonadotropin-releasing hormone (GnRH) increases, stimulating pituitary LH secretion, which increases testosterone production from the testes. The increase in systemic testosterone is associated with a significant conversion to DHT at its target tissues. This DHT promotes further growth and maturation of the penis and scrotum. DHT is also the primary androgen responsible for facial hair, body hair, pubic hair, and prostate growth. The circulating level of DHT in the blood is only 10% of the circulating level of testosterone. However, the DHT level can be as much as ten times greater than testosterone due to its isolated production in peripheral tissues.[2]

Adult:

DHT does not play a significant role in the normal physiology of adults. The most notable effects are prostate enlargement and male pattern hair loss as they age.[5]

The effects of DHT are mediated through the intracellular androgen receptor. It passes through the cell membrane and binds to the androgen receptor in the cytoplasm of the cell. This interaction initiates a cascade leading to the transport of the ligand-androgen receptor complex to the nucleus, where it acts as a transcription factor to alter gene expression.[1]

DHT levels are useful in the diagnosis of 5-alpha-reductase deficiency and male-pattern baldness. The elevated testosterone-to-DHT ratio is a diagnostic of 5-alpha-reductase deficiency. The test is done during early infancy or puberty when the HPG axis is active. The axis becomes stimulated with the administration of hCG in the period between infancy and puberty. The serum DHT level does not directly correlate with the production in peripheral tissues. Its level increases to near-normal following puberty due to the activity of functional 5-alpha-reductase type 1 enzymes. A definitive diagnosis requires genetic testing to identify the aberration. The utility of DHT levels in diagnosing male-pattern alopecia is controversial, with no statistical significance or correlation of DHT levels with the progression of baldness.[6]

The variations in dihydrotestosterone levels are associated with various pathological conditions. These conditions usually affect people in different stages of life.

5-alpha-reductase deficiency:

The 5-alpha-reductase enzyme is involved in the production of DHT. The enzyme deficiencies are an autosomal recessive condition, typically arising due to loss-of-function mutations in the gene encoding 5-alpha-reductase type 2.[7] Males born with a 5-alpha-reductase deficiency have underdeveloped genitalia, undescended functional testes, and a small or absent prostate. The development of the testes and the internal organs of sexual differentiation are unaltered. The presentation is variable depending on the enzyme level. In severe cases, the infants have external genitalia that appears typical for a female, and hence, are raised as one. They have a small clitoris-like penis, with an unfused scrotum appearing as labia, and a short, blind-ending vagina. DHT levels are about 30% of their normal values. Testosterone and AMH, however, are produced normally, maintaining the mesonephric duct, and inhibiting the paramesonephric duct, respectively. The testes continue to develop normally, but due to the lack of DHT, they fail to descend. At the onset of puberty, the patients have a rapid increase in testosterone production from the testicles leading to the development of many secondary sexual characteristics. Their voice deepens, testes may descend, muscle mass increases, and the penis enlarges. Although DHT is involved in some of these processes at puberty, testosterone levels are sufficiently elevated to induce these changes without its influence, though they remain undervirilized in other ways. Facial hair growth is greatly diminished, and pubic hair grows in a typical female pattern. The prostate does not develop normally. The patients ultimately develop male gender identity and a sexual preference for females. These individuals can become fertile with a surgery correcting the male ductal system. Female development is largely unimpacted by a congenital 5-alpha-reductase deficiency. Normal female development is not dependent on significant DHT activity. The low DHT levels may lead to reduced body hair growth and a mild decrease in pubic hair.

Androgen deficiency:

Testosterone is the primary hormone used in androgen-deficiency states like male hypogonadism, androgen deficiency of severe illness, androgen deficiency of aging, and microphallus in infancy. DHT has also been proposed as a treatment for androgen deficiency as it is a pure androgen and does not convert to estrogen. A potential advantage of DHT over testosterone is the reported and seemingly paradoxically muted effects of DHT on prostate growth. The decreased effect of DHT on the prostate gland of humans may be due to the decrease in intraprostatic estradiol levels.[8]

5-alpha-reductase inhibitors:

5-alpha-reductase inhibitors are useful in the treatment of conditions that have excessive DHT activity. The conditions include benign prostatic hyperplasia (BPH), prostate cancer, androgenic alopecia (male pattern hair loss), and hirsutism. These drugs work by inhibiting the 5-alpha-reductase enzymes, thereby reducing DHT production in tissues.[9] The most common drugs are finasteride and dutasteride. Finasteride inhibits only 5-alpha-reductase type 2, while dutasteride inhibits both type 1 and type 2 isoforms of the enzyme. Generally, the drugs are well tolerated, though they may diminish libido and sexual function.[9]

Benign Prostatic Hyperplasia:

The prostate has a significant 5-alpha-reductase type 2 activity, producing large amounts of the potent DHT. This local DHT stimulates normal activity but also commonly induces hypertrophy and hyperplasia of the prostate. More than 50% of men over the age of 50 have some degree of BPH.[10] The increase in prostate growth is likely due to increased local production of DHT, or increased activity of its receptor.[10] The patients may experience symptoms such as difficulty urinating and sexual dysfunction due to increased prostate growth.

The treatment of BPH mainly involves the administration of alpha-1 adrenergic antagonists. But in some patients, 5-alpha-reductase inhibitors, such as finasteride and dutasteride, are indicated. These drugs are effective in reducing the size of the prostate and relieving symptoms associated with BPH.[9]

Prostate Cancer:

Prostate cancer also characteristically demonstrates an increase in the activity of DHT. There is an upregulation in all three isoforms of the 5-alpha reductase enzyme. The mutations in genes result in uncontrolled proliferation and inhibition of apoptosis, which are related to pathways involving DHT.[11] The mutations in the androgen receptor also have implications in many cases of prostate cancer.

The 5-alpha-reductase inhibitors: finasteride and dutasteride are effective in treating and decreasing the risk of prostate cancer.[11] Though several clinical trials have demonstrated an overall decrease in prostate cancer incidence with these drugs, patients undergoing these therapies have increased rates of higher-grade cancers.[11]

Male Androgenic Alopecia (MAA):

Male androgenic alopecia is commonly known as male pattern hair loss. It is a form of hair loss occurring commonly on the top and frontal region of the scalp that recedes progressively. Increased DHT activity is responsible, amongst other factors, in the pathology of androgenic alopecia.[6] Men with androgenic alopecia are genetically predisposed to higher 5-alpha-reductase enzyme levels and androgen receptor activity at the hair follicles.[12] Similarly, patients with enzyme deficiency are less likely to be prone to male androgenic alopecia.[12]

The oral 5-alpha-reductase inhibitors, such as finasteride, are very effective in slowing or even reversing this pattern of hair loss. In two large randomized controlled trials, approximately 99% of participants showed either a decrease in or reversal of hair loss.[13] The other first-line therapy for treating MAA is topical minoxidil, an arterial vasodilator.

Polycystic ovarian syndrome (PCOS):

DHT has a negligible role in regulating the normal female physiology. However, there are implications in the pathophysiology of the PCOS. It is known to cause an increase in body weight, body fat, serum cholesterol, and adipocyte hypertrophy in experimental mice.[14] Surprisingly, the administration of prenatal DHT in experimental female mice does not induce penile formation.[15]