AKR1D1 (steroid 5-reductase) reduces all ⌬
4-3-ketosteroids to form 5-dihydrosteroids, a first step in the clearance of steroid hormones and an essential step in the synthesis of all bile acids. The reduction of the carbon-carbon double bond in an ␣,-unsaturated ketone by 5-reductase is a unique reaction in steroid enzymology because hydride transfer from NADPH to the -face of a ⌬ 4 -3-ketosteroid yields a cis-A/B-ring configuration with an ϳ90°b end in steroid structure. Here, we report the first x-ray crystal structure of a mammalian steroid hormone carbon-carbon double bond reductase, human ⌬
120. The Y58F and E120A mutants are devoid of activity, supporting a role for this dyad in the catalytic mechanism. Intriguingly, testosterone binds nonproductively, thereby rationalizing the substrate inhibition observed with this particular steroid. The locations of disease-linked mutations thought to be responsible for bile acid deficiency are also revealed.