The reproductive endocrine system in cystic fibrosis. I. Basal gonadotropin and sex steroid levels

Factors associated with pubertal growth outcomes in cystic fibrosis: Early Growth and Puberty in CF

BACKGROUND

Pubertal delays in children with cystic fibrosis (CF) have historically been common. It is unclear to what degree puberty is affected in the new era of CF care or the role of early nutritional status. We hypothesized that more favorable early growth trajectories are associated with improved pubertal growth outcomes.

METHODS

We used data from the United States CF Foundation Patient Registry to analyze associations between early weight-for-length/body mass index (WFL-BMI) growth trajectories and pubertal outcomes, using peak height velocity (PHV) and age at PHV (APHV) as proxy measures for puberty in addition to adult height (defined as height at age 18 years). Our analysis consisted of shape invariant mixed modeling and multivariable linear regression.

RESULTS

Our sample consisted of 9,186 people with CF aged 18 to 21 years between 2010-2019. APHV was earliest and PHV/adult height were highest in those with WFL-BMI always >50th percentile from 0-6 years. However, there was no difference after adjusting for key covariates. Receiving CF transmembrane conductance regulator (CFTR) modulator therapy in childhood was associated with being taller at 18 years, by 0.92 cm in males (p=0.048) and 1.02 cm in females (p=0.010) in adjusted models. Higher height z-score at 2 years was associated with improved APHV and PHV for males and improved adult height for both males and females (p<0.001) in adjusted models.

CONCLUSIONS

Early height, but not early WFL-BMI trajectories, may be associated with pubertal growth outcomes. CFTR modulator therapy shows the potential to improve pubertal growth outcomes, but further research is necessary.

Auxological and Endocrinological Features in Children and Adolescents with Cystic Fibrosis

Cystic fibrosis (CF) is a multisystem autosomal recessive disease caused by mutations that lead to deficient or dysfunctional CF transmembrane conductance regulator (CFTR) proteins. Patients typically present malnutrition resulting from the malabsorption of fundamental nutrients and recurring lung infections, with a progressive worsening of the respiratory function. For these reasons, the clinical management of CF requires a multidisciplinary team. From an endocrinological point of view, patients often present major complications, such as diabetes, bone disease, thyroid disorders, delayed growth and puberty, hypogonadism and infertility, which negatively affect their quality of life and, in some cases, significantly reduce life expectancy. These complications can arise as a direct result of CFTR dysfunction and/or as a consequence of a deterioration in the function of the organs affected. The objective of this review is to analyze all the possible endocrinological complications that can occur in patients with CF by evaluating the most recent papers in the literature.

Use of estrogen supplementation is associated with higher quality of life scores in women with cystic fibrosis

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Supplemental estrogen was associated with higher quality of life scores in women with CF.

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Women with CF used estrogen for menses regulation, contraception & menstrual symptoms.

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Regardless of estrogen supplementation, women with CF had similar mobility scores.

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Women with CF using estrogen had similar rates of sexual dysfunction to those not using estrogen.

The association of estrogen supplementation use and quality of life in women with cystic fibrosis (CF) is not well characterized. In this cross-sectional study, women with CF completed quality of life questionnaires during a routine CF clinic visit. The use of estrogen supplementation was associated with higher quality of life scores in all domains of the CF questionnaire-revised (CFQ-R) and was significant in the role limitations and respiratory domains. Most participants who were not currently using estrogen supplementation had previously used estrogen supplementation. Most participants had used estrogen to regulate menses, prevent pregnancy and control symptoms around menses. Use of estrogen supplementation was not associated with differences in life-space mobility or screening for sexual dysfunction. This is the largest study to date investigating the association of estrogen supplementation and quality of life in women with CF. Prospective randomized studies are needed to clarify the association of estrogen supplementation and quality of life in women with CF.

Most Short Children with Cystic Fibrosis Do Not Catch Up by Adulthood

Poor linear growth is common in children with cystic fibrosis (CF) and predicts pulmonary status and mortality. Growth impairment develops in infancy, prior to pulmonary decline and despite aggressive nutritional measures. We hypothesized that growth restriction during early childhood in CF is associated with reduced adult height. We used the Cystic Fibrosis Foundation (CFF) patient registry to identify CF adults between 2011 and 2015 (ages 18–19 y, n = 3655) and had height for age (HFA) records between ages 2 and 4 y. We found that only 26% CF adults were ≥median HFA and 25% were <10th percentile. Between 2 and 4 years, those with height < 10th percentile had increased odds of being <10th percentile in adulthood compared to children ≥ 10th percentile (OR = 7.7). Of HFA measured between the 10th and 25th percentiles at ages 2–4, 58% were <25th percentile as adults. Only 13% between the 10th and 25th percentile HFA at age 2–4 years were >50th percentile as adults. Maximum height between ages 2 and 4 highly correlated with adult height. These results demonstrate that low early childhood CF height correlates with height in adulthood. Since linear growth correlates with lung growth, identifying both risk factors and interventions for growth failure (nutritional support, confounders of clinical care, and potential endocrine involvement) could lead to improved overall health.

Findings from a feasibility study of estradiol for hypogonadal women with cystic fibrosis-related bone disease

Background

Advancements in therapies for patients with cystic fibrosis (CF) have decreased mortality, leading to increased prevalence of chronic complications including bone disease. CF-related bone disease (CFBD) is characterized by low bone mineral density (BMD) and fragility fractures. Estrogen deficiency increases bone resorption, resulting in decreased BMD that can be restored with estrogen replacement. Current CF guidelines recommend treating female hypogonadal patients with CFBD with estrogen replacement, but no prospective study has investigated the effects of estrogen supplementation on CFBD. Estrogen is known to modulate inflammatory markers and autoimmune diseases.

We proposed to test the hypothesis that estrogen status plays a critical role in optimizing bone health, modulating inflammation, preserving lung function, and maximizing quality of life in premenopausal women with CF.

Methods

We planned a randomized, placebo-controlled, investigator- and patient-blinded, pilot trial with two parallel arms. Eligible subjects were women with CF 18–50 years old with hypogonadism and low BMD who were not taking systemic glucocorticoids, had not had a prior transplant, and did not have contraindications to oral estradiol. Subjects would be block randomized to receive oral estradiol or placebo for 6 months. The primary outcome was feasibility metrics. Secondary outcomes included relative changes in estradiol, bone turnover markers, lung function, inflammatory markers, and quality of life metrics. The study was funded through departmental funds.

Results

Of 233 subjects screened, 86 subjects were women with CF 18–50 years old and none were eligible for participation. Most subjects were excluded due to absent DXA report (24%), normal BMD (22%), or use of systemic estrogen (16%). Due to difficulty recruiting the planned 52 subjects, the trial was closed for recruitment and no subjects were randomized.

Conclusion

This study was designed to investigate the feasibility of a safety and efficacy trial of estrogen therapy for women with CF. Unfortunately, due to eligibility criteria, the study was unable to recruit subjects. This feasibility study highlights the need for improved BMD screening in young women with CF. Future study designs may require the incorporation of a screening DXA as part of subject recruitment.

Trial registration

The study was registered on ClinicalTrials.gov (NCT03724955).

Female reproductive health in cystic fibrosis

Women with cystic fibrosis (CF) are living longer and healthier lives, and opportunities for childbearing are increasingly promising. However, this population can also face sexual and reproductive health concerns, including menstrual irregularities, unplanned pregnancies, infertility and pregnancy complications. Additionally, more women are entering menopause and are at risk for the consequences of estrogen deficiency. The exact mechanisms involved in female reproductive health conditions in CF are not clearly understood, but are thought to include cystic fibrosis transmembrane regulator (CFTR)-mediated abnormalities, changes in female sex hormones, and other CF health-related factors. In the era of CFTR modulator therapy, new data are necessary to understand the impact of CFTR modulation on contraceptive effectiveness, fertility, and pregnancy outcomes to help guide future clinical care. This article reviews the current scientific knowledge of major reproductive health issues for women with CF.

Gender differences in bronchiectasis: a real issue?

Gender differences in chronic respiratory disease, including cystic fibrosis and non-cystic fibrosis bronchiectasis are clinically apparent and of increasing importance. Differences in disease prevalence, severity and outcome are all described, however, the precise cause of the gender dichotomy and their associated underlying mechanisms have been poorly characterised. A lack of dedicated clinical and epidemiological research focused in this area has led to a paucity of data and therefore a lack of understanding of its key drivers. Diagnosis, disease pathogenesis and treatment response are all complex but important aspects of bronchiectasis with an evident gender bias. Broadening our understanding of the interplay between microbiology, host physiology and the environment in the context of chronic lung diseases, such as bronchiectasis, is critical to unravelling mechanisms driving the observed gender differences. In this review, epidemiological, biological and environmental evidence related to gender in bronchiectasis is summarised. This illustrates gender differences as a “real issue” with the objective of mapping out a future framework upon which a gender-tailored medical approach may be incorporated into the diagnosis, monitoring and treatment of bronchiectasis.

CF and non-CF bronchiectasis are complex multifactorial chronic pulmonary diseases demonstrating gender differences in their prevalence, severity and infections, some of which are attributable to sex hormoneshttp://ow.ly/beDf30jseK4

Sex differences in statural growth impairment in Crohn's disease: role of IGF-1

BACKGROUND

Growth impairment in Crohn's disease (CD) is more common in males than females for unknown reasons. Since insulin-like growth factor-1 (IGF-1) is important for statural growth, we hypothesized that IGF-1 levels are lower in males with CD.

METHODS

Sex differences in hormone Z-scores based on chronological age (CA-Z) and bone age (BA-Z) were examined in a cross-sectional study of 82 CD patients <21 years of age (43% female).

RESULTS

IGF-1 CA-Z and BA-Z-scores were 0.50 units (P = 0.04) and 1.24 units (P = 0.003) lower in males. Mean bone age (12.2 years) was lower than chronological age (13.1 years) (P < 0.0001). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and albumin did not differ by sex (P ≥ 0.08), but were associated with IGF-1 CA-Z and BA-Z-scores (P ≤ 0.02). Insulin-like growth factor binding protein-3 (IGFBP-3) CA-Z and BA-Z-scores were 0.71 units (P = 0.004) and 1.26 units (P < 0.001) lower in males. Inflammatory markers were correlated with sex hormone CA-Z and BA-Z and pituitary hormone BA-Z-scores in males (P ≤ 0.03), but not females (P ≥ 0.25). IGF-1 BA-Z-scores were positively associated with height BA-Z-scores (P = 0.03). Mean height BA-Z-scores were lower in males (P = 0.03).

CONCLUSIONS

Lower IGF-1 levels in males may explain sex differences in growth impairment in CD. Inflammation appears to more adversely affect hormone levels and statural growth in males. Prospective longitudinal studies are needed to further clarify the role of IGF-1 in sex differences in statural growth impairment in pediatric CD.

Cystic fibrosis Δf508 mutation screening in Brazilian women with altered fertility

Cystic Fibrosis (CF) is an autosomal recessive disease, caused by mutations in the Cystic Fibrosis Transmembrane Regulator gene (CFTR). The most frequent mutation in CF is ΔF508. The disease is clinically characterized by elevated concentrations of sweat chlorides and abnormally thick mucus. It affects organs such as lung, pancreas, gastrointestinal and reproductive tract. Women with CF commonly present delayed puberty and amenorrhea due to malnutrition. Our objective was to screen the presence of ΔF508 mutation in 24 women with altered fertility. Nine of these women presented reduced fertility without a known cause, four showed polycystic ovaries and two had early menopause. One woman with early menopause was a carrier of the ΔF508 mutation. Our study demonstrates that it is possible that the frequency of CF mutations among patients with altered fertility may be higher than expected. Previous data showed that fibrocystic women can show reduced fertility, maternal mortality associated with pregnancy and increased incidence of spontaneous abortion. We therefore recommend that women with reduced fertility undertake genetic tests for a better evaluation of pregnancy risks and clinical monitoring.

Fertility in men with cystic fibrosis assessment, investigations and management

Congenital absence of the vas deferens is the primary cause of azoospermia in men with cystic fibrosis [CF]. In some there may also be an abnormality in spermatogenesis and sperm maturation. Despite these abnormalities, sperm capable of fertilizing mature oocytes in vitro can be extracted from the majority of men with cystic fibrosis. Experience at Westmead Hospital over the last 12 years has shown mature spermatozoa can be obtained by a simple percutaneous needle aspiration of the epididymis or testis after local anaesthetic has been infiltrated around the spermatic chord. This procedure has been successfully repeated up to six times in some men. Epididymal or testicular sperm can be used to fertilize mature oocytes by intracytoplasmic injection in vitro. All offspring resulting from such procedures will be CF carriers and to reduce the probability this will result in a child with CF it is important the female partner has pre-treatment screening for CF mutations.

Murine model for cystic fibrosis bone disease demonstrates osteopenia and sex-related differences in bone formation

As the incidence of cystic fibrosis (CF) bone disease is increasing, we analyzed CF transmembrane conductance regulator (CFTR) deficient mice (CF mice) to gain pathogenic insights. In these studies comparing adult (14 wk) CF and C57BL/6J mice, both bone length and total area were decreased in CF mice. Metaphyseal trabecular and cortical density were also decreased, as well as diaphyseal cortical and total density. Trabecular bone volume was diminished in CF mice. Female CF mice revealed decreased trabecular width and number compared with C57BL/6J, whereas males demonstrated no difference in trabecular number. Female CF mice had reduced mineralizing surface and bone formation rates. Conversely, male CF mice had increased mineralizing surface, mineral apposition, and bone formation rates compared with C57BL/6J males. Bone formation rate was greater in males compared with female CF mice. Smaller bones with decreased density in CF, despite absent differences in osteoblast and osteoclast surfaces, suggest CF transmembrane conductance regulator influences bone cell activity rather than number. Differences in bone formation rate in CF mice are suggestive of inadequate bone formation in females but increased bone formation in males. This proanabolic observation in male CF mice is consistent with other clinical sex differences in CF.

Deficits in bone mineral content in children and adolescents with cystic fibrosis are related to height deficits

Despite reports of decreased bone density, children with mild to moderate cystic fibrosis (CF)-associated pulmonary disease do not have increased fracture rates. Short stature and delayed puberty complicate interpretations of bone mineral status in many children with chronic diseases. This study sought to characterize bone mineral content (BMC) in children with CF and determine its relationship to growth, body composition, and disease severity. Dual-energy X-ray absorptiometry measurements of whole body BMC (WB-BMC), spine BMC (Sp-BMC), and lean body mass (LBM) were converted to Z-scores in 82 CF and 322 healthy children. Effects of growth, body composition, and CF-disease characteristics on BMC were determined using linear regression. Children with CF had lower weight, height (HT), BMI, and LBM-Z. Females with CF had lower (p<0.001) WB-BMC-Z (-1.1+/-1.1) and Sp-BMC-Z (-0.9+/-1.1) than controls. Following adjustment for height standard deviation score (HT-Z), deficits were absent. Males with CF had lower (p<0.001) WB-BMC-Z (-1.3+/-0.9) and Sp-BMC-Z (-0.9+/-1.3). Following adjustment for HT-Z, WB-BMC-Z deficits were attenuated and Sp-BMC-Z deficits absent. HT-Z, LBM-Z, and pulmonary function had independent effects on WB-BMC-Z and Sp-BMC-Z. BMC deficits are related to altered body size, reduced LBM, and pulmonary function in children with CF. Interventions targeting improved growth, muscle mass, and pulmonary function may benefit bone health in CF.

Infertility in females with cystic fibrosis is multifactorial: evidence from mouse models

Infertility is commonly associated with cystic fibrosis (CF). Although infertility in men with CF has been thoroughly investigated, the infertility observed in women with CF has not been well studied. To investigate female infertility associated with CF, we used two independently derived mouse models of CF. Both of these models displayed decreased fertility characterized by a reduction in litter number and litter size. Our findings suggest that much of the reduced fertility in these mice originates from decreased fertilization due to inadequate sperm transport within the female reproductive tract. However, our data indicate that additional reproductive phenotypes in the CF female mice also contribute to the reduced fertility including small ovarian and uterine size, aberrant estrous cycles, and decreased oocyte ovulation rates. These data, along with previous work demonstrating that the gene mutated in CF, the cystic fibrosis transmembrane conductance regulator (CFTR), is normally expressed in tissues vital to reproduction, raises the possibility that CFTR may have a direct effect on fertility. If so, CFTR may also play an important role in normal female fertility within the general population.

Controlled longitudinal study of bone mass accrual in children and adolescents with cystic fibrosis

BACKGROUND

A study was undertaken to observe the gains in bone mass in children and adolescents with cystic fibrosis (CF) over 24 months and to examine the relationship between areal bone mineral density (aBMD) and associated clinical parameters including physical activity, nutrition, and 25-hydroxyvitamin D (25OHD).

METHODS

Areal BMD of the total body (TB), lumbar spine (LS), and total femoral neck (FNt) were repeatedly measured in 85 subjects aged 5-18 years with CF and 100 age and sex matched controls over 2 years. At each visit anthropometric variables, nutritional parameters, pubertal status, disease severity, physical activity, dietary calcium, caloric intake, and serum 25OHD were assessed and related to aBMD.

RESULTS

After adjusting for age, sex, and height Z-score, gains in LS aBMD in children (5-10 years) and TB and FNt aBMD in adolescents (11-18 years) with CF were significantly less than in controls. Lean tissue mass was significantly associated with TB and LS aBMD gains in children and adolescents and explained a significant proportion of the aBMD deficit observed. Lung function parameters were significantly associated with aBMD gains in adolescents with CF.

CONCLUSIONS

Inadequate bone mass accrual during childhood and adolescence contributes to the low bone mass observed in adults with CF. Accounting for the height discrepancy which is frequently observed in those with CF, in addition to age and sex, is important when assessing low bone mass in children and adolescents with CF. To optimise an individual's potential to acquire maximal bone mass, it is necessary to maximise nutritional status and limit the progression of chronic suppurative lung disease.

Pubertal development and its influences on bone mineral density in Australian children and adolescents with cystic fibrosis

BACKGROUND

Pubertal delay is thought to contribute to suboptimal peak bone mass acquisition in young people with cystic fibrosis (CF), leading to an increased fracture incidence. This study aims to compare pubertal development in young people with CF with that of a local healthy population and assess the influence it has on areal bone mineral density (aBMD).

METHODS

Tanner stage, age of menarche, bone age (BA), sex hormone levels and aBMD were examined in 85 individuals with CF (aged 5.3-18.1 years, 39 females) and 100 local controls (5.6-17.9 years, 54 females).

RESULTS

Tanner stage and age of menarche were not significantly different between controls and CF. Tanner stage-adjusted mean values for follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) were lower in males with CF (FSH: P = 0.004, LH: P = 0.01 and T: P = 0.002). Bone age was delayed in adolescents with CF compared to controls (chronological age-BA: controls = 0.13 years (SE = 0.16), CF = 0.95 years (SE = 0.22), P = 0.003). Areal bone mineral density (adjusted for age, sex, height and lean tissue mass) was not significantly different between CF and controls. Moderate negative correlations were found between delayed BA and weight (r = -0.41, P < 0.001) and height (r = -0.41, P < 0.001).

CONCLUSIONS

There was no evidence of clinical pubertal delay or low aBMD (adjusted for short stature and lean tissue mass) in young people with CF when compared with a local population, despite lower nutritional markers, height and weight and delayed skeletal maturation.

Calcium kinetics are altered in clinically stable girls with cystic fibrosis

Reduced bone mass in individuals with cystic fibrosis (CF) may result from alterations in calcium metabolism. Bone calcium deposition and resorption rates, calcium balance, and markers of bone turnover were assessed using stable isotopes of calcium in 22 prepubertal and pubertal girls with CF. Bone calcium deposition was associated with the availability of dietary calcium, total serum osteocalcin, and leptin concentrations. Reduced bone mass in individuals with CF may result from inadequate bone calcium (Ca) deposition, and excessive resorption, although these parameters have not been directly assessed in children with CF. We used stable Ca isotopes to measure rates of bone Ca deposition (Vo+), resorption, and retention in 22 clinically stable girls with CF (aged 7-18 yr). Rates of bone Ca deposition were determined by mathematically modeling the disappearance of iv Ca stable isotope ((42)Ca) for 6 d post dosing. Indirect markers of bone turnover and hormones associated with pubertal development were also assessed. Rates of bone Ca deposition and retention were highest during early puberty (Tanner stages 2 and 3). Calcium deposition rates in prepubertal (Tanner 1) and postmenarchal girls (Tanner stages 4 and 5) did not support substantial bone Ca retention. Net absorption of dietary Ca and serum osteocalcin and leptin concentrations were positively associated with Vo+. Time post menarche and serum leptin concentrations explained 91% of the variability in Vo+ (P = 0.0007). Serum total osteocalcin was low (10.9 +/- 5.4 ng/ml), and a substantial percentage of osteocalcin was undercarboxylated (54.3 +/- 11.8%). We concluded that increased calcium absorption and serum leptin concentrations were significantly associated with rates of bone Ca deposition, demonstrating an impact of nutritional status on this process. Rates of bone Ca deposition were lower than typically reported in healthy children, as were indirect markers of bone formation. These alterations in bone turnover contribute to reduced bone mass in girls with CF.

Low bone mineral density in cystic fibrosis patients

The goals of this practice-based, observational study were to describe the prevalence of low bone mineral density in patients at the Edmonton Cystic Fibrosis Centre, and to determine if body mass index and previous systemic corticosteroid use of over one month's duration were predictors of low bone mineral density. One hundred and thirteen pediatric and adult patients were studied. Bone mineral density of the lumbar spine region was measured using dual-energy X-ray absorptiometry. A total of 42.5% of patients had a bone mineral density Z-score of less than -1 standard deviation. Low bone mineral density was apparent at nine to 12 years of age, and was most evident in the 20- to 34-year-old group. All but one patient under age 20 with a Z-score of less than -2.5 also had a body mass index below the fifth percentile. A low Z-score was also associated with previous systemic corticosteroid use of over one month's duration (relative risk 1.81, p=0.003). We conclude that low bone mineral density is common in cystic fibrosis patients. Low body mass index percentiles may be used to identify children and adolescents at risk of low bone mineral density. These patients may benefit from aggressive nutrition therapy. Systemic corticosteroid use should be assessed carefully, as it is a risk factor for low bone mineral density.

The outcome of 72 pregnancies in 55 women with cystic fibrosis in the United Kingdom 1977-1996

OBJECTIVE

To identify pregnancies in women with cystic fibrosis and describe obstetric, infant and maternal medical outcomes in relation to the severity of maternal disease.

DESIGN

Retrospective study, based on casenotes.

SETTING

Eleven cystic fibrosis centres in the United Kingdom.

POPULATION

Pregnant women with cystic fibrosis.

METHODS

Single observer medical and obstetric casenote review categorising maternal cystic fibrosis (e.g. genotype, pancreatic, hepatic and diabetic status) and pre-pregnant severity (e.g. weight and lung function) and noting fetal outcome and maternal morbidity.

MAIN OUTCOME MEASURES

Completed pregnancies and pregnancy losses, fetal outcome and complications, maternal morbidity, such as changes in weight, lung function, pulmonary infections during and after pregnancy. Relation of outcomes to severity of maternal cystic fibrosis.

RESULTS

From 72 pregnancies identified, the outcomes were known for 69; there were 48 live births (70%) of which 22 were premature (46%); 14 therapeutic abortions (20%); and 7 miscarriages (10%). There were no stillbirths, neonatal or early maternal deaths. Three major fetal anomalies were seen, but no infant had cystic fibrosis. At the conclusion of our study three pregnancies were still continuing. Prematurity with increased fetal complications and maternal morbidity with infection, declining lung function and poor weight gain were associated with poor pre-partum lung function.

CONCLUSION

Pregnancy occurs in women with cystic fibrosis of all degrees of severity. Outcomes for the infant are generally good but are variable for the mother. Predicting outcome on the basis of maternal severity is difficult but lung function appears to be the most significant determining factor. Pregnancy may be normal in women with normal lung function (forced expiratory volume > 80%). However, it may adversely affect mild and moderate lung disease due to cystic fibrosis and should be avoided in pulmonary hypertension, cor pulmonale and when forced expiratory volume < 50% predicted. Ideally, all pregnancies should be planned with prior counselling and monitored by dedicated cystic fibrosis teams, including obstetricians who are experienced in managing high risk pregnancies.

Osteoporosis: a new challenge in cystic fibrosis

The increased life expectancy of patients with cystic fibrosis (CF) may lead to medical complications such as osteoporosis. Based on data collected through a MEDLINE search (1985-May 1999) and review of references for additional relevant articles, nutrition status, weight, and disease severity are factors most highly correlated with osteopenia. Links also were noted with calcium and vitamin D intake, hypogonadism, chronic inflammation, and age, but findings in these areas are not consistent from one report to the next. Increased fracture rates and kyphosis are consequences of osteoporosis. Simple measures such as compliance with recommended nutrition guidelines and restrictions in corticosteroid therapy could be considered first-line management options. Further studies must be conducted to clarify factors involved in the etiology of osteoporosis in patients with CF and to identify the best treatment and prevention methods.

Gynecologic care of medically complicated adolescents

Gynecologic care of adolescents presents a challenge under the best of circumstances, but when the patient has significant medical processes that interact with the process of puberty, the care of these patients may become extremely difficult. A review of the more common medical illnesses of adolescents and the interaction on the events of puberty and normal menstrual function is presented with emphasis on contraception and future fertility. Although many of the contraceptive options present a possible increased risk to these patients, it must be kept in mind that these adolescent patients will develop emotionally and become sexually active at some point in their lives, and the potential risk of the resultant pregnancy must be weighed carefully. The various options of management for gynecologic problems are discussed.

Self-assessment of sexual maturation in adolescent females with anorexia nervosa

PURPOSE

To evaluate the accuracy of self-assessment of pubertal maturation and to determine the desired stage of pubertal maturity in adolescent females with anorexia nervosa.

METHODS

Standardized figure drawings depicting Tanner's sexual maturation stages were given to a consecutive sample of 40 adolescent females with anorexia nervosa who were instructed to assess current and desired pubertal development. Pubertal development was assessed independently by two investigators. The percent agreement between physician and subject ratings was determined.

RESULTS

Percent agreement between physician and subject ratings was 30% for developmental stage for breasts and 50% for pubic hair. Subjects underestimated breast development 3.4 times as often as they overestimated it and overestimated pubic hair development 1.5 times as often as they underestimated it. Multivariate probit analysis showed that inaccuracy in breast self-assessment was inversely related to a desire for sexual maturity (p < 0.05). Ninety percent of subjects stated that their desired stage of breast development was equal to or more mature than their present stage. Eighty percent stated that their desired stage of pubic hair development was equal to or more mature than their present stage.

CONCLUSIONS

Self-assessment of sexual maturity by adolescents with anorexia nervosa using standardized figure drawings depicting Tanner's stages is not accurate. Patients desiring a sexually immature body were most likely to be inaccurate in their self-assessment of their pubertal stage.

Cystic fibrosis through a female perspective: psychosocial issues and information concerning puberty and motherhood

The purpose of the study was to investigate psychosocial issues concerning puberty and motherhood among CF adult females, to see how they had obtained and conceived information on these matters and how they would like information to be given. Fourteen adult CF females were interviewed. The majority of the women felt socially accepted and did not remember being ashamed over their delayed puberty. Thirteen of the women had been or were living in stable sexual relationships. However, the study revealed problems with destructive behaviour during puberty due to thoughts about premature death, secret worries over delayed puberty, poorly received information about puberty and fertility, avoidance of close relationships with the opposite sex during adolescence and concerns about being a mother with a chronic illness. Information about puberty and fertility should be given individually and in small discussion groups with teenage girls combined with thorough medical and psychological guidance concerning motherhood.

Osteoporosis in adults with cystic fibrosis

Osteoporosis is prevalent in adults with CF Longitudinal data have not been collected and so the natural history is unknown. The aetiology is not known. There are no published randomized controlled trials evaluating treatments for osteoporosis in CF patients.

Bone demineralization in cystic fibrosis: evidence of imbalance between bone formation and degradation

Bone turnover, collagen metabolism, and bone mineral status were investigated in 59 patients with cystic fibrosis and in 72 sex and age-matched control subjects. In all patients and control subjects serum concentrations of osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (PICP), amino-terminal propeptide of type III procollagen (PIIINP), and cross-linked carboxy-terminal telopeptide of type I collagen (ICTP), and urinary values of cross-linked N-telopeptides of type I collagen (NTX), as well as total body bone mineral content (TBBM) were measured. Higher ICTP (microgram/L) and NTX (bone collagen equivalent/urinary creatinine (nmol/mmol) values were found in pre-pubertal, pubertal, and young adult patients than in control subjects (ICTP: 15.4 +/- 2.1 and 13.2 +/- 1.8, p < 0.001; 23.3 +/- 5.3 and 20.1 +/- 4.1, p < 0.02; 4.8 +/- 1.1 and 4.0 +/- 1.0, p < 0.05. respectively; NTX: 1047.5 +/- 528.6 and 227.8 +/- 71.8, p < 0.01; 997.8 +/- 391.7 and 376.3 +/- 91.0, p < 0.01; 993.2 +/- 398.0 and 73.9 +/- 28.5, p < 0.01, respectively). Lower OC and PICP levels (microgram/L) were showed in pubertal patients in comparison with control subjects (OC: 20.2 +/- 12.3 and 39.0 +/- 15.1, p < 0.01; PICP: 305.8 +/- 130.4 and 436.2 +/- 110.1, p < 0.02, respectively). Lower OC and higher PIIINP levels (microgram/L) were found in young adult patients than in control subjects (OC: 4.4 +/- 3.0 and 7.0 +/- 3.1, p < 0.05; PIIINP: 4.8 +/- 1.1 and 3.1 +/- 1.0, p < 0.001, respectively). TBBM (z score) was reduced in prepubertal, pubertal, and young adult patients (-0.8 +/- 0.4, -1.0 +/- 0.4, -1.1 +/- 0.5, respectively). Patients with cystic fibrosis have bone demineralization and imbalance between bone formation and degradation.

Cystic fibrosis mRNA expression in rat brain: cerebral cortex and medial preoptic area

Cystic fibrosis transmembrane conductance regulator (CFTR) mRNA expression has been found in the medial preoptic area using in situ hybridization, addressing the possibility of CFTR regulation of sexual maturation and reproductive behaviour. CFTR mRNA has also been found in the cortical deep pyramidal layer V implying possible involvement of CFTR in 'motor' function and output control over bodily movements and secretion. CFTR production in the brain regions observed in this study implicate involvement of CFTR in cerebral control over motor/visceral and endocrine systems.

Delayed puberty in girls with cystic fibrosis despite good clinical status

BACKGROUND

Previous studies have shown that puberty is delayed among patients with cystic fibrosis (CF). Malnutrition has been considered the main etiologic factor. Today with improved medical therapy and nutritional support, most CF patients obtain an almost normal nutritional status.

OBJECTIVES

To investigate whether pubertal development among female CF patients at the Stockholm CF Center was normal and, if not, what other parameters besides nutrition might influence this.

METHODS

Seventeen patients were studied retrospectively regarding age at peak height velocity and menarche. Menarcheal age (MA) was compared with normal population data and related to clinical and nutritional status, genotype, oral glucose tolerance test (OGTT), and essential fatty acid levels.

RESULTS

The mean age at peak height velocity (12.9 +/- 0.8 years) and at menarche (14.9 +/- 1.4 years) was significantly higher in the CF patients compared with normal controls (11.9 +/- 1.0 years and 13.0 +/- 1.0 years, respectively). No correlation was found between menarchal age and nutritional or clinical parameters. The patients with pathological OGTT without overt diabetes were significantly older at menarche (15.8 +/- 1.7 years) compared with the patients with normal OGTT (14.3 +/- 0.9 years). The patients who were homozygous for the most common mutation, deltaF508, were significantly older at menarche (15.2 +/- 1.9 years) than those who were not (14.7 +/- 0.9 years).

CONCLUSIONS

Pubertal delay still existed among the CF patients despite good clinical status. The patients homozygous for deltaF508 and those with pathological OGTT showed the most delayed puberty.

Anabolic effect of biosynthetic growth hormone in cystic fibrosis patients

The purpose of this study was to determine whether GH treatment of cystic fibrosis (CF) patients can result in an anabolic effect, i.e., increased weight gain, improved growth rate, nitrogen retention, and improved pulmonary function. Nine prepubertal endocrinologically normal CF patients (3 girls, 6 boys; chronological age (CA) 5.5-9.8 years, and bone age (BA) 4.5-9.0 years), received recombinant human growth hormone (rhGH) 0.3 mg/kg/week subcutaneously for a period of 12 months (N = 8) or 9 months (N = 1). Normal glucose tolerance was determined before treatment. Pulmonary function studies and anthropometric measurements were done every 3 months. Thyroid status, somatomedin C (SmC), BA, and routine chemistries were evaluated every 6 months. The pretreatment growth velocity averaged 5.7 +/- 0.3 (SE) cm/year and significantly increased to 7.8 +/- 0.4 (SE) cm/year during therapy, (P < 0.01). Standard deviation scores (SDS) for height significantly increased during rhGH therapy as compared with pretreatment, (P < 0.05). Weight of the patients during rhGH therapy did not significantly change during or after rhGH therapy. After therapy, all patients showed a significant increase in arm muscle area (AMA) and a significant decrement in arm fat area (AFA) (P < 0.01). Net nitrogen anabolism was negative in all subjects before therapy but became more positive in five patients during rhGH therapy. Three patients achieved positive nitrogen retention. SmC values significantly increased from a mean value of 0.62 +/- 0.1 (SE) U/ml to 1.6 +/- 0.6 (SE) U/ml after therapy. BA advanced 1.0 +/- 0.1 SE per year after treatment. Of the seven patients able to perform adequate pulmonary function testing, improvement occurred in FVC, FEV1.0, and PEFR in 5, 5, and 4 patients, respectively, but these changes did not reach statistical significance. We conclude that biosynthetic rhGH therapy had a significant anabolic effect in CF patients as shown by increased growth velocity, SmC values, increased protein and decreased fet stores, and a positive or less negative net nitrogen retention in five of the patients.

Factors limiting anaerobic performance in adolescent males with cystic fibrosis

Forty-one adolescent males (11.1-18.3 yr) with cystic fibrosis (CF) and 37 healthy adolescent males (11.1-17.9 yr) performed a Wingate Anaerobic Test (WAnT). The group with CF was subdivided by sexual maturity, nutritional status, and degree of airway obstruction. The subjects with CF had lower absolute power outputs than the healthy controls [mean power in Watts (mean +/- SD): 350.2 +/- 135.9 vs 424.5 +/- 120.4, P < 0.001; peak power: 525.2 +/- 178.4 vs 665.9 +/- 191.3, P < 0.001). When absolute power was corrected for lean body mass, the subjects with CF had lower power outputs than the healthy controls (mean power in W.kg-1: 8.9 +/- 1.7 vs 9.6 +/- 0.9, P < 0.05; peak power: 13.4 +/- 2.1 vs 15.0 +/- 1.6, P < 0.05). The subgroup with CF with a higher body mass index (BMI > 17.5 kg.m-2) had higher peak and mean power output than subjects with CF with a lower BMI in both absolute power and when power was expressed per lean body mass. When sexual maturation was considered, subjects with CF with salivary testosterone greater than 4.0 ng.dl-1 had a higher mean and peak power in both absolute terms and relative to lean body mass than subjects with CF with salivary testosterone less than 4.0 ng.dl-1. Multiple regression analysis indicated that the nutritional factor accounted for 70%-80% of the variability in power output in the subjects with CF, while testosterone accounted for 10% of the variability. Pulmonary function was not a significant independent correlate of anaerobic power. Our results suggest that nutritional status, and to a lesser extent maturational factors, may play a more important role than pulmonary function in determining anaerobic fitness in male adolescents with CF.

Bone density in children and adolescents with cystic fibrosis

OBJECTIVE

To assess bone mineralization in children and adolescents with cystic fibrosis.

DESIGN

A cross-sectional, observational study of bone mineral density (BMD) in the lumbar vertebrae and the proximal femur of 62 patients aged 4.9 to 17.8 years (mean, 10.7 years). The age-normalized BMD findings (z scores) were correlated with multiple variables, including measures of pulmonary disease, nutritional status and growth, genotype, calcium intake, and serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels.

RESULTS

The mean BMD z score was -1.03 +/- 0.14 (+/- SE) in the lumbar vertebrae and -0.71 +/- 0.17 in the proximal femur. The BMD in this age range declined relative to normal values at a rapid rate of roughly 1 SD every 6 to 8 years. The BMD z scores correlated well with multiple measures of disease severity, particularly weight and forced expiratory volume in 1 second.

CONCLUSIONS

Significant osteoporosis in adults with CF results at least in part from a failure to accumulate bone mineral at a normal rate during skeletal growth and development. The cause of this is likely multifactorial. With increasing longevity, the skeletal consequences of CF become an important consideration.

Genetic determination of diabetes mellitus in patients with cystic fibrosis. Multicenter Cystic Fibrosis Study Group

Data from 1348 patients with cystic fibrosis in mid-Europe show that the prevalence of diabetes mellitus in these patients is 4.9%, that diabetes develops in more female than male patients with cystic fibrosis during childhood and adolescence and at a younger age, and that diabetes mellitus is more likely to affect delta F508 homozygous patients.

Kyphosis and fractures in children and young adults with cystic fibrosis

The purpose of this study was to examine children and adolescents with cystic fibrosis for an increased frequency of fracture and excessive thoracic kyphosis, which may result from inadequate skeletal mineralization. In a survey of 143 patients (ages 4.7 to 21.9 years; mean, 11.3 years), the fracture rate for male patients from birth to 5 years of age was higher than for female patients and both rates were comparable with those for normal children. In contrast, female patients 6 to 16 years of age with cystic fibrosis had a higher-than-normal fracture rate and a higher rate than their male counterparts. Review of the chest radiographs showed that thoracic kyphosis correlated with age and with disease severity as judged by Brasfield scoring. In the > 15-year-old age group, kyphosis exceeding 40 degrees, the upper limit of normal, was found in 77% of the female patients and 36% of the male patients. The cause of these findings is uncertain and perhaps multifactorial, but osteopenia is likely a contributing factor. As the life expectancy of patients with cystic fibrosis continues to increase, the skeletal consequences, particularly in female patients, may become increasingly significant.

Osteopenia in adults with cystic fibrosis

PURPOSE

To examine the frequency and severity of osteopenia in adults with cystic fibrosis and the clinical variables associated with reduced bone mineral.

PATIENTS AND METHODS

The bone mineral status of 22 white adults (14 women) with cystic fibrosis was compared with normative data from healthy white control subjects in a university medical center. Lumbar spine, femoral neck, and whole-body bone mineral was determined by dual energy x-ray absorptiometry and expressed as bone mineral content (g), bone mineral density (g/cm2), and bone mineral apparent density (g/cm3). Bone mass was related to age, body mass, gonadal function, pulmonary status, and glucocorticoid exposure to identify variables associated with reduced bone mineral in cystic fibrosis.

RESULTS

Bone mineral in adults with cystic fibrosis was significantly below expected values for age and sex at all sites using all expressions of bone mass. The mean Z-score was -2.8 for the lumbar spine bone density, -2.5 for the femoral neck, and -2.0 for the whole body. Bone mineral apparent density (a term that minimizes the influence of bone dimensions) was also significantly reduced in patients at the lumbar spine (p < 0.0001) and femoral neck (p < 0.001 to p < 0.0001), indicating that the bone mineral deficit seen in adults with cystic fibrosis could not be attributed to differences in bone size. Age, weight, height, and body mass index were significantly correlated with bone mineral. Pulmonary status, glucocorticoid use, and gonadal function failed to predict bone mineral status.

CONCLUSIONS

Osteopenia and osteoporosis occur commonly in young adults with cystic fibrosis. Age and body mass are predictive of bone mineral, although the pathogenesis of this bone mineral deficit is likely multifactorial.

Correlation between puberty and the development of autoimmunity to spermatozoa in men with cystic fibrosis

OBJECTIVE

To test the hypothesis that puberty is a necessary factor in the pathogenesis of autoimmunity to sperm in men with cystic fibrosis (CF), we studied prepubertal and postpubertal males with CF versus an age-matched group of males with type 1 diabetes as controls.

DESIGN

Sera from CF and diabetic males treated at University Hospital, State University of New York, Stony Brook, were tested by indirect immunobead binding for antisperm antibodies and by radioimmunoassay for testosterone (T), luteinizing hormone, and follicle-stimulating hormone. The finding of autoantibodies to spermatozoa was correlated with chronological age, as well as with clinical and hormonal pubertal status.

RESULTS

Autoimmunity to sperm, as detected by humoral antisperm antibodies, was documented solely in postpubertal males, as judged by hormonal and clinical criteria. Eighty-three percent of sexually mature CF males and 6.3% (1 of 16) diabetic males exhibited autoantibodies to sperm. These antibodies were only detected when serum T levels were > 8.7 nmol/L (250 ng/dL).

CONCLUSIONS

These results suggest that puberty, and presumably, active spermatogenesis is a requirement for the development of autoimmunity to sperm in men with CF.

Microscopic epididymal sperm aspiration (MESA): a new option for treatment of the obstructive azoospermia associated with cystic fibrosis

Cystic fibrosis is a life-threatening disease. Only recently has the prognosis improved. In the male patient there is an almost invariable absence or maldevelopment of the vas deferens, creating a situation of obstructive azoospermia. Consequently, their fertility potential has been considered nonexistent. Having gained experience in microscopic epididymal sperm aspiration coupled with the advanced reproductive technologies for the treatment of congenital absence of the vasa, we sought to extend this treatment option to the male cystic fibrosis population. An Indian male with clinically evident and genetically confirmed cystic fibrosis underwent microscopic retrieval of epididymal sperm. The anatomy of the epididymis and the quality of sperm obtained were similar to those patients with congenital absence of the vas deferens. After appropriate spousal genetic testing, superovulation, and transvaginal oocyte retrieval, in vitro insemination of sperm was performed. Fifty percent of the oocytes were subjected to partial zona dissection and a single embryo resulted. Subsequent to transfer, no conception was realized but the effort expanded the clinical usefulness of microscopic epididymal sperm aspiration. This should open up an avenue of treatment for couples in whom only the most dire predictions for fertility have been made to date.

Osteoporosis in cystic fibrosis

To determine if osteoporosis is prevalent among patients with cystic fibrosis, we compared the vertebral bone density measured by quantitative computed tomography in 57 such patients (29 male, 28 female, aged 3 to 21 years) with those of an age-, race-, and sex-matched control group of 57 healthy subjects. Patients with cystic fibrosis had significantly lower bone density (10% lower, p less than 0.001) than in controls. The decrease in bone density in patients with cystic fibrosis was unrelated to age. Shwachman clinical evaluation scores (based on case history, pulmonary physical findings, growth, and x-ray findings) correlated positively with age-standardized bone density values (p less than 0.01). Male patients had substantially lower bone density than did female patients (p less than 0.02), but bone density differences related to gender were not significant when effects of disease severity were controlled for. Decreased bone density was more common in patients with poor nutritional status as determined by anthropometric measurements (p less than 0.05). We conclude that osteoporosis is a frequent complication in children with cystic fibrosis regardless of their age and is more prevalent in patients with greater disease severity.

Neuroendocrine control processes. Pubertal onset and progression

This discussion has outlined current concepts in neuroendocrinologic control of pubertal onset and progression. Central nervous system regulation of the arcuate nucleus (ventromedial hypothalamus) pulse generator that subsequently controls pituitary gonadotropin synthesis and secretion has been highlighted. Significant investigative issues that deserve assessment in the next several years include the following: 1. Systematic neuropharmacologic, electrophysiologic, and anatomic assessment of the hypothalamic arcuate nucleus. These assessments would include the use of recombinant DNA technology to probe cellular regulation of GnRH production. 2. Physiologically oriented examination of hypothalamic GnRH synthesis and secretion, along with function in the remaining reproductive endocrine system, during situations of nutritional impairment and excessive energy utilization and psychologic stress. 3. Further assessment of the neurophysiologic inhibition of GnRH production during childhood and the late prepubertal reactivation of the arcuate nucleus pulse generator. Roles of opioids, dopamine, other neurotransmitters, and metabolic signals remain to be clarified. 4. Exploration of regulators of hypothalamic, pituitary, and gonadal function when pulsatile GnRH administration has replaced the usual hypothalamic mechanisms. Pituitary-gonadal interactions may be independently assessed. 5. Assessment of pubertal growth, endocrine function, and neuropharmacologic control mechanisms in circumstances of chemical removal of pituitary gonadotrope function by GnRH agonists or antagonists. 6. Concordance and discordance of potency estimates of gonadotropins made by bioassay and immunoassay. The biologic basis for qualitative changes in bioassayable levels of LH and FSH, often related to carbohydrate content of the glycoprotein, may help to explain changes of gonadal function during the pubertal process. The potential for significant molecular heterogeneity of the gonadotropins is recognized and suggests substantial posttranslational changes of LH and FSH. 7. A cogent delineation of the hormonal, nutritional, and energy regulators of the pubertal growth spurt, though not discussed in this manuscript, remains to be accomplished. The relationship between pituitary gonadotropins and growth hormone, sex steroids, and the various peptide growth factors, especially the relationship between the growth factors and intragonadal steroidogenesis and germ-cell production, remain to be resolved. The importance of local production and action of peptide-growth factors in diverse tissues, skeletal and other, is being increasingly recognized.(ABSTRACT TRUNCATED AT 400 WORDS)

Amenorrhoea in cystic fibrosis

Menstrual history in relation to nutritional status and lung function was assessed in 45 adolescent and adult patients with cystic fibrosis (CF). Twenty patients had regular menstrual cycles (of whom six had been pregnant), 12 had primary or secondary amenorrhoea, 11 had irregular cycles and two were premenarcheal. Patients with regular menstruation had a significantly higher body mass index and percentage body fat (estimated from skinfold thickness measurements) than those with amenorrhoea (P less than 0.001), and also better lung function (P less than 0.01). A linear discriminant analysis indicated that of the four indices studied percentage body fat was the most important predictor of menstrual function. Ovarian and uterine morphology were studied by ultrasonography in 28 patients and 17 healthy controls. In 10 patients multicystic ovaries were noted. Even in patients with regular cycles uterine size was reduced (P less than 0.01) and in those with amenorrhoea appeared to be related to thinness. Amenorrhoea in CF is an appropriate adaptive response in preventing pregnancy, but the resultant oestrogen deficiency and psychological effects must be considered.

Social maturation. A challenge for handicapped and chronically ill adolescents

Adolescents who are disabled may develop excellent self-esteem if they feel supported by their families and can take advantage of opportunities to develop their own identity and independence. Their illness, and/or their reluctance to participate in peer and school activities, and/or their parents' inability to encourage optimal growth of their independence, may all discourage disabled adolescents from maturing into meaningful adulthood. Efforts should be focused on assisting disabled adolescents and their families to realize the full potential of the adolescent's social maturation.

Inadequate erythroid response to hypoxia in cystic fibrosis

An increase in hemoglobin concentration characterizes the normal compensatory response to chronic tissue hypoxia. We observed no such increase in 42 chronically hypoxic patients with cystic fibrosis, in whom the mean concentration was 12.6 gm/dl; one third of the patients were anemic. Compared with patients with cyanotic heart disease, patients with cystic fibrosis did not have a compensatory increase in P50 or 2,3-diphosphoglycerate. Despite anemia, erythropoietin levels in patients with cystic fibrosis were not significantly different from normal control values. The growth of colony-forming units-erythroid in patients with cystic fibrosis was similar to that in control subjects, and there was no inhibition of growth with the addition of autologous serum. Erythropoietin sensitivity, determined by measuring the CFUe dose response curve, was normal in both patients and controls. Results of iron studies were consistent with iron deficiency in the majority of patients. Impaired absorption of iron was observed in six of 13 iron-deficient patients with cystic fibrosis. An inverse correlation between erythrocyte sedimentation rate and peak serum iron was obtained during the iron absorption study. Eight patients who underwent a therapeutic trial of iron demonstrated a 1.8 gm/dl rise in hemoglobin concentration. Two patients with previously documented iron malabsorption responded to parenteral iron therapy after failure to respond to oral supplementation. These studies demonstrate that patients with cystic fibrosis not only have an impaired erythroid response to hypoxia, but are frequently anemic. Their inadequate erythroid response to hypoxia results in part from disturbances in erythropoietin regulation and iron availability.