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Ogawa M, Komura H, Ono Y, Nose-Ogura S, Kawai K, Terauchi M. Attitude and experience of obstetricians and gynecologists toward eating disorders assessment and management in Japan: A nationwide survey. J Obstet Gynaecol Res 2024. [PMID: 38952189 DOI: 10.1111/jog.16017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 06/20/2024] [Indexed: 07/03/2024]
Abstract
AIM To investigate the attitudes and experiences of obstetricians and gynecologists in treating women with eating disorders (EDs) in Japan. METHODS Members of the Japan Society of Obstetrics and Gynecology were invited to participate in a web-based survey from March 1 to 31, 2022. We asked about the attitudes of obstetricians and gynecologists toward women with weight loss-related amenorrhea and their experiences in treating EDs. We also assessed the characteristics of physicians who see many ED patients. RESULTS A total of 662 ob/gyns. responded to the survey. While treating weight loss-related amenorrhea, 25.8% reported screening patients for EDs. 88.5% of respondents reported having treated ED patients. The main medical concerns described when treating pregnant women with ED were fetal growth restriction and preterm delivery. The most common type of ED encountered by participants in both perinatal and infertility care settings was anorexia nervosa. Characteristics of physicians who treated 10 or more EDs per year were being board certified in women's health care and not providing delivery services (OR = 4.809, 1.896). The most common comment regarding optimizing the management of patients with EDs in obstetrics and gynecology practice was the need to implement guidelines for ED management. CONCLUSIONS Many obstetricians and gynecologists in Japan treat patients with ED. Standardized guidelines for the management of EDs for obstetricians and gynecologists are needed.
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Affiliation(s)
- Mariko Ogawa
- Fukushima Medical Center for Children and Women, Fukushima Medical University, Fukushima, Japan
| | | | - Yoko Ono
- Tsushima Ruriko Women's Life Clinic, Chuo, Japan
| | - Sayaka Nose-Ogura
- Department of Sport Medicine and Research, Japan Institute of Sports Sciences, Kita-ku, Japan
| | - Keisuke Kawai
- Department of Psychosomatic Medicine, Kohnodai Hospital National Center for Global Health and Medicine, Ichikawa, Japan
| | - Masakazu Terauchi
- Department of Women's Health, Tokyo Medical and Dental University, Tokyo, Japan
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Memi E, Pavli P, Papagianni M, Vrachnis N, Mastorakos G. Diagnostic and therapeutic use of oral micronized progesterone in endocrinology. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09882-0. [PMID: 38652231 DOI: 10.1007/s11154-024-09882-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
Progesterone is a natural steroid hormone, while progestins are synthetic molecules. In the female reproductive system, progesterone contributes to the control of luteinizing hormone and follicle-stimulating hormone secretion and their pulsatility, via its receptors on the kisspeptin, neurokinin B, and dynorphin neurons in the hypothalamus. Progesterone together with estradiol controls the cyclic changes of proliferation and decidualization of the endometrium; exerts anti-mitogenic actions on endometrial epithelial cells; regulates normal menstrual bleeding; contributes to fertilization and pregnancy maintenance; participates in the onset of labor. In addition, it exerts numerous effects on other endocrine systems. Micronized progesterone (MP) is natural progesterone with increased bioavailability, due to its pharmacotechnical micronized structure, which makes it an attractive diagnostic and therapeutic tool. This critical literature review aims to summarize and put forward the potential diagnostic and therapeutic uses of MP in the field of endocrinology. During reproductive life, MP is used for diagnostic purposes in the evaluation of primary or secondary amenorrhea as a challenge test. Moreover, it can be prescribed to women presenting with amenorrhea or oligomenorrhea for induction of withdrawal bleeding, in order to time blood-sampling for diagnostic purposes in early follicular phase. Therapeutically, MP, alone or combined with estrogens, is a useful tool in various endocrine disorders including primary amenorrhea, abnormal uterine bleeding due to disordered ovulation, luteal phase deficiency, premenstrual syndrome, polycystic ovary syndrome, secondary amenorrhea [functional hypothalamic amenorrhea, premature ovarian insufficiency], perimenopause and menopause. When administrated per os, acting as a neurosteroid directly or through its metabolites, it exerts beneficial effects on brain function such as alleviation of symptoms of anxiety and depression, asw well as of sleep problems, while it improves working memory in peri- and menopausal women. Micronized progesterone preserves full potential of progesterone activity, without presenting many of the side-effects of progestins. Although it has been associated with more frequent drowsiness and dizziness, it can be well tolerated with nocturnal administration. Because of its better safety profile, especially with regard to metabolic ailments, breast cancer risk and veno-thromboembolism risk, MP is the preferred option for individuals with an increased risk of cardiovascular and metabolic diseases and of all-cause mortality.
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Affiliation(s)
- Eleni Memi
- Unit of Endocrinology, Diabetes mellitus, and Metabolism, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Vas. Sophias Av. 76, 11528, Athens, Greece
| | - Polina Pavli
- Unit of Endocrinology, Diabetes mellitus, and Metabolism, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Vas. Sophias Av. 76, 11528, Athens, Greece
| | - Maria Papagianni
- Department of Nutrition and Dietetics, School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42100, Trikala, Greece
- Endocrine Unit, 3rd Department of Pediatrics, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - Nikolaos Vrachnis
- Third Department of Obstetrics and Gynecology, Attikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini Str. 1, 12462, Chaidari, Athens, Greece
- St George's NHS Foundation Trust Teaching Hospitals, St George's University of London, London, UK
| | - George Mastorakos
- Unit of Endocrinology, Diabetes mellitus, and Metabolism, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Vas. Sophias Av. 76, 11528, Athens, Greece.
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Trinh A, Lim A, Wong P, Brown J, Pitkin J, Wollenhoven B, Ebeling P, Fuller P, Milat F, Zacharin M. A pilot study proposing an algorithm for pubertal induction in cerebral palsy. J Pediatr Endocrinol Metab 2024; 37:222-227. [PMID: 38374118 DOI: 10.1515/jpem-2024-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 01/18/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES To explore delayed puberty in cerebral palsy (CP) and to test the acceptability of an interventional puberty induction algorithm. METHODS A two phase cohort study in children and adolescents diagnosed with CP who have delayed puberty. Phase 1: Retrospective review of clinical records and interviews with patients who have been treated with sex-steroids and Phase 2: Prospective interventional trial of pubertal induction with a proposed algorithm of transdermal testosterone (males) or oestrogen (females). Phase 1 examined experiences with sex-steroid treatment. Phase 2 collected data on height adjusted bone mineral density (BMAD), fractures, adverse effects, mobility and quality of life over two years during the induction. RESULTS Phase 1, treatment was well tolerated in 11/20 treated with sex-steroids; phase 2, using the proposed induction algorithm, 7/10 treated reached Tanner stage 3 by nine months. One participant reached Tanner stage 5 in 24 months. Mean change in BMAD Z-scores was +0.27 % (SD 0.002) in those who could be scanned by dual-energy X-ray absorptiometry (DXA). CONCLUSIONS Delayed puberty may be diagnosed late. Treatment was beneficial and well tolerated, suggesting all patients with severe pubertal delay or arrest should be considered for sex hormone supplementation.
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Affiliation(s)
- Anne Trinh
- Monash Health, Clayton, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Angelina Lim
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Phillip Wong
- Hudson Institute of Medical Research, Clayton, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Justin Brown
- Monash Health, Clayton, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Janne Pitkin
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Beverley Wollenhoven
- Monash Health, Clayton, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Peter Ebeling
- Monash Health, Clayton, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Peter Fuller
- Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Frances Milat
- Hudson Institute of Medical Research, Clayton, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Margaret Zacharin
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Royal Children's Hospital, Melbourne, Australia
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Maciejewska B, Maciejewska-Szaniec Z, Małaczyńska B, Rajewska-Rager A, Michalak M, Iwanowski P. Effects of Age-Dependent Hormonal Changes and Estrogen Supplementation on Voice in Girls with Anorexia Nervosa-Preliminary Report. J Voice 2024:S0892-1997(24)00028-6. [PMID: 38493018 DOI: 10.1016/j.jvoice.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Human development includes lots of physical and emotional changes. The human voice depends on age. Voice production is a complex physiological and acoustic phenomenon that depends on many factors such as structure, hormone level, degree of fatigue or nutrition and hydration of the body, systemic diseases, and emotional state. All these factors can be present in anorexia nervosa (AN), such as excessive weight loss, generated hydro-electrolytic changes, nutritional deficiencies, hormonal disturbances in the function of the hypothalamic-pituitary-adrenal axis, the hypothalamic-pituitary-thyroid axis, the hypothalamic-pituitary-ovarian axis, and emotional distress. The prevalence of AN ranges between 0.3% and 3%, and it is the third most common chronic disease affecting adolescent girls. However, voice changes related to AN have not been fully investigated. OBJECTIVE The purpose of this study was to evaluate the impact of AN on age-related changes in the voice of adolescent women-before and after puberty, particularly through acoustic analysis. An additional objective was to evaluate estrogen substitution in female patients with AN in order to investigate their effect on voice condition. MATERIALS AND METHODS 126 girls diagnosed with AN (15.32 ± 2.12 years, range 12-19, BMI = 14.38 ± 1.67), were assessed for the condition of the voice such as perceptual voice evaluation on the GRBAS scale, maximal phonation time (MPT), laryngoscopy, with special attention to voice acoustic analysis-Multi-Dimensional Voice Program (MDVP). The control group (B) included 93 girls without eating disturbances (aged 12-19, mean age 15.52 ± 2.40, BMI = 21.50 ± 1.54). Perceptual voice assessment, aerodynamic test MPT, and acoustic parameters were analyzed in age groups (≤16 years and >16 years). The human vocal tract is sensitive to sex hormones, so the analysis was carried out in the group up to the age of 16 and above 16 to check possible effects. RESULTS GRBAS scale was higher in girls with AN compared to the control group for breathiness (B) (P = 0.0002) and asthenia (A) (P < 0.05). The median GRBAS scale for the older group of anorexic women was the highest (2.0). The mean MPT for group A was significantly lower (15.40 ± 3.51 seconds). Comparing age subgroups there was a prolongation of MPT in the healthy group (in groups ≤16 years and >16 years respectively 21.13 seconds versus 25.40 seconds) and a shortening in the anorectic group (≤16 years versus >16 years: 17.06 seconds versus 14.17 seconds). There was no difference between groups A and C up to 16 years of age, but above 16 years of age appeared (14.17 seconds versus 25.40 seconds). Acoustic analysis revealed lower F0 values in group A and C in older subgroups (215,85 Hz versus 236,01 Hz-statistically significant), as well as between subgroups both groups (A: 251,38 Hz versus 215,85 Hz; C: 248,20 Hz versus 236,01 Hz). A narrowing of the vocal range in girls over 16 years in group A was observed. There were no statistically significant differences in F0 between subgroups ≤16 years in groups A and C (251.38 Hz versus 248.20 Hz). The ENT study found that more than half of the girls (54.55%) over the age of 16 who took hormone supplementation manifested laryngeal structure that was normal for their age, there was no effect of hormone supplementation on any of the MDVP parameters between the drug-taking and non-drug-taking groups. CONCLUSIONS The acoustic results of the voice in MDVP measurements in adolescent women with AN are not within the normal range and do not mimic the normal developmental changes of the voice. The most important acoustic characteristics of the voice are changes in the fundamental frequency F0 and the range of the voice tended to be more severe in anorectic women >16 years of age and to increase with age, indicating a possible cumulative effect of malnutrition-related disorders as well as hormonal dysfunctions. MDVP can be considered a simple, non-invasive method of assessing the voice organ in AN. MPT differentiated the study groups well: statistically significant differences were noted both between the groups, as well as between age groups. There was no significant effect of oral hormone supplementation on any parameters of the voice. In conclusion, body mass and fat volume in AN may be related to voice production/physiology, affecting voice quality, voice acoustic parameters, voice aerodynamics, and phonatory range in an age-dependent manner. Future studies are needed to assess the long-term efficacy of estrogen treatment in AN.
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Affiliation(s)
- Barbara Maciejewska
- Department and Clinic of Phoniatrics and Audiology, Poznan University of Medical Sciences
| | | | - Bogna Małaczyńska
- Department and Clinic of Phoniatrics and Audiology, Poznan University of Medical Sciences
| | | | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences
| | - Piotr Iwanowski
- Department of Neurology, Poznan University of Medical Sciences.
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Hebebrand J, Gradl-Dietsch G, Peters T, Correll CU, Haas V. The Diagnosis and Treatment of Anorexia Nervosa in Childhood and Adolescence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:164-174. [PMID: 38170843 DOI: 10.3238/arztebl.m2023.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/09/2023] [Accepted: 10/09/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Anorexia nervosa (AN) is a serious disease with a lifetime prevalence of up to 3.6% in women and 0.3% in men. Abnormally low weight and the associated starvation partly account for its somatic and mental manifestations. METHODS This review is based on publications retrieved by a selective search concerning AN in childhood and adolescence. RESULTS The peak age of onset of AN is 15.5 years. The frequency of inpatient treatment for AN rose by 40% during the COVID pandemic, indicating the importance of environmental factors; the heritability of AN is estimated at 0.5. The ICD-11 sets the threshold for AN-associated underweight at the fifth percentile for age of the body mass index, as long as the remaining diagnostic criteria are met. The main goal of the multiprofessional treatment of AN is the return to normal body weight, which is a central prerequisite for regaining somatic and mental health. The mean duration of AN is 3.4 years, and approximately twothirds of patients recover from the disease over the long term. CONCLUSION Marked weight loss in childhood and adolescence can trigger AN in the presence of a predisposition to this disease. Patients and their families should receive psychoeducation regarding the symptoms of starvation and their overlap with those of AN. Important objectives are to shorten the duration of the illness, minimize mortality and the risk of chronic illness, and to identify pharmacological approaches to treatment.
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Affiliation(s)
- Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, LVR-Klinikum Essen, University of Duisburg-Essen; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin; The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA; German Center for Mental Health (DZPG), Partner Site Berlin
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Amorim T, Khiyami A, Latif T, Fazeli PK. Neuroendocrine adaptations to starvation. Psychoneuroendocrinology 2023; 157:106365. [PMID: 37573628 PMCID: PMC10543597 DOI: 10.1016/j.psyneuen.2023.106365] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023]
Abstract
Famine and starvation have punctuated the evolutionary past of the human species. As such, we have developed hormonal responses to undernutrition that minimize energy expenditure on processes that are not critical for the survival of the individual, such as reproduction. In this review, we discuss neuroendocrine adaptations to starvation including hypogonadotropic hypogonadism, growth hormone resistance, hypercortisolemia, and the downregulation of the hypothalamic-pituitary-thyroid axis. We review the time-course of these adaptations by describing studies involving the short-term fasting of healthy individuals as well as studies describing the hormonal changes in states of chronic undernutrition, using individuals with anorexia nervosa as a model of chronic starvation. Lastly, we review representative clinical effects of chronic undernutrition.
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Affiliation(s)
- Tânia Amorim
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Center for Human Integrative Physiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Anamil Khiyami
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Tariq Latif
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Pouneh K Fazeli
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Center for Human Integrative Physiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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Tuli S, Singhal V, Slattery M, Gupta N, Brigham KS, Rosenblum J, Ebrahimi S, Eddy KT, Miller KK, Misra M. Bone Density, Geometry, Structure and Strength Estimates in Adolescent and Young Adult Women with Atypical Anorexia Nervosa versus Typical Anorexia Nervosa and Normal-Weight Healthy Controls. Nutrients 2023; 15:3946. [PMID: 37764731 PMCID: PMC10534603 DOI: 10.3390/nu15183946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Our objective was to characterize bone outcomes in adolescent and young adult women with atypical anorexia nervosa (AAN) compared to typical AN and normal-weight healthy controls (HC) based on DSM-5 criteria. Four hundred thirty-two participants (141 AN, 131 AAN and 160 HC), ages 12-21 years, underwent dual-energy X-ray absorptiometry for areal BMD, and a subset had high-resolution peripheral quantitative CT assessment of the distal radius and tibia for volumetric BMD (vBMD), bone geometry and microarchitecture, and microfinite element analysis for estimated strength. The groups did not differ for age, pubertal stage, menarcheal age or physical activity. BMI and bone outcomes overall were intermediate in AAN compared with AN and HC. This applied to spine, total hip and femoral neck BMD measures and many distal tibial measures. However, the mean whole-body less head BMD Z-score did not differ between AAN and AN, and it was lower in both vs. HC. Similarly, many distal radius measures did not differ between AAN vs. AN or HC but were lower in AN than HC. Lower BMI, lean mass and bone age, older menarcheal age and longer illness duration correlated with greater impairment of bone outcomes. These data indicate that individuals with AAN overall have bone outcomes that are intermediate between AN and HC.
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Affiliation(s)
- Shubhangi Tuli
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- MGH Weight Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Meghan Slattery
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Nupur Gupta
- Division of Adolescent Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Kathryn S. Brigham
- Division of Adolescent Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Jennifer Rosenblum
- Division of Adolescent Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Seda Ebrahimi
- Cambridge Eating Disorders Center, Cambridge, MA 02138, USA
| | - Kamryn T. Eddy
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Karen K. Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Saadedine M, Kapoor E, Shufelt C. Functional Hypothalamic Amenorrhea: Recognition and Management of a Challenging Diagnosis. Mayo Clin Proc 2023; 98:1376-1385. [PMID: 37661145 PMCID: PMC10491417 DOI: 10.1016/j.mayocp.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 09/05/2023]
Abstract
Functional hypothalamic amenorrhea is responsible for approximately a third of the cases of secondary amenorrhea. The condition is a result of disturbances in gonadotropin-releasing hormone pulsatile secretion at the level of the hypothalamus, which in turn disrupts gonadotropin secretion. It is due to psychosocial stress, disordered eating, and/or excessive exercise. Often, however, it is a combination of more than one etiology, with a possible role for genetic or epigenetic predisposition. The dysfunctional gonadotropin-releasing hormone release leads to the cessation of ovarian function, resulting in amenorrhea, infertility, and a long-term impact on affected women's bone health, cardiovascular risk, cognition, and mental health. Functional hypothalamic amenorrhea is a diagnosis of exclusion, and treatment involves identifying and reversing the underlying cause(s). The aim of this concise review is to summarize the current knowledge of functional hypothalamic amenorrhea, review its pathophysiology and the adverse health consequences, and provide recommendations for diagnosis and management of this condition. Furthermore, this review will emphasize the gaps in research on this common condition impacting women of reproductive age all over the world.
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Affiliation(s)
- Mariam Saadedine
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL; Center for Women's Health, Mayo Clinic, Rochester, MN
| | - Ekta Kapoor
- Center for Women's Health, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN; Women's Health Research Center, Mayo Clinic, Rochester, MN
| | - Chrisandra Shufelt
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL; Center for Women's Health, Mayo Clinic, Rochester, MN; Women's Health Research Center, Mayo Clinic, Rochester, MN.
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Fricke C, Voderholzer U. Endocrinology of Underweight and Anorexia Nervosa. Nutrients 2023; 15:3509. [PMID: 37630700 PMCID: PMC10458831 DOI: 10.3390/nu15163509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
More than any other mental illness, the course, prognosis, and therapy of anorexia nervosa are shaped by the physical changes associated with being underweight. This article provides an overview of the endocrine changes associated with malnutrition and underweight. This overview serves as a basis for understanding the other articles in this special issue, which deal with the health risks associated with being underweight. In this context, the differences between underweight in anorexia nervosa and in constitutional thinness are of particular importance in assessing the impact of intentional weight loss. In this context, the regulation of hunger and satiety deserves special interest, as this is the area in which the intentional influence on body weight comes into play. Clinical consequences on, for example, fertility, bone metabolism, the homeostasis of, for example, serum glucose levels, or body temperature have been observed for a long time; nonetheless, the medical responses, apart from vitamin supplementations and advice to gain weight, are still limited. Therefore, emphasis was placed on the potential improvement of outcomes through the administration of central or peripheral hormones. Studies were identified on PubMed via a selection of relevant keywords; original texts that were cited in reviews were studied where it was advantageous. This review found some promising data on bone health and the administration of transdermal oestrogen, which is not yet widely used, as well as distinct hormonal markers to differentiate between CT and AN. We concluded that the continuous efforts to investigate the role of endocrinology in underweight and/or anorexia nervosa lead to outcome benefits and that more and higher-powered studies are needed.
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Affiliation(s)
| | - Ulrich Voderholzer
- Schoen Klinik Roseneck, 83209 Prien am Chiemsee, Germany;
- Klinik für Psychiatrie und Psychotherapie, Ludwig Maximilians Universität, 80336 Munich, Germany
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Naseem H, Lokman M, Fitzgerald C. Management of congenital hypogonadotropic hypogonadism in females. HUM FERTIL 2023; 26:622-631. [PMID: 34753367 DOI: 10.1080/14647273.2021.1998929] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 08/02/2021] [Indexed: 10/19/2022]
Abstract
This review explores the challenges in the diagnosis of hypogonadotropic hypogonadism, the transition of care from paediatric to adult care and the considerable health implications of this condition. The role gynaecologists and general practitioners have in managing hormone replacement therapy and reproductive potential is also highlighted. The fertility treatment options, which include ovulation induction with gonadotrophins and in-vitro fertilisation, are discussed in detail along with highlighting the fact that anovulation and markers of low ovarian reserve prior to priming treatment may not be reflective of poor reproductive potential. The holistic management of women with hypogonadotropic hypogonadism is still not standardised and evidence for subfertility management is scarce. This review aims to highlight this concern and provide guidance by evaluating current evidence.
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Affiliation(s)
- Hafiza Naseem
- Reproductive Medicine Department, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mariam Lokman
- Reproductive Medicine Department, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Cheryl Fitzgerald
- Reproductive Medicine Department, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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11
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Battipaglia C, Petrillo T, Semprini E, Ricciardiello F, Rusce ML, Prampolini G, Ambrosetti F, Sponzilli A, Genazzani AD. Low-Dose Estrogens as Neuroendocrine Modulators in Functional Hypothalamic Amenorrhea (FHA): The Putative Triggering of the Positive Feedback Mechanism(s). Biomedicines 2023; 11:1763. [PMID: 37371858 DOI: 10.3390/biomedicines11061763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/29/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Functional hypothalamic amenorrhea (FHA) is a non-organic reversible chronic endocrine disorder characterized by an impaired pulsatile secretion of the gonadotropin-releasing hormone (GnRH) from the hypothalamus. This impaired secretion, triggered by psychosocial and metabolic stressors, leads to an abnormal pituitary production of gonadotropins. As LH and FSH release is defective, the ovarian function is steadily reduced, inducing a systemic hypoestrogenic condition characterized by amenorrhea, vaginal atrophy, mood changes and increased risk of osteoporosis and cardiovascular disease. Diagnosis of FHA is made excluding other possible causes for secondary amenorrhea, and it is based upon the findings of low serum gonadotropins and estradiol (E2) with evidence of precipitating factors (excessive exercise, low weight, stress). Treatments of women with FHA include weight gain through an appropriate diet and physical activity reduction, psychological support, and integrative approach up to estrogen replacement therapy. If no spontaneous ovarian function is restored, assisted reproductive technologies may be used when pregnancy is desired. Because subjects with FHA are hypoestrogenic, the use of low-dose estrogens has been proposed as a putative treatment to positively modulate the spontaneous restart of gonadotropin secretion, counteracting the blockade of the reproductive axis triggered by stress acting through the neuroendocrine pathways at the basis of positive feedback of estrogens. The mechanism through which low-dose estrogens acts is still unknown, but kisspeptin-secreting neurons may be involved.
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Affiliation(s)
- Christian Battipaglia
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Tabatha Petrillo
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Elisa Semprini
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Francesco Ricciardiello
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Maria Laura Rusce
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Greta Prampolini
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Fedora Ambrosetti
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Alessandra Sponzilli
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
| | - Alessandro D Genazzani
- Center for Gynecological Endocrinology, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Via del Pozzo 41, 41100 Modena, Italy
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Tanner AB. Unique considerations for the medical care of restrictive eating disorders in children and young adolescents. J Eat Disord 2023; 11:33. [PMID: 36864525 PMCID: PMC9980853 DOI: 10.1186/s40337-023-00759-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/20/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The medical complications of eating disorders are often approached through an age-neutral lens. However, children and young adolescents may have unique medical complications related to the energy needs and timing of growth and development. Providers caring for patients in this vulnerable age range should understand how to identify, approach, and manage these potential age-related complications. REVIEW Evidence continues to accumulate that increasingly younger patients are being diagnosed with eating disorders. These children and young adolescents have significant risk for unique and potentially irreversible medical complications. Without early identification and treatment, restrictive eating disorders may negatively impact linear growth, bone development and brain maturation in children and young adolescents. Additionally, due to the energy needs of growth and development, unique considerations exist for the use of acute medical stabilization and the identification of patients at risk for refeeding syndrome with initial nutritional rehabilitation. This review presents an approach to the evaluation and management of children and young adolescents with eating disorders. CONCLUSION Children and young adolescents with restrictive eating disorders may have unique medical complications related to the energy needs and timing of linear growth and pubertal development. Significant risk exists for irreversible medical complications of impaired growth, bone, and brain health. Increased awareness of the energy needs for growth and development may improve early recognition, appropriate intervention, and future outcomes for children and young adolescents with restrictive eating disorders.
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Affiliation(s)
- Anna B Tanner
- Department of Pediatrics, Emory University, 30322, Atlanta, GA, Georgia. .,, Dunwoody, Georgia.
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13
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Haines MS. Endocrine complications of anorexia nervosa. J Eat Disord 2023; 11:24. [PMID: 36793059 PMCID: PMC9933399 DOI: 10.1186/s40337-023-00744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/02/2023] [Indexed: 02/17/2023] Open
Abstract
An important component in the treatment of anorexia nervosa (AN) is the evaluation and management of its endocrine complications, including functional hypogonadotropic hypogonadism and increased fracture risk. The body's adaptive response to chronic starvation results in many endocrine abnormalities, most of which are reversible upon weight restoration. A multidisciplinary team with experience in treating patients with AN is critical to improving endocrine outcomes in patients with this disorder, including in women with AN who are interested in fertility. Much less is understood about endocrine abnormalities in men, as well as sexual and gender minorities, with AN. In this article, we review the pathophysiology and evidence-based recommendations for the treatment of endocrine complications in AN, as well as discuss the status of clinical research in this area.
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Affiliation(s)
- Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital, 50 Staniford Street, Suite 750B, Boston, MA, 02114, USA. .,Harvard Medical School, Boston, MA, USA.
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14
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Ross J, Bowden MR, Yu C, Diaz-Thomas A. Transition of young adults with metabolic bone diseases to adult care. Front Endocrinol (Lausanne) 2023; 14:1137976. [PMID: 37008909 PMCID: PMC10064010 DOI: 10.3389/fendo.2023.1137976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
As more accurate diagnostic tools and targeted therapies become increasingly available for pediatric metabolic bone diseases, affected children have a better prognosis and significantly longer lifespan. With this potential for fulfilling lives as adults comes the need for dedicated transition and intentional care of these patients as adults. Much work has gone into improving the transitions of medically fragile children into adulthood, encompassing endocrinologic conditions like type 1 diabetes mellitus and congenital adrenal hyperplasia. However, there are gaps in the literature regarding similar guidance concerning metabolic bone conditions. This article intends to provide a brief review of research and guidelines for transitions of care more generally, followed by a more detailed treatment of bone disorders specifically. Considerations for such transitions include final adult height, fertility, fetal risk, heritability, and access to appropriately identified specialists. A nutrient-dense diet, optimal mobility, and adequate vitamin D stores are protective factors for these conditions. Primary bone disorders include hypophosphatasia, X-linked hypophosphatemic rickets, and osteogenesis imperfecta. Metabolic bone disease can also develop secondarily as a sequela of such diverse exposures as hypogonadism, a history of eating disorder, and cancer treatment. This article synthesizes research by experts of these specific disorders to describe what is known in this field of transition medicine for metabolic bone diseases as well as unanswered questions. The long-term objective is to develop and implement strategies for successful transitions for all patients affected by these various conditions.
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Affiliation(s)
- Jordan Ross
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- *Correspondence: Jordan Ross,
| | - Michelle R. Bowden
- Division of General Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
| | - Christine Yu
- Endocrinology Division, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alicia Diaz-Thomas
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
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Dural O, Ulusoy HE, Tikiz MA, Gurbanova T, Yasa C, Ugurlucan FG, Akhan SE. Effects of Hormone Replacement Therapy on Low Bone Mineral Density in Adolescents and Young Women with Hypogonadism: Comparison of Oral and Transdermal 17 Beta-Estradiol Administration. J Pediatr Adolesc Gynecol 2022; 35:634-637. [PMID: 35644512 DOI: 10.1016/j.jpag.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To evaluate the effects of physiological dose 17 beta-estradiol (E2) replacement on low bone mineral density (BMD) and compare the results of oral and transdermal (TD) E2 administration in adolescents and young women with hypogonadism DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed the medical records of patients aged 15 to 24 years who were diagnosed with hypogonadism, who had begun receiving oral or TD E2 replacement, and whose initial dual-energy X-ray absorptiometry scan detected a lumbar spine BMD Z-score of -1 or lower between 2014 and 2018. The patients were divided into 2 groups according to the E2 route of administration as those who received 2 mg orally (Group 1) and 0.1 mg TD (Group 2). INTERVENTIONS None MAIN OUTCOME MEASURE: BMD scans of the patients at baseline and repeated within 2 years after E2 replacement RESULTS: In total, 43 patients who met the inclusion criteria were included in the study. Two groups did not differ for BMD scores at baseline. A significant improvement in BMD was observed with physiological dose E2 replacement in both groups. Mean BMD Z-score increased by +0.7 (95% CI, 0.47-0.93) in response to TD E2 administration, compared with +0.41 (95% CI, 0.25-0.58) during oral E2 replacement (P = .037). CONCLUSION We conclude that physiological dose E2 replacement, even within a short period of 2 years, has a significant beneficial effect on bone mass acquisition on the lumbar spine. Our study also demonstrates the possible superiority of TD E2 replacement over the oral route in increasing lumbar spine BMD.
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Affiliation(s)
- Ozlem Dural
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey.
| | - Hevra Ekin Ulusoy
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Muge Ates Tikiz
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Turkane Gurbanova
- Medical Park Gebze Hospital, Section of Obstetrics and Gynecology, Gebze, Kocaeli, Turkey
| | - Cenk Yasa
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Funda Gungor Ugurlucan
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Suleyman Engin Akhan
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
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Abstract
Childhood osteoporosis leads to increased propensity to fracture, and thus is an important cause of morbidity, pain and healthcare utilisation. Osteoporosis in children may be caused by a primary bone defect or secondary to an underlying medical condition and/or its treatment. Primary osteoporosis is rare, but there is an increasing number of children with risk factors for secondary osteoporosis. Therefore it is imperative that all paediatricians are aware of the diagnostic criteria and baseline investigations for childhood osteoporosis to enable timely referral to a specialist in paediatric bone health. This review will discuss the approach to diagnosis, investigation and management of childhood osteoporosis, with particular consideration to advances in molecular diagnosis of primary bone disorders, and current and emerging therapies for fracture reduction.
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Affiliation(s)
- David B. N. Lim
- University Hospital Southampton NHS Foundation Trust, Southampton Children’s Hospital, Paediatric Endocrinology, Hampshire, England
| | - Rebecca J. Moon
- University Hospital Southampton NHS Foundation Trust, Southampton Children’s Hospital, Paediatric Endocrinology, Hampshire, England,MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, England
| | - Justin H. Davies
- University Hospital Southampton NHS Foundation Trust, Southampton Children’s Hospital, Paediatric Endocrinology, Hampshire, England,University of Southampton, Faculty of Medicine, Southampton, England
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17
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Avery K, Noble M, Flexer L, Williams C, Briggs P. Eating disorders and bone health: A missed opportunity?. Post Reprod Health 2022; 28:248-251. [PMID: 36375825 DOI: 10.1177/20533691221141129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Kuki Avery
- 156761Liverpool Women's Hospital, Liverpool, UK
| | - Matt Noble
- 156761Liverpool Women's Hospital, Liverpool, UK
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18
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Lopes MP, Robinson L, Stubbs B, Dos Santos Alvarenga M, Araújo Martini L, Campbell IC, Schmidt U. Associations between bone mineral density, body composition and amenorrhoea in females with eating disorders: a systematic review and meta-analysis. J Eat Disord 2022; 10:173. [PMID: 36401318 PMCID: PMC9675098 DOI: 10.1186/s40337-022-00694-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/23/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lower bone mineral density (BMD) increases the risk of osteoporosis in individuals with eating disorders (EDs), particularly women with anorexia nervosa (AN), making them susceptible to pain and fractures throughout adulthood. In AN, low weight, hypothalamic amenorrhoea, and longer illness duration are established risk factors for low BMD, and in people with other EDs a history of AN seems to be an important risk factor for low BMD. PURPOSE To conduct a systematic review and meta-analysis of BMD in individuals with EDs, including AN, bulimia nervosa (BN), binge-eating disorder (BED) and other specified feeding or eating disorders (OSFED) compared to healthy controls (HC). METHODS Following PRISMA guidelines, electronic databases were reviewed and supplemented with a literature search until 2/2022 of publications measuring BMD (dual-energy X-ray absorptiometry or dual photon absorptiometry) in females with any current ED diagnosis and a HC group. Primary outcomes were spine, hip, femur and total body BMD. Explanatory variables were fat mass, lean mass and ED clinical characteristics (age, illness duration, body mass index (BMI), amenorrhoea occurrence and duration, and oral contraceptives use). RESULTS Forty-three studies were identified (N = 4163 women, mean age 23.4 years, min: 14.0, max: 37.4). No study with individuals with BED met the inclusion criteria. BMD in individuals with AN (total body, spine, hip, and femur), with BN (total body and spine) and with OSFED (spine) was lower than in HC. Meta-regression analyses of women with any ED (AN, BN or OSFED) (N = 2058) showed low BMI, low fat mass, low lean mass and being amenorrhoeic significantly associated with lower total body and spine BMD. In AN, only low fat mass was significantly associated with low total body BMD. CONCLUSION Predictors of low BMD were low BMI, low fat mass, low lean mass and amenorrhoea, but not age or illness duration. In people with EDs, body composition measurement and menstrual status, in addition to BMI, are likely to provide a more accurate assessment of individual risk to low BMD and osteoporosis.
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Affiliation(s)
- Mariana P Lopes
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil. .,Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.
| | - Lauren Robinson
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK
| | - Brendon Stubbs
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.,Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
| | - Marle Dos Santos Alvarenga
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil
| | - Ligia Araújo Martini
- Nutrition Department, School of Public Health University of São Paulo, Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo, São Paulo, 01246-904, Brazil
| | - Iain C Campbell
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 6 De Crespigny Park, London, SE5 8AF, UK.,Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
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19
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Haines MS, Kimball A, Meenaghan E, Santoso K, Colling C, Singhal V, Ebrahimi S, Gleysteen S, Schneider M, Ciotti L, Belfer P, Eddy KT, Misra M, Miller KK. Denosumab increases spine bone density in women with anorexia nervosa: a randomized clinical trial. Eur J Endocrinol 2022; 187:697-708. [PMID: 36134902 PMCID: PMC9746654 DOI: 10.1530/eje-22-0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/21/2022] [Indexed: 12/15/2022]
Abstract
Objective Anorexia nervosa is complicated by high bone resorption, low bone mineral density (BMD), and increased fracture risk. We investigated whether off-label antiresorptive therapy with denosumab increases BMD in women with anorexia nervosa. Design Twelve-month, randomized, double-blind, placebo-controlled study. Methods Thirty ambulatory women with anorexia nervosa and areal BMD (aBMD) T-score <-1.0 at ≥1 sites were randomized to 12 months of denosumab (60 mg subcutaneously q6 months)(n = 20) or placebo (n = 10). Primary end point was postero-anterior (PA) lumbar spine aBMD by dual-energy x-ray absorptiometry. Secondary end points included femoral neck aBMD, tibia and radius volumetric BMD and bone microarchitecture by high-resolution peripheral quantitative CT, tibia and radius failure load by finite element analysis (FEA), and markers of bone turnover. Results Baseline mean (±s.d.) age (29 ± 8 (denosumab) vs 29 ± 7 years (placebo)), BMI (19.0 ± 1.7 vs 18.0 ± 2.0 kg/m2), and aBMD (PA spine Z-score -1.6±1.1 vs -1.7±1.4) were similar between groups. PA lumbar spine aBMD increased in the denosumab vs placebo group over 12 months (P = 0.009). The mean (95% CI) increase in PA lumbar spine aBMD was 5.5 (3.8-7.2)% in the denosumab group and 2.2 (-0.3-4.7)% in the placebo group. The change in femoral neck aBMD was similar between groups. Radial trabecular number increased, radial trabecular separation decreased, and tibial cortical porosity decreased in the denosumab vs placebo group (P ≤ 0.006). Serum C-terminal telopeptide of type I collagen and procollagen type I N-terminal propeptide decreased in the denosumab vs placebo group (P < 0.0001). Denosumab was well tolerated. Conclusions Twelve months of antiresorptive therapy with denosumab reduced bone turnover and increased spine aBMD, the skeletal site most severely affected in women with anorexia nervosa.
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Affiliation(s)
- Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Kimball
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Erinne Meenaghan
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kate Santoso
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Seda Ebrahimi
- Cambridge Eating Disorder Center, Cambridge, Massachusetts, USA
| | - Suzanne Gleysteen
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Marcie Schneider
- Greenwich Adolescent & Young Adult Medicine, Greenwich, Connecticut, USA
| | - Lori Ciotti
- The Renfrew Center, Boston, Massachusetts, USA
| | - Perry Belfer
- Harvard Medical School, Boston, Massachusetts, USA
- Newton-Wellesley Eating Disorders & Behavioral Medicine, Brookline, Massachusetts, USA
- McLean Hospital, Belmont, Massachusetts, USA
| | - Kamryn T Eddy
- Harvard Medical School, Boston, Massachusetts, USA
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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20
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Szeliga A, Podfigurna A, Bala G, Meczekalski B. The influence of estro-progestin therapy on neurohormonal activity in functional hypothalamic amenorrhea. Gynecol Endocrinol 2022; 38:997-1002. [PMID: 36170883 DOI: 10.1080/09513590.2022.2128103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Functional hypothalamic amenorrhea (FHA) is a chronic endocrine disorder caused by the abnormal pulsatile secretion of neurohormones in the hypothalamus. Secretion of GnRH is regulated by kisspeptin/neurokinin B/dynorphin (KNDy) neurons. These neurons produce, among other neurohormones, neurokinin B (NKB) which regulates the coordinated stimulation or inhibition of GnRH secreting neurons. Aim of the study: Assessment and comparison of serum NKB in patients with FHA at baseline, and following 6 months of estrogen-progestagen therapy. Materials and methods: Fifty-five patients with functional hypothalamic amenorrhea were included in the study group. Serum concentrations of neurokinin B (NKB), follicle stimulating hormone (FSH), luteinizing hormone (LH), 17-β-estradiol (E2), prolactin (PRL), cortisol, testosterone (T), dehydroepiandrosterone sulfate (DHEA-S), thyroid-stimulating hormone (TSH), free thyroxine (fT4), fasting glucose and insulin, as well as lipid profile were measured at baseline. At the time of diagnosis, patients with FHA were prescribed a course of 2 mg 17-β-estradiol and 10 mg dydrogesterone for duration of 6 months. Serum NKB was then reassessed following treatment at 6 months. Results: At baseline, the FHA group was found to have a decreased serum NKB concentration when compared to a healthy control group. Following 6 months of sequential estrogen-progestogen hormone therapy, this study did not find any statistically significant difference in serum NKB concentration in the treatment arm compared to baseline. Conclusions: For the first time, NKB secretion has been studied in patients with FHA. A significantly lower level of serum NKB was observed in these patients at baseline, when compared to a control group. After 6 months of combination estrogen-progesterone therapy, no significant changes in NKB levels were observed in these patients. These findings, for the first time in the literature, provide insight into the perceived benefit of HRT, calling into question its benefit in addressing the underlying etiopathogenetic contributors of FHA. These new findings may contribute to more targeted and appropriate treatment of such patients in the future.
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Affiliation(s)
- Anna Szeliga
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Podfigurna
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
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21
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Delisle B. Blutungsstörungen im Kindes- und Jugendalter. GYNAKOLOGISCHE ENDOKRINOLOGIE 2022. [DOI: 10.1007/s10304-022-00453-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Abstract
Eating disorders are common behavioral disorders associated with substantial psychological and physical morbidity and mortality. Persons with eating disorders frequently present to primary care providers, who may also be responsible for their general medical management. This article reviews the diagnosis, medical assessment, and treatment of the most common eating disorders.
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Affiliation(s)
- Blair Uniacke
- Columbia Center for Eating Disorders, New York, New York
| | - B Timothy Walsh
- Columbia University Irving Medical Center, New York, New York
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23
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Saldanha N, Fisher M. Menstrual disorders in adolescents and young adults with eating disorders. Curr Probl Pediatr Adolesc Health Care 2022; 52:101240. [PMID: 35909056 DOI: 10.1016/j.cppeds.2022.101240] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Although amenorrhea is no longer a specific criterion required to make the diagnosis of anorexia nervosa (AN), the relationship between restrictive eating and menstrual status remains important in the diagnosis, treatment, and consequences for patients with eating disorders. Clinicians should understand the relationship between menstrual irregularities and malnutrition due to eating disorders, as it may be possible to intervene sooner if the diagnosis is made earlier. Treatment of AN (in those who are underweight) and atypical AN (in those who are not underweight) is aimed at cessation of restrictive thoughts and behaviors, restoration of appropriate nutrition and weight, and normal functioning of the body. While eating disorder thoughts and behaviors are helped by both therapy and nutrition, regular functioning of the body, including regular menstruation, is linked to both appropriate nutrition and weight. Patients who are not underweight based on their body mass index (BMI) may still have oligo/amenorrhea due to their caloric restriction; thus any patient who has irregular menses should have a detailed dietary evaluation as part of their workup. Timely diagnosis and treatment of patients with eating disorders and amenorrhea is important due to the impact on bone mass accrual for adolescents who have prolonged amenorrhea. Menstrual abnormalities may also be seen in patients with bulimia nervosa (BN).
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Affiliation(s)
- Nadia Saldanha
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, New York 11042, USA; Donald and Barbara Zucker, School of Medicine at Hofstra / Northwell, Hempstead, New York, USA.
| | - Martin Fisher
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, New York 11042, USA; Donald and Barbara Zucker, School of Medicine at Hofstra / Northwell, Hempstead, New York, USA
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Rodd C, Kirouac N, Orkin J, Grimes R. Evaluating and optimizing bone health in children with chronic health conditions. Paediatr Child Health 2022; 27:232-242. [PMID: 35859678 DOI: 10.1093/pch/pxac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.
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Affiliation(s)
- Celia Rodd
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Nicole Kirouac
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Julia Orkin
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Ruth Grimes
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
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Modan-Moses D, Megnazi O, Tripto-Shkolnik L, Talmor H, Toledano A, Shilton T, Enoch-Levy A, Stein D, Levy-Shraga Y. Changes in trabecular bone score and bone density in female adolescents with anorexia nervosa: a longitudinal study. J Clin Densitom 2022; 25:416-423. [PMID: 34933783 DOI: 10.1016/j.jocd.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/23/2021] [Accepted: 11/08/2021] [Indexed: 12/25/2022]
Abstract
Impaired bone health is a common complication of anorexia nervosa (AN). We aimed to assess longitudinal changes in bone mineral density (BMD) and trabecular bone score (TBS), a measure of bone quality, in female adolescents with anorexia nervosa (AN). We conducted a retrospective longitudinal study of 41 female adolescents with AN who underwent two dual-energy X-ray absorptiometry (DXA) scans. Clinical data, including age, weight, height, body mass index (BMI), and DXA measurements were retrieved from the medical charts. Lumbar bone mineral apparent density (BMAD) was calculated to correct for size. Changes (Δ) in BMD, BMAD, and TBS were examined for correlations with clinical characteristics. Mean ages at the time of DXA scans were 14.8±1.9 and 16.8±2.0 years. There was a significant improvement in anthropometric parameters and DXA measurements at the second DXA scan. However, these values were still significantly lower than expected in the general population. The Δlumbar BMD Z-score was 0.3±0.7, the Δlumbar BMAD Z-score was 0.2±0.7 and the ΔTBS Z-score was 0.5±0.7. ΔTBS Z-score was positively correlated with Δheight Z-score, Δweight Z-score and ΔBMI Z-scores, and negatively correlated height Z-score, weight Z-score and TBS Z-scores at the first DXA scan (p<0.05). Δheight Z-score, ΔBMI Z-score and the progression from early to late puberty were identified as significant independent predictors of Δlumbar BMAD Z-score (p<0.05). During two years of treatment, both BMD and TBS increased significantly. Improvement in height and in weight status, and progression in puberty are predictors of improvement in BMD and TBS.
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Affiliation(s)
- Dalit Modan-Moses
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israe; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv
| | - Ophir Megnazi
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv
| | - Liana Tripto-Shkolnik
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israe
| | - Helit Talmor
- Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Anat Toledano
- Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Tal Shilton
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Enoch-Levy
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Daniel Stein
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Yael Levy-Shraga
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israe; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv.
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Rodd C, Kirouac N, Orkin J, Grimes R. L'évaluation et l'optimisation de la santé osseuse chez les enfants ayant des affections chroniques. Paediatr Child Health 2022; 27:232-242. [PMID: 35859683 DOI: 10.1093/pch/pxac035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
Les professionnels de la santé des enfants jouent un rôle important dans l'optimisation de la santé osseuse. Il est essentiel d'intervenir rapidement pour maximiser le pic de masse osseuse à l'adolescence et au début de l'âge adulte et d'ainsi réduire le risque d'ostéoporose et de fractures plus tard dans la vie. Les enfants et les adolescents ayant une affection chronique peuvent présenter plusieurs facteurs de risque de mauvaise santé osseuse, notamment des maladies inflammatoires sous-jacentes, des activités avec mise en charge limitées, un retard pubertaire et un apport insuffisant de calcium et de vitamine D. Certains médicaments, et particulièrement les glucocorticoïdes, peuvent compromettre la masse osseuse et exposer l'enfant à un risque de fractures de fragilisation. Le présent point de pratique décrit une approche ciblée pour déterminer les facteurs de risque liés à la santé osseuse chez les enfants et les adolescents ayant une affection chronique, expose les mesures à prendre en cabinet pour optimiser l'acquisition de la masse osseuse et propose des outils en ligne utiles et des références médicales à l'intention des professionnels de la santé des enfants. Les indications pour diriger les patients vers un spécialiste de la santé osseuse et pour procéder à des interventions pharmacologiques visant les os sont également abordées.
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Affiliation(s)
- Celia Rodd
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Nicole Kirouac
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Julia Orkin
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Ruth Grimes
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
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Singhal V, Nimmala S, Slattery M, Eddy KT, Miller KK, Klibanski A, Misra M. Physiologic Transdermal Estradiol Replacement Mimics Effects of Endogenous Estrogen on Bone Outcomes in Hypoestrogenic Women with Anorexia Nervosa. Nutrients 2022; 14:2557. [PMID: 35807738 PMCID: PMC9268216 DOI: 10.3390/nu14132557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 02/01/2023] Open
Abstract
Background: While physiologic estrogen replacement results in increases in areal bone mineral density (aBMD) in hypoestrogenic adolescent girls and young adult women with AN, data are lacking regarding its impact on measures of volumetric BMD (vBMD), bone geometry, and structure. Methods: 23 young women with anorexia nervosa (AN) and 27 normal-weight healthy controls (HC) between 14−25 years old were followed for 12 months. AN participants received transdermal 17β-estradiol (continuously) with 10 days of cyclic oral progesterone (100 mg daily) every month for the study duration (AN-E+). DXA was used to measure aBMD and body composition, high resolution peripheral quantitative CT (HRpQCT) to assess vBMD, bone geometry and structure at the distal radius and tibia, and microfinite element analysis to estimate strength. Results: Groups did not differ for age. Median baseline BMI z-scores were −1.13 (−1.58, −0.38) in AN-E+ vs. 0.08 (−0.40, 0.84) in HC (p < 0.0001). For most HRpQCT parameters and strength estimates, young women with AN receiving physiologic estrogen replacement demonstrated similar changes over 12 months as did normoestrogenic HC. Additionally, radial cortical tissue mineral density, cortical vBMD, and failure load increased (p = 0.01; p = 0.02; p = 0.004 respectively) over 12 months in AN-E+ compared to HC. Conclusions: With physiologic estrogen replacement, bone accrual improved in AN to approximate changes observed in normoestrogenic controls followed without any intervention, with additional benefits observed for cortical tissue mineral density, cortical vBMD, and failure load at the radius in AN vs. controls. Thus, this strategy for estrogen replacement effectively mimics the effects of endogenous estrogen on bone structure and estimated strength.
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Affiliation(s)
- Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
- MGH Weight Center, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Supritha Nimmala
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
| | - Meghan Slattery
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
| | - Kamryn T. Eddy
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Karen K. Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; (S.N.); (M.S.); (K.T.E.); (K.K.M.); (A.K.); (M.M.)
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Behary P, Comninos AN. Bone Perspectives in Functional Hypothalamic Amenorrhoea: An Update and Future Avenues. Front Endocrinol (Lausanne) 2022; 13:923791. [PMID: 35795153 PMCID: PMC9251506 DOI: 10.3389/fendo.2022.923791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/11/2022] [Indexed: 01/22/2023] Open
Abstract
One of the most important and potentially long-lasting detrimental consequences of Functional Hypothalamic Amenorrhoea (FHA) is on skeletal homeostasis. Beyond oestrogen deficiency, FHA is associated with a cascade of additional neuro-endocrine and metabolic alterations, some adaptive, but which combine to disrupt skeletal homeostasis. Ultimately, this leads to a two-fold increased risk of fractures in women with FHA compared to healthy eumenorrhoeic women. Although the cornerstone of management of FHA-related bone loss remains recovery of menses via restoration of metabolic/psychological balance, there is rapidly developing evidence for hormonal manipulations (with a particular emphasis on route of administration) and other pharmacological treatments that can protect or improve skeletal homeostasis in FHA. In this mini-review, we provide an update on the pathophysiology, clinical management and future avenues in the field from a bone perspective.
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Affiliation(s)
- Preeshila Behary
- Endocrine Bone Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alexander N. Comninos
- Endocrine Bone Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
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Lin J, Kao TW, Cheng YC, Fan KC, Huang YC, Liu CW. Dehydroepiandrosterone status and efficacy of dehydroepiandrosterone supplementation for bone health in anorexia nervosa: A systematic review and meta-analysis. Int J Eat Disord 2022; 55:733-746. [PMID: 35460091 DOI: 10.1002/eat.23714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study was designed to determine the status of dehydroepiandrosterone (DHEA) in women with anorexia nervosa (AN) and to assess the efficacy of DHEA supplementation as a treatment for bone health in women with AN. METHOD Studies were retrieved from the PubMed, Embase, Cochrane Library, MEDLINE, and Scopus databases from inception to February 14, 2022. Observational studies that compared serum DHEA levels between women with AN and healthy controls were included for meta-analysis, and randomized controlled trials (RCTs) that evaluated the effects of DHEA supplementation on bone mass were reviewed. RESULTS Meta-analysis of 15 cross-sectional studies revealed that patients with AN had significantly elevated serum DHEA levels (mean difference (MD) = 311.63 ng/dl; 95% confidence interval (CI), 78.01-545.25) and reduced DHEAS levels (MD = -24.90 μg/dl; 95% CI, -41.72 to -8.07) compared with healthy controls. A systematic review of seven RCTs found that DHEA monotherapy does not improve bone mineral density (BMD) compared with placebo after adjusting for weight gain. While the combination of DHEA and conjugated oral contraceptives has led to increased bone strength and decreased bone loss, the beneficial effect appears to be limited to older adolescents and adults with closed physes. Potential detrimental effects on BMD were identified in younger adolescents with open physes in one study. DISCUSSION Due to the lack of apparent benefit of DHEA in women with AN and its potential detrimental effect on BMD in young patients with AN, current evidence does not support the use of DHEA. PUBLIC SIGNIFICANCE This study demonstrates that women with anorexia nervosa have abnormal levels of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS), which have been suggested by previous studies to play a role in the development of low bone density in this condition. However, current evidence does not support the use of DHEA as a treatment to preserve bone health in patients with anorexia nervosa given the lack of clear benefit following its use and also because of a potential detrimental effect on bone mineral density in young patients with anorexia nervosa.
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Affiliation(s)
- James Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ting-Wan Kao
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ying-Chih Cheng
- Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, China Medical University Hsinchu Hospital, China Medical University, Hsinchu, Taiwan.,Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Kang-Chih Fan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Chen Huang
- Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Che-Wei Liu
- Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Orthopedics, Cathay General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.,School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
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Mazziotti G, Lania AG, Canalis E. Skeletal disorders associated with the growth hormone-insulin-like growth factor 1 axis. Nat Rev Endocrinol 2022; 18:353-365. [PMID: 35288658 DOI: 10.1038/s41574-022-00649-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/08/2022]
Abstract
Growth hormone (GH) and insulin-like growth factor 1 (IGF1) are important regulators of bone remodelling and metabolism and have an essential role in the achievement and maintenance of bone mass throughout life. Evidence from animal models and human diseases shows that both GH deficiency (GHD) and excess are associated with changes in bone remodelling and cause profound alterations in bone microstructure. The consequence is an increased risk of fractures in individuals with GHD or acromegaly, a condition of GH excess. In addition, functional perturbations of the GH-IGF1 axis, encountered in individuals with anorexia nervosa and during ageing, result in skeletal fragility and osteoporosis. The effect of interventions used to treat GHD and acromegaly on the skeleton is variable and dependent on the duration of the disease, the pre-existing skeletal state, coexistent hormone alterations (such as those occurring in hypogonadism) and length of therapy. This variability could also reflect the irreversibility of the skeletal structural defect occurring during alterations of the GH-IGF1 axis. Moreover, the effects of the treatment of GHD and acromegaly on locally produced IGF1 and IGF binding proteins are uncertain and in need of further study. This Review highlights the pathophysiological, clinical and therapeutic aspects of skeletal fragility associated with perturbations in the GH-IGF1 axis.
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Affiliation(s)
- Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele Milan, Italy.
- Endocrinology, Diabetology and Andrology Unit - Bone Diseases and Osteoporosis Section, IRCCS, Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele Milan, Italy
- Endocrinology, Diabetology and Andrology Unit - Bone Diseases and Osteoporosis Section, IRCCS, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ernesto Canalis
- Departments of Orthopaedic Surgery and Medicine, UConn Health, Farmington, CT, USA
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Hung C, Muñoz M, Shibli-Rahhal A. Anorexia Nervosa and Osteoporosis. Calcif Tissue Int 2022; 110:562-575. [PMID: 33666707 DOI: 10.1007/s00223-021-00826-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/14/2021] [Indexed: 12/12/2022]
Abstract
Patients with anorexia nervosa (AN) often experience low bone mineral density (BMD) and increased fracture risk, with low body weight and decreased gonadal function being the strongest predictors of the observed bone mineral deficit and fractures. Other metabolic disturbances have also been linked to bone loss in this group of patients, including growth hormone resistance, low insulin-like growth factor-1 (IGF-1) concentrations, low leptin concentrations, and hypercortisolemia. However, these correlations lack definitive evidence of causality. Weight restoration and resumption of menstrual function have the strongest impact on increasing BMD. Other potential treatment options include bisphosphonates and teriparatide, supported by data from small clinical trials, but these agents are not approved for the treatment of low BMD in adolescents or premenopausal women with AN.
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Affiliation(s)
- Chermaine Hung
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Marcus Muñoz
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Amal Shibli-Rahhal
- Division of Endocrinology, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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Kerns J, Itriyeva K, Fisher M. Etiology and management of amenorrhea in adolescent and young adult women. Curr Probl Pediatr Adolesc Health Care 2022; 52:101184. [PMID: 35525789 DOI: 10.1016/j.cppeds.2022.101184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In this article, we will review the etiology and management of amenorrhea in adolescent and young adult women, beginning with the diagnostic work-up and followed by etiologies organized by system. Most cases of amenorrhea are caused by dysfunction of the hypothalamic-pituitary-ovarian (HPO) axis, which is the major regulator of the female reproductive hormones: estrogen and progesterone. We begin by reviewing hypothalamic etiologies, including eating disorders and relative energy deficiency in sport. Then, pituitary causes of amenorrhea are reviewed, including hyperprolactinemia, empty sella syndrome, Sheehan's syndrome and Cushing's syndrome. Next, ovarian causes of amenorrhea are reviewed, including polycystic ovarian syndrome and primary ovarian insufficiency. Finally, other etiologies of amenorrhea are discussed, including thyroid disease, adrenal disease and reproductive tract anomalies. In conclusion, there is a wide and diverse range of causes of amenorrhea in adolescents that originate from any level of the HPO axis, as well as anatomic and chromosomal etiologies. Treatment should be focused on the underlying cause. Preservation of bone density and risk of fractures should be discussed with amenorrheic patients since many causes of amenorrhea can result in decreased bone density and may be irreversible.
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Affiliation(s)
- Jessica Kerns
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.
| | - Khalida Itriyeva
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Martin Fisher
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Sobh MM, Abdalbary M, Elnagar S, Nagy E, Elshabrawy N, Abdelsalam M, Asadipooya K, El-Husseini A. Secondary Osteoporosis and Metabolic Bone Diseases. J Clin Med 2022; 11:jcm11092382. [PMID: 35566509 PMCID: PMC9102221 DOI: 10.3390/jcm11092382] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/17/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.
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Affiliation(s)
- Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, KY 40506, USA;
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
- Correspondence: ; Tel.: +1-859-218-0934
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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Ng E, Sztal‐Mazer S, Davis SR. Functional hypothalamic amenorrhoea: a diagnosis of exclusion. Med J Aust 2022; 216:73-76. [DOI: 10.5694/mja2.51376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Susan R Davis
- Alfred Health Melbourne VIC
- Women's Health Research Program Monash University Melbourne VIC
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Abstract
PURPOSE OF REVIEW Adolescence and young adulthood are a critical period in the life of women for optimizing long-term bone health. Young athletes lead a demanding lifestyle with increased dietary requirements to meet the robust demands of energy expenditure to maintain a state of energy balance. During a time of fast paced changes and unpredictable societal demands on young athletes, it is important to review the severe consequences of energy deficiency and options for adequate management. RECENT FINDINGS This review focuses on hormonal adaptations that occur in energy deficient female athletes that lead to menstrual irregularities and impaired bone health, increasing the risk for stress and other fractures. We also describe management strategies to mitigate the consequences of limited energy availability on bone and other outcomes. SUMMARY These strategies should help guide the management of young female athletes to prevent irreversible changes to their bone health. Identifying current knowledge should help increase awareness among medical providers, which can then be communicated to the sports community, parents, and athletes.
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Affiliation(s)
- Jacqueline Maya
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Curran KA, Pitt PD. The Reproductive Impact of Eating Disorders in Adolescents. Semin Reprod Med 2022; 40:79-86. [PMID: 35073591 DOI: 10.1055/s-0042-1742326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Eating disorders are common, chronic illnesses that frequently arise during adolescence. Because of the impact on nutrition, individuals with eating disorders have significant health consequences, including effects on reproductive health. Adolescent women with eating disorders frequently have menstrual irregularities, though the causes of these abnormalities are complex and vary depending on the type of eating disorder. Teens with eating disorders may have changes in current and future fertility, and eating disorders during pregnancy can have medical and psychologic impacts for both mother and child. Though not well researched, eating disorders in men can affect reproductive health and potentially impact fertility. Lastly, eating disorders in adolescents can have significantly deleterious, irreversible effects on bone health.
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Affiliation(s)
- Kelly A Curran
- Section of Adolescent Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Paulette D Pitt
- Department of Education and Psychology, East Central University, Ada, Oklahoma
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Herath M, Cohen A, Ebeling PR, Milat F. Dilemmas in the Management of Osteoporosis in Younger Adults. JBMR Plus 2022; 6:e10594. [PMID: 35079682 PMCID: PMC8771004 DOI: 10.1002/jbm4.10594] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
Osteoporosis in premenopausal women and men younger than 50 years is challenging to diagnose and treat. There are many barriers to optimal management of osteoporosis in younger adults, further enhanced by a limited research focus on this cohort. Herein we describe dilemmas commonly encountered in diagnosis, investigation, and management of osteoporosis in younger adults. We also provide a suggested framework, based on the limited available evidence and supported by clinical experience, for the diagnosis, assessment, and management of osteoporosis in this cohort. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Madhuni Herath
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Adi Cohen
- Department of Medicine Columbia University College of Physicians & Surgeons New York NY USA
| | - Peter R. Ebeling
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Frances Milat
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
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Kelly AW, Hecht S. The female athlete triad. ANNALS OF JOINT 2022; 7:6. [PMID: 38529159 PMCID: PMC10929343 DOI: 10.21037/aoj-2020-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/24/2020] [Indexed: 03/27/2024]
Abstract
The female athlete triad represents the 3 interrelated components: of energy availability (EA), menstrual function and bone health. Each component exists on a spectrum ranging from optimal health to dysfunction. Screening for the triad during the annual wellness exam, the preparticipation physical evaluation (PPE) or when the athlete presents with any single component can help identify athletes at risk. A multidisciplinary team is helpful in managing the treatment of the Triad which relies on improving EA. Screening, early recognition and aggressive treatment is important, especially in adolescent athletes to optimize bone health.
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Affiliation(s)
- Amanda Weiss Kelly
- University Hospitals of Cleveland, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Suzanne Hecht
- University Hospitals of Cleveland, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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40
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Aging of Skeletal Stem Cells. ADVANCES IN GERIATRIC MEDICINE AND RESEARCH 2022; 4. [PMID: 36037035 PMCID: PMC9409336 DOI: 10.20900/agmr20220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The skeletal system is generated and maintained by its progenitors, skeletal stem cells (SSCs), across the duration of life. Gradual changes associated with aging result in significant differences in functionality of SSCs. Declines in bone and cartilage production, increase of bone marrow adipose tissue, compositional changes of cellular microenvironments, and subsequent deterioration of external and internal structures culminate in the aged and weakened skeleton. The features and mechanisms of skeletal aging, and of its stem and progenitor cells in particular, are topics of recent investigation. The discovery of functionally homogeneous SSC populations with a defined cell surface phenotype has allowed for closer inspection of aging in terms of its effects on transcriptional regulation, cell function, and identity. Here, we review the aspects of SSC aging on both micro- and macroscopic levels. Up-to-date knowledge of SSC biology and aging is presented, and directions for future research and potential therapies are discussed. The realm of SSC-mediated bone aging remains an important component of global health and a necessary facet in our understanding of human aging.
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Pedreira CC, Maya J, Misra M. Functional hypothalamic amenorrhea: Impact on bone and neuropsychiatric outcomes. Front Endocrinol (Lausanne) 2022; 13:953180. [PMID: 35937789 PMCID: PMC9355702 DOI: 10.3389/fendo.2022.953180] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/29/2022] [Indexed: 12/01/2022] Open
Abstract
Functional hypothalamic amenorrhea is a state of reversible hypogonadism common in adolescents and young women that can be triggered by energy deficit or emotional stress or a combination of these factors. Energy deficit may be a consequence of (i) reduced caloric intake, as seen in patients with eating disorders, such as anorexia nervosa, or (ii) excessive exercise, when caloric intake is insufficient to meet the needs of energy expenditure. In these conditions of energy deficit, suppression of the hypothalamic secretion of gonadotrophin-releasing hormone (with resulting hypoestrogenism) as well as other changes in hypothalamic-pituitary function may occur as an adaptive response to limited energy availability. Many of these adaptive changes, however, are deleterious to reproductive, skeletal, and neuropsychiatric health. Particularly, normoestrogenemia is critical for normal bone accrual during adolescence, and hypoestrogenemia during this time may lead to deficits in peak bone mass acquisition with longstanding effects on skeletal health. The adolescent years are also a time of neurological changes that impact cognitive function, and anxiety and depression present more frequently during this time. Normal estrogen status is essential for optimal cognitive function (particularly verbal memory and executive function) and may impact emotion and mood. Early recognition of women at high risk of developing hypothalamic amenorrhea and its timely management with a multidisciplinary team are crucial to prevent the severe and long-term effects of this condition.
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Affiliation(s)
- Clarissa Carvalho Pedreira
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuroendocrine Unit, Center for Endocrinology and Diabetes of Bahia State, Salvador, Brazil
- *Correspondence: Clarissa Carvalho Pedreira,
| | - Jacqueline Maya
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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42
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Estrogen for the Treatment of Low Bone Mineral Density in Anorexia Nervosa. JOURNAL OF PSYCHIATRY AND BRAIN SCIENCE 2022; 7. [PMID: 35874115 PMCID: PMC9302594 DOI: 10.20900/jpbs.20220004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anorexia nervosa is a disorder of chronic, self-induced negative energy balance which typically results in a low body weight. Functional hypothalamic amenorrhea is an adaptive response to states of negative energy balance and chronic undernutrition. A majority of women with anorexia nervosa are amenorrheic with resultant hypoestrogenemia, and longer durations of amenorrhea are associated with lower bone mineral density in this population. In this review, we highlight studies that have investigated the effects of estrogen replacement on bone mineral density in anorexia nervosa, including prospective and randomized studies that show no benefit to treatment with oral estrogen with respect to bone mineral density in either adolescent girls or women with anorexia nervosa. We also review data from a randomized, placebo-controlled study in adolescent girls and a prospective, open-label pilot study in women with anorexia nervosa suggesting that transdermal estrogen may have beneficial effects with respect to bone mineral density in this population.
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Indirli R, Lanzi V, Mantovani G, Arosio M, Ferrante E. Bone health in functional hypothalamic amenorrhea: What the endocrinologist needs to know. Front Endocrinol (Lausanne) 2022; 13:946695. [PMID: 36303862 PMCID: PMC9592968 DOI: 10.3389/fendo.2022.946695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
In the original definition by Klinefelter, Albright and Griswold, the expression "hypothalamic hypoestrogenism" was used to describe functional hypothalamic amenorrhoea (FHA). Given the well-known effects of estrogens on bone, the physiopathology of skeletal fragility in this condition may appear self-explanatory. Actually, a growing body of evidence has clarified that estrogens are only part of the story. FHA occurs in eating disorders, overtraining, and during psychological or physical stress. Despite some specific characteristics which differentiate these conditions, relative energy deficiency is a common trigger that initiates the metabolic and endocrine derangements contributing to bone loss. Conversely, data on the impact of amenorrhoea on bone density or microarchitecture are controversial, and reduced bone mass is observed even in patients with preserved menstrual cycle. Consistently, oral estrogen-progestin combinations have not proven beneficial on bone density of amenorrheic women. Low bone density is a highly prevalent finding in these patients and entails an increased risk of stress or fragility fractures, and failure to achieve peak bone mass and target height in young girls. Pharmacological treatments have been studied, including androgens, insulin-like growth factor-1, bisphosphonates, denosumab, teriparatide, leptin, but none of them is currently approved for use in FHA. A timely screening for bone complications and a multidisciplinary, customized approach aiming to restore energy balance, ensure adequate protein, calcium and vitamin D intake, and reverse the detrimental metabolic-endocrine changes typical of this condition, should be the preferred approach until further studies are available.
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Affiliation(s)
- Rita Indirli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Rita Indirli,
| | - Valeria Lanzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Iwasa T, Minato S, Imaizumi J, Yoshida A, Kawakita T, Yoshida K, Yamamoto Y. Effects of low energy availability on female reproductive function. Reprod Med Biol 2021; 21:e12414. [PMID: 34934398 PMCID: PMC8656184 DOI: 10.1002/rmb2.12414] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/03/2021] [Indexed: 01/15/2023] Open
Abstract
Background It is known that metabolic and nutritional disturbances induce reproductive dysfunction in females. The main cause of these alterations is reduced gonadotrophin‐releasing hormone (GnRH) secretion from the hypothalamus, and the underlying mechanisms have gradually been elucidated. Methods The present review summarizes current knowledge about the effects of nutrition/metabolism on reproductive functions, especially focusing on the GnRH regulation system. Main findings Various central and peripheral factors are involved in the regulation of GnRH secretion, and alterations in their activity combine to affect GnRH neurons. Satiety‐related factors, i.e., leptin, insulin, and alpha‐melanocyte‐stimulating hormone, directly and indirectly stimulate GnRH secretion, whereas orexigenic factors, i.e., neuropeptide Y, Agouti‐related protein, orexin, and ghrelin, attenuate GnRH secretion. In addition, kisspeptin, which is a potent positive regulator of GnRH, expression is reduced by metabolic and nutritional disturbances. Conclusion These neuroendocrine systems may be defensive mechanisms, which help organisms to survive adverse conditions by temporarily suppressing reproduction.
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Affiliation(s)
- Takeshi Iwasa
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
| | - Saki Minato
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
| | - Junki Imaizumi
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
| | - Atsuko Yoshida
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
| | - Takako Kawakita
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
| | - Kanako Yoshida
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
| | - Yuri Yamamoto
- Department of Obstetrics and Gynecology Graduate School of Biomedical Sciences Tokushima University Tokushima Japan
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Lahoti A, Yu C, Brar PC, Dalgo A, Gourgari E, Harris R, Kamboj MK, Marks S, Nandagopal R, Page L, Raman V, Reynolds DG, Sarafoglou K, Terrell C, Stanley TL. An endocrine perspective on menstrual suppression for adolescents: achieving good suppression while optimizing bone health. J Pediatr Endocrinol Metab 2021; 34:1355-1369. [PMID: 34388330 DOI: 10.1515/jpem-2020-0539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 07/19/2021] [Indexed: 11/15/2022]
Abstract
Suppression of menstruation and/or ovarian function in adolescent girls may be desired for a variety of reasons. Numerous medical options exist. The choice of the appropriate modality for an individual patient depends on several factors based on differences in the efficacy of achieving menstrual suppression as well as in their side effect profiles. Adolescence is also a period of bone mass accrual in girls, and several of these modalities may negatively influence peak bone mass. This review focuses on the efficacy of achieving menstrual suppression and the effect on bone health of the various options through an overview of the current literature and also highlights areas in need of further research.
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Affiliation(s)
- Amit Lahoti
- Pediatric Endocrine Division, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christine Yu
- Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, University of Chicago, Chicago, IL, USA
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, NYU Grossman School of Medicine, New York, NY, USA
| | - Austin Dalgo
- Center for Bioethics and Health Equity, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evgenia Gourgari
- Pediatric Endocrinology Division, Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Rebecca Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Manmohan K Kamboj
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital at The Ohio State University, Columbus, OH, USA
| | - Seth Marks
- Section of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, Children's Hospital HSC Winnipeg, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Radha Nandagopal
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Laura Page
- Division of Endocrinology, Department of Pediatrics, Duke University, Durham, NC, USA
| | | | - Danielle G Reynolds
- Diabetes and Endocrinology Center, University of South Florida, Tampa, FL, USA
| | - Kyriakie Sarafoglou
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.,Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Carrie Terrell
- Division of General Obstetrics, Gynecology, Midwifery and Family Planning at the University of Minnesota Medical School, Minneapolis, MN, USA
| | - Takara L Stanley
- Pediatric Endocrine Unit and Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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46
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Hirschberg AL. Female Hyperandrogenism in Elite Sports and the Athletic Triad. Semin Reprod Med 2021; 40:32-41. [PMID: 34634825 DOI: 10.1055/s-0041-1736337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Essential hyperandrogenism seems to be overrepresented in female elite athletes. This applies to mild forms such as polycystic ovary syndrome, as well as rare differences/disorders of sex development (DSD). The reason is likely a selection bias since there is increasing evidence that androgens are beneficial for athletic performance by potent anabolic effects on muscle mass and bone mass, and stimulation of erythropoiesis. XY DSD may cause a greatly increased production of testosterone in the male range, that is, 10 to 20 times higher than the normal female range. The established regulations concerning the eligibility of female athletes with severe hyperandrogenism to compete in the female classification remain controversial. The most common cause of menstrual disorders in female athletes, however, is probably an acquired functional hypothalamic disturbance due to energy deficiency in relation to energy expenditure, which could lead to low bone mineral density and increased risk of injury. This condition is particularly common in endurance and esthetic sports, where a lean body composition is considered an advantage for physical performance. It is important to carefully evaluate endocrine disturbances and menstrual disorders in athletes since the management should be specific according to the underlying cause.
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Affiliation(s)
- Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
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Abstract
The aim of the study is to present the problem of functional hypothalamic amenorrhea, taking into account any disease and treatment, diagnosis, and consequences of this disease. We searched PubMed (MEDLINE) and included 38 original and review articles concerning functional hypothalamic amenorrhea. Functional hypothalamic amenorrhea is the most common cause of secondary amenorrhea in women of childbearing age. It is a reversible disorder caused by stress related to weight loss, excessive exercise and/or traumatic mental experiences. The basis of functional hypothalamic amenorrhea is hormonal, based on impaired pulsatile GnRH secretion in the hypothalamus, then decreased secretion of gonadotropins, and, consequently, impaired hormonal function of the ovaries. This disorder leads to hypoestrogenism, manifested by a disturbance of the menstrual cycle in the form of amenorrhea, leading to anovulation. Prolonged state of hypoestrogenism can be very detrimental to general health, leading to many harmful short- and long-term consequences. Treatment of functional hypothalamic amenorrhea should be started as soon as possible, and it should primarily involve lifestyle modification. Only then should pharmacological treatment be applied. Importantly, treatment is most often long-term, but it results in recovery for the majority of patients. Effective therapy, based on multidirectional action, can protect patients from numerous negative impacts on fertility, cardiovascular system and bone health, as well as reducing mental morbidity.
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Aalberg K, Stavem K, Norheim F, Russell MB, Chaibi A. Effect of oral and transdermal oestrogen therapy on bone mineral density in functional hypothalamic amenorrhoea: a systematic review and meta-analysis. BMJ Open Sport Exerc Med 2021; 7:e001112. [PMID: 34306727 PMCID: PMC8264872 DOI: 10.1136/bmjsem-2021-001112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 11/03/2022] Open
Abstract
Background Female athletes might develop reduced bone mineral density (BMD) and amenorrhoea due to low energy intake. Objective To systematically review the literature of randomised controlled trials (RCTs) assessing the effect of oestrogen oral contraceptives (OCP), conjugated oestrogens (CE) and transdermal estradiol (TE) on BMD in premenopausal women with functional hypothalamic amenorrhoea (FHA) due to weight loss, vigorous exercise and/or stress. Methods A comprehensive literature search in PubMed, MEDLINE, Cochrane Library, Ovid and CINAHL from inception to 1 October 2020. Data extraction and synthesis Two authors independently extracted data. When possible, the data were pooled in a random-effects meta-analysis. Main outcomes Difference in BMD (g/cm2) at the lumbar spine. Results Nine RCTs comprising 770 participants met the inclusion criteria; five studies applied OCP, two CE and two TE. Four RCTs (two OCP, two TE) found an increased BMD in premenopausal women with FHA, and five (three OCP, two CE) found a decreased BMD compared with controls. A meta-analysis showed no difference in BMD between the treatment and control groups, (standardised mean difference (SMD) 0.30, 95% CI -0.12 to 0.73). A secondary analysis for change scores from baseline to first assessment point, showed a similar overall result (SMD 0.17, 95% CI -0.16 to 0.51). No serious adverse events were reported. Conclusion The literature suggests that TE might increase lumbar BMD in premenopausal women with FHA, but pooled results revealed no effect of the intervention. The findings do not support oestrogen therapy to improve BMD in these patient groups.
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Affiliation(s)
| | - Knut Stavem
- Institute of Clinical Medicine, Akershus University Hospital, Lorenskog, Norway.,Department of Pulmonary Medicine, University of Oslo, Akershus University Hospital, Lorenskog, Norway
| | - Frode Norheim
- Department of Nutrition, University of Oslo, Institute of Basic Medical Sciences, Oslo, Norway
| | - Michael Bjørn Russell
- Institute of Clinical Medicine, Akershus University Hospital, Lorenskog, Norway.,Head and Neck Research Group, Division for Research and Innovation, Akershus University Hospital, Lorenskog, Norway
| | - Aleksander Chaibi
- Head and Neck Research Group, Division for Research and Innovation, Akershus University Hospital, Lorenskog, Norway.,Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo Faculty of Medicine, Oslo, Norway
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Fredericson M, Kussman A, Misra M, Barrack MT, De Souza MJ, Kraus E, Koltun KJ, Williams NI, Joy E, Nattiv A. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play. Clin J Sport Med 2021; 31:349-366. [PMID: 34091538 DOI: 10.1097/jsm.0000000000000948] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
ABSTRACT The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.
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Affiliation(s)
- Michael Fredericson
- Division of Physical Medicine & Rehabiilitation, Stanford University, Stanford, California
| | - Andrea Kussman
- Division of Physical Medicine & Rehabiilitation, Stanford University, Stanford, California
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michelle T Barrack
- Department of Family and Consumer Sciences, California State University, Long Beach, Long Beach, California
| | - Mary Jane De Souza
- Department of Kinesiology and Physiology Penn State University, University Park, Pennsylvania
| | - Emily Kraus
- Division of Physical Medicine & Rehabiilitation, Stanford University, Stanford, California
| | | | - Nancy I Williams
- Department of Kinesiology and Physiology Penn State University, University Park, Pennsylvania
| | | | - Aurelia Nattiv
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, California
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Singhal V, Bose A, Slattery M, Haines MS, Goldstein MA, Gupta N, Brigham KS, Ebrahimi S, Javaras KN, Bouxsein ML, Eddy KT, Miller KK, Schoenfeld D, Klibanski A, Misra M. Effect of Transdermal Estradiol and Insulin-like Growth Factor-1 on Bone Endpoints of Young Women With Anorexia Nervosa. J Clin Endocrinol Metab 2021; 106:2021-2035. [PMID: 33693703 PMCID: PMC8427708 DOI: 10.1210/clinem/dgab145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Anorexia nervosa (AN) is prevalent in adolescent girls and is associated with bone impairment driven by hormonal alterations in nutritional deficiency. OBJECTIVE To assess the impact of estrogen replacement with and without recombinant human insulin-like growth factor-1 (rhIGF-1) administration on bone outcomes. DESIGN Double-blind, randomized, placebo-controlled 12-month longitudinal study. PARTICIPANTS Seventy-five adolescent and young adult women with AN age 14 to 22 years. Thirty-three participants completed the study. INTERVENTION Transdermal 17-beta estradiol 0.1 mg/day with (i) 30 mcg/kg/dose of rhIGF-1 administered subcutaneously twice daily (AN-IGF-1+) or (ii) placebo (AN-IGF-1-). The dose of rhIGF-1 was adjusted to maintain levels in the upper half of the normal pubertal range. MAIN OUTCOME MEASURES Bone turnover markers and bone density, geometry, microarchitecture, and strength estimates. RESULTS Over 12 months, lumbar areal bone mineral density increased in AN-IGF-1- compared to AN-IGF-1+ (P = 0.004). AN-IGF-1+ demonstrated no improvement in areal BMD in the setting of variable compliance to estrogen treatment. Groups did not differ for 12-month changes in bone geometry, microarchitecture, volumetric bone mineral density (vBMD), or strength (and results did not change after controlling for weight changes over 12 months). Both groups had increases in radial cortical area and vBMD, and tibia cortical vBMD over 12 months. Levels of a bone resorption marker decreased in AN-IGF-1- (P = 0.042), while parathyroid hormone increased in AN-IGF-1+ (P = 0.019). AN-IGF-1- experienced irregular menses more frequently than did AN-IGF-1+, but incidence of all other adverse events did not differ between groups. CONCLUSIONS We found no additive benefit of rhIGF-1 administration for 12 months over transdermal estrogen replacement alone in this cohort of young women with AN.
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Affiliation(s)
- Vibha Singhal
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
- Correspondence: Vibha Singhal. MD, 101 Merrimac Street, Boston, MA 01124, USA.
| | - Amita Bose
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Meghan Slattery
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melanie S Haines
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark A Goldstein
- Division of Adolescent Medicine, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
| | - Nupur Gupta
- Division of Adolescent Medicine, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
| | - Kathryn S Brigham
- Division of Adolescent Medicine, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
| | - Seda Ebrahimi
- Cambridge Eating Disorders Center, Cambridge, MA, USA
| | - Kristin N Javaras
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Division of Women’s Mental Health, McLean Hospital, Belmont, MA, USA
| | - Mary L Bouxsein
- Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kamryn T Eddy
- Eating Disorders Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Karen K Miller
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David Schoenfeld
- Biostatistics Center at Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Anne Klibanski
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
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