Reduction of adult height in tall girls

Estrogen-mediated Height Control in Girls with Marfan Syndrome

This study evaluated the efficacy of a stepwise regimen of estradiol valerate for height control in girls with Marfan syndrome. Eight girls with Marfan syndrome who had completed estrogen treatment for height control were included. Estradiol valerate was started at a dose of 2 mg/day, and then was increased. The projected final height was estimated using the initial height percentile (on a disease-specific growth curve for Korean Marfan syndrome [gcPFHt]), and the initial bone age (baPFHt). After the estrogen treatment, the projected final height was compared to the actual final height (FHt). The median baseline chronological and bone age were 10.0 and 10.5 years, respectively. After a median of 36.5 months of treatment, the median FHt (172.6 cm) was shorter than the median gcPFHt (181.0 cm) and baPFHt (175.9 cm). In the six patients who started treatment before the age of 11 years, the median FHt (171.8 cm) was shorter than the median gcPFHt (181.5 cm) and baPFHt (177.4 cm) after treatment. The median differences between the FHt and gcPFHt and baPFHt were 9.2 and 8.3 cm, respectively. In two patients started treatment after the age of 11, the differences between FHt and gcPFHt, and baPFHt after treatment were -4 and 1.4 cm, and -1.2 and 0 cm for each case, respectively. A stepwise increasing regimen of estradiol valerate may be an effective treatment for height control in girls with Marfan syndrome, especially when started under 11 years old.

Effects of growth reduction therapy using high-dose 17beta-estradiol in 26 constitutionally tall girls

OBJECTIVE

The efficacy and safety of height-limiting therapy with high-dose 17beta-oestradiol in girls with constitutionally tall stature (CTS) are controversial. We evaluated the effectiveness of high-dose 17beta-oestradiol in premenarchal girls with CTS treated until their bone age reached 14 years.

DESIGN

We retrospectively reviewed the medical records of the girls managed between 1989 and 2000 with high-dose 17beta-estradiol for CTS with a predicted final height greater than +3SDs.

PATIENTS

Twenty-six girls met our inclusion criteria. At baseline, mean chronological age was 12.06 +/- 1.51 years and mean height was 171.1 +/- 6.5 cm with a height standard deviation score of 4.5 +/- 0.24, and mean predicted final height was 183.0 +/- 4.2 cm. Treatment was stopped when bone age reached 14 years; mean treatment duration was 1.62 +/- 0.76 years.

MEASUREMENTS

The following were obtained at 6-month intervals: height, body weight, Tanner stage, bone age, plasma cholesterol and triglycerides, plasma glucose and side effects. A mailed questionnaire on final height and satisfaction was sent 2 years after treatment discontinuation (response rate, 24/26). Results Final height was significantly (P < 0.001) reduced, by 2.4 +/- 3.2 cm, as compared to predictions. High-dose 17beta-estradiol therapy decreased growth velocity and significantly increased skeletal maturation (P < 0.001). Linear growth after treatment discontinuation was 3.3 +/- 1.9 cm. No serious side effects were recorded. Most of the patients were satisfied with the treatment.

CONCLUSION

High-dose 17beta-estradiol was moderately effective in reducing final height and should probably be reserved for selected patients, particularly as knowledge on potential long-term side effects is lacking.

Oestrogen treatment of constitutional tall stature: a risk-benefit ratio

Oestrogens are given in high doses for the treatment of tall stature in girls. The aim of this study was to obtain data considering efficiency, side effects, and acceptance of the treatment of 50 constitutionally tall girls treated with conjugated oestrogens (7.5-11.25 mg/day). The mean (SD) adult height predictions were 188.3 (4.4) cm and the achieved height was 5.2 (3.3) cm less than the predicted height. A greater reduction from final predicted height occurred when treatment was started at an early bone age (< 13.0 years) and with a remaining growth potential of greater than 10 cm. Even postmenarcheal girls, however, had a mean reduction of 4.8 (3.2) cm. The main side effects were considerable weight gain (> 10 kg), an increase in triglyceride concentrations (37.5% of the patients), and increased platelet aggregation (60% of the patients). Altogether 84.6% of the patients were satisfied with the treatment and 15.4% regretted having had it.

Impact of different doses of ethinyl oestradiol on reduction of final height in constitutionally tall girls

Fifty-two tall girls were treated for constitutionally tall stature with different ethinyl oestradiol (EE) dosages. They were divided into three different treatment groups: group B (100 micrograms EE/day; n = 11); group C (300 micrograms; n = 25) and group D (500 micrograms; n = 16) and compared with an untreated group A (n = 21) matched for age, height, bone age (BA) and height prediction. Using the height prediction method TW II, EE treatment reduced final height compared with the untreated girls in a weak dose-dependent manner, 2.3 cm (100 micrograms/day), 3.0 cm (300 micrograms/day), and 3.8 cm (500 micrograms/day). Such a dose dependency was not found on applying the Bayley-Pineau height prediction method (100 micrograms/day; 4.1 cm; 300 micrograms/day: 4.2 cm; 500 micrograms/day: 4.5 cm). However, there was a striking inverse correlation of the BA at the onset of treatment with the height reduction achieved using the TW II method (r: -0.43; P < 0.001). Importantly, girls with a BA below 12 years at the onset of treatment experienced a height reduction of more than 6 cm. CONCLUSION The EE dose used in the range of 100-500 micrograms/day is not crucial for the amount of height reduction in tall girls. In general high dose EE treatment should be given restrictively, and especially so in girls with a BA (TW2 RUS-ZH) above 12.0 years.

The effect of oestrogen treatment on body proportions in constitutionally tall girls

Body proportions were studied in 31 girls with constitutional tall stature during treatment with 200 micrograms ethinyl oestradiol per day continuously, combined with 5-10 mg medroxyprogesterone on the first 10 days of each month. Their mean (+/- SD) predicted adult height was 186.0 (+/- 4.0) cm. At the start of therapy, leg length (LL) standard deviation score (SDS) (3.8 +/- 0.7) was significantly greater than the sitting height (SH) SDS (2.3 +/- 1.1). During therapy, the mean sitting height increased by 2.9 cm, in contrast to an increment of only 0.8 cm for LL. The SDS of the ratio between SH and LL remained below zero. The expected gain without therapy, assuming a stable SDS position over time, was 5.4 cm for SH and 4.4 cm for LL, significantly more than the observed gains. In conclusion, tall girls have relatively long legs. Oestrogen therapy leads to an almost complete stop of leg growth, while the growth of the trunk is reduced to a lesser extent. This selective inhibition results in a trunk/leg ratio which is closer to, though still significantly different from that of normal girls.

Adult height in constitutionally tall stature: accuracy of five different height prediction methods

The accuracy of height predictions at various ages based on five different methods (Tanner-Whitehouse mark I; Tanner-Whitehouse mark II; index of potential height; Bayley-Pinneau; Roche-Wainer-Thissen) was compared at yearly intervals with final height achieved in 32 boys (78 predictions) and 100 girls (227 predictions) with constitutionally tall stature. The boys were initially seen at a mean (SD) chronological age of 12.5 (3) years whereas the mean chronological age in girls was 11.8 (2.1) years. In tall boys Tanner-Whitehouse mark II gives a good estimation of final height up to the bone age of 13 years with a mean overestimation of 1 cm. The overestimation of final height is higher in the bone age groups 13-14 years (2.7 cm) and 14-15 years (3.4 cm) mainly due to the tall boys with a height greater than 3 SD scores. Up to the bone age of 12 years the final height is massively overestimated by the Bayley-Pinneau method but this method give relatively accurate estimations thereafter. The estimated confidence limits are large (+/- 8 cm) for the two methods up to a bone age of 15 years. In tall girls the Tanner-Whitehouse mark II method was accurate from bone age nine to 12 years but overestimated final height in the bone age groups 12-13 years and 13-15 years by a mean of 1.8 and 1.4 cm respectively. The Bayley-Pinneau method overestimated final height in the bone age groups 12-14 years whereas the height predictions are accurate thereafter. Up to a bone age of 13 years the estimated confidence limits for the two methods are large, +/- cm, but tend to improve thereafter. It is concluded that there is no best or most accurate method for predicting adult height in tall children. There are methods of first choice differing with respect to sex and bone age. In addition, correcting factors may improve their accuracy and correct their tendency to overestimate or underestimate adult height.

Psychological effects of sodium valproate and carbamazepine in epilepsy

Information from standardised tests of intelligence, school attainments, attention, memory and visuomotor function, together with parent and teacher questionnaire information about various aspects of behaviour, was obtained for 63 schoolchildren with newly diagnosed epilepsy before treatment with sodium valproate or carbamazepine, and again at intervals for a total period of 12 months. The same information was collected on 47 matched controls. The children with epilepsy represented those under non-specialised paediatric care. The result showed that both drugs were effective in most cases at modest dosage without causing notable psychological effects 12 months into treatment. Modest and temporary adverse cognitive effects seen earlier in treatment could have been the result of uncontrolled seizure discharge. Improved function was the same in children with epilepsy and controls. Some psychological abnormalities in the children with epilepsy were evident before treatment suggesting early unwanted effects of the epileptic process itself.

Oestrogen treatment of tall girls: effect decreases with age

Fifty-nine tall girls were treated with oestrogen to reduce final height, starting at the ages of 9.1 to 16.2 years. We assessed the result of this treatment by comparison with matched controls. The epiphyseal bone age at the start of therapy, the final height, the Bayley-Pinneau (BP) and Roche-Wainer-Thissen (RWT) predictions of final height, and the errors in both predictions were evaluated. The matched pairs were divided into three groups according to bone age at the start of treatment; I less than 10.5 (n = 16), II 10.5-12.0 (n = 22) and III greater than 12.0 years (n = 21). The mean (SD) intrapair reduction of height for these groups was 9.7 (4.0) cm, 4.3 (4.3) cm and 3.5 (3.2) cm, respectively, according to BP predictions and 6.3 (4.3) cm, 3.4 (3.0) cm and 1.2 (3.3) cm according to RWT predictions. No method of predicting height is accurate for tall girls and simultaneous predictions may differ greatly. Close agreement between the BP and RWT predictions does not indicate greater accuracy. The earlier therapy is started, the greater is the effect. Young girls need psychosocial support with therapy.

A preliminary report on the role of somatostatin analogue (SMS 201-995) in the management of children with tall stature

We have studied the effect of somatostatin analogue (SMS 201-995) given as a subcutaneous injection on the growth and growth hormone secretion in seven tall children (two male; five female). SMS 201-995 was given in doses of 37.5 or 50 micrograms on a once or twice-daily regimen. Growth velocity decreased from a pretreatment median of 8.3 cm/year (range 5.5-12.2) to 3.0 cm/year (range 0.2-4.5) after 6 months treatment (Wilcoxon, P = 0.02). In three of the children therapy was discontinued for the next 6 months with restoration of growth rate to pretreatment values in two of the three. Growth hormone secretion decreased as a result of SMS 201-995 therapy although one child needed a twice-daily regimen to achieve long-term suppression. Final height measurements were reduced in four of five patients with an overall reduction between 1.1 and 6.3 cm and no change in the other. No effects of treatment on fasting glucose and insulin, glycosylated haemoglobin or serum thyroxine concentrations were observed. These preliminary studies suggest that SMS 201-995 may have a role in the management of the growth of tall children but the optimum mode of administration remains to be established.

Oestrogen treatment of constitutionally tall girls with 0.1 mg/day ethinyl oestradiol

For the treatment of tall stature in girls, oestrogens are usually given in high doses. In this study, growth data of 35 constitutionally tall girls treated with only 0.1 mg/day ethinyl oestradiol (EE) are reported (Group 1). The data were compared with those of 23 untreated girls with comparable bone ages and growth potential (Group 2), and with those of 5 girls treated with 0.3 mg/day EE (Group 3). All groups were followed until cessation of growth. In group 1, the median bone age at the onset of treatment was 12.50 years (Greulich-Pyle, range 10.50-13.75), and the median height prediction was calculated to be 184.4 cm (Bayley-Pinneau, range 179.5-191.5). Following oestrogen treatment of 21 months duration (range 10-37) the median adult height was reduced by 4.3 cm (range 0.0-9.0), or 3.9 cm if corrected for the error of prediction in the control group. The effect was greater in those girls with bone ages below 12.5 years at the onset of treatment (6.7 cm/corrected value 7.4 cm) than in the older girls (4.2 cm/3.6 cm). In Group 2 (controls) the median final adult height was over-estimated by 0.4 cm (range-4.9 to 4.9), but was under-estimated by 0.7 cm in those girls with bone ages below 12.5 years. In girls of comparable bone age similar reductions were obtained whether 0.3 mg/day EE (Group 3) or 0.1 mg/day was given (4.4 vs. 4.2 cm). A comparison of these results with published data indicates that higher EE doses (0.3-0.5 mg/day) have only little, if any, greater effect on the growth of girls than the dosage of 0.1 mg/day EE used in this study.

Critical analysis of height reduction in oestrogen-treated tall girls

Twenty-one girls with familial tall stature were reevaluated at 18 years of age. Fourteen of them had been treated with high-dose oestrogens (I), while seven girls had not been treated (II). The untreated group is comparable but not a strict control group. Recordings on initiation of the study were: Chronologic age: 12.0 +/- 1.4 (I) versus 13.5 +/- 1.5 years (II; means +/- SD), Bone age: (1) Greulich-Pyle: 11.8 +/- 1.4 (I) versus 13.1 +/- 1.1 years (II), (2) Tanner-Whitehouse II: 12.7 +/- 1.0 (I) versus 13.6 +/- 1.1 years (II). Mean height predictions according to (1) Bayley-Pinneau, (2) Roche-Wainer-Thissen and Tanner (3) with, and (4) without allowance for mid-parent height ranged from 179.4-184 (I) to 175.7-179.5 cm (II). In the treated group there was an average reduction of predicted height of between 2.3 and 6.5 cm, depending on which of the four methods was used. In the untreated group the average differences between calculated and observed mature height varied from 0.2-3.4 cm. The difference in the reduction of predicted height between the treated and untreated groups was significant (P less than 0.05) only with the Bayley-Pinneau method and not with the others. In the treated group highly significant correlations were found between height reduction and the initial chronologic age, bone age and duration of therapy.