1
|
Harrington J. Delayed Puberty Including Constitutional Delay: Differential and Outcome. Endocrinol Metab Clin North Am 2024; 53:267-278. [PMID: 38677869 DOI: 10.1016/j.ecl.2024.01.007] [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] [Indexed: 04/29/2024]
Abstract
Constitutional delay of growth and puberty (CDGP) is the most common cause of delayed puberty in both male and female individuals. This article reviews the causes of delayed puberty focusing on CDGP, including new advances in the understanding of the genetics underpinning CDGP, a clinical approach to discriminating CDGP from other causes of delayed puberty, outcomes, as well as current and potential emerging management options.
Collapse
Affiliation(s)
- Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, Adelaide, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.
| |
Collapse
|
2
|
Sahoo BK, Kumar PR, Pattanaik SR, Dash DK, Patro D, Telagareddy R. Role of Inhibin B, AMH, GnRHa Test and HCG Stimulation Test to Distinguish Isolated Hypogonadotropic Hypogonadism (IHH) from Constitutional Delay in Growth and Puberty (CDGP). Indian J Endocrinol Metab 2024; 28:153-159. [PMID: 38911112 PMCID: PMC11189279 DOI: 10.4103/ijem.ijem_146_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/11/2023] [Accepted: 06/25/2023] [Indexed: 06/25/2024] Open
Abstract
Introduction This study aimed to distinguish isolated hypogonadotropic hypogonadism (IHH) from constitutional delay in growth and puberty (CDGP) by various hormonal tests in both sexes. Methods Boys with testicular volume (TV) <4 ml (14-18 years) and girls with breast B1 stage (13-18 years) were enrolled in this study. A detailed history, clinical examination and hormonal analysis including basal luteinising hormone (LH), follicle-stimulating hormone (FSH), inhibin B, anti-Mullerian hormone (AMH), testosterone (boys), oestradiol (girls), triptorelin stimulation test and 3-day human chorionic gonadotropin (HCG) stimulation test (boys) were performed. All patients were followed for 1.5 years or till 18 years of age. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-offs with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for various hormones to distinguish IHH from CDGP. Results Of 34 children (male: 22 and female: 12), CDGP and IHH were diagnosed in 21 and 13 children, respectively. 4 hours post-triptorelin LH had the highest sensitivity (100%) and specificity (100%) for identifying IHH in both sexes. Basal inhibin B had good sensitivity (male: 85.7% and female: 83.8%) and specificity (male: 93.3% and female: 100%) for diagnosing IHH. 24 hours post-triptorelin testosterone (<34.5 ng/dl), day 4 post-HCG testosterone (<99.7 ng/dl) and 24 hours post-triptorelin oestradiol (<31.63 pg/ml) had reasonable sensitivity and specificity for identifying IHH. Basal LH, FSH and AMH were poor discriminators for IHH in both sexes. Conclusion The best indicator was post-triptorelin 4-hour LH followed by inhibin B, which had a reasonable diagnostic utility to distinguish IHH from CDGP in both boys and girls.
Collapse
Affiliation(s)
- Bijay K. Sahoo
- Department of Endocrinology, M.K.C.G Medical College, Berhampur, Odisha, India
| | - Padala Ravi Kumar
- Department of Endocrinology, M.K.C.G Medical College, Berhampur, Odisha, India
| | | | - Deepak Kumar Dash
- Department of Endocrinology, M.K.C.G Medical College, Berhampur, Odisha, India
| | - Debasish Patro
- Department of Endocrinology, M.K.C.G Medical College, Berhampur, Odisha, India
| | | |
Collapse
|
3
|
Aung Y, Kokotsis V, Yin KN, Banerjee K, Butler G, Dattani MT, Dimitri P, Dunkel L, Hughes C, McGuigan M, Korbonits M, Paltoglou G, Sakka S, Shah P, Storr HL, Willemsen RH, Howard SR. Key features of puberty onset and progression can help distinguish self-limited delayed puberty from congenital hypogonadotrophic hypogonadism. Front Endocrinol (Lausanne) 2023; 14:1226839. [PMID: 37701896 PMCID: PMC10493306 DOI: 10.3389/fendo.2023.1226839] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Introduction Delayed puberty (DP) is a frequent concern for adolescents. The most common underlying aetiology is self-limited DP (SLDP). However, this can be difficult to differentiate from the more severe condition congenital hypogonadotrophic hypogonadism (HH), especially on first presentation of an adolescent patient with DP. This study sought to elucidate phenotypic differences between the two diagnoses, in order to optimise patient management and pubertal development. Methods This was a study of a UK DP cohort managed 2015-2023, identified through the NIHR clinical research network. Patients were followed longitudinally until adulthood, with a definite diagnosis made: SLDP if they had spontaneously completed puberty by age 18 years; HH if they had not commenced (complete, cHH), or had commenced but not completed puberty (partial, pHH), by this stage. Phenotypic data pertaining to auxology, Tanner staging, biochemistry, bone age and hormonal treatment at presentation and during puberty were retrospectively analysed. Results 78 patients were included. 52 (66.7%) patients had SLDP and 26 (33.3%) patients had HH, comprising 17 (65.4%) pHH and 9 (34.6%) cHH patients. Probands were predominantly male (90.4%). Male SLDP patients presented with significantly lower height and weight standard deviation scores than HH patients (height p=0.004, weight p=0.021). 15.4% of SLDP compared to 38.5% of HH patients had classical associated features of HH (micropenis, cryptorchidism, anosmia, etc. p=0.023). 73.1% of patients with SLDP and 43.3% with HH had a family history of DP (p=0.007). Mean first recorded luteinizing hormone (LH) and inhibin B were lower in male patients with HH, particularly in cHH patients, but not discriminatory. There were no significant differences identified in blood concentrations of FSH, testosterone or AMH at presentation, or in bone age delay. Discussion Key clinical markers of auxology, associated signs including micropenis, and serum inhibin B may help distinguish between SLDP and HH in patients presenting with pubertal delay, and can be incorporated into clinical assessment to improve diagnostic accuracy for adolescents. However, the distinction between HH, particularly partial HH, and SLDP remains problematic. Further research into an integrated framework or scoring system would be useful in aiding clinician decision-making and optimization of treatment. .
Collapse
Affiliation(s)
- Yuri Aung
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Vasilis Kokotsis
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
| | - Kyla Ng Yin
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
| | - Kausik Banerjee
- Department of Paediatrics, Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Gary Butler
- Department of Paediatric and Adolescent Endocrinology, University College London Hospital NHS Foundation Trust, London, United Kingdom
- UCL Great Ormond Street (GOS) Institute of Child Health, University College London, London, United Kingdom
| | - Mehul T. Dattani
- Department of Paediatric and Adolescent Endocrinology, University College London Hospital NHS Foundation Trust, London, United Kingdom
- UCL Great Ormond Street (GOS) Institute of Child Health, University College London, London, United Kingdom
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Paul Dimitri
- Department of Paediatric Endocrinology, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield, United Kingdom
| | - Leo Dunkel
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
| | - Claire Hughes
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Michael McGuigan
- Department of Paediatrics, Countess of Chester NHS Foundation Trust, Chester, United Kingdom
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
- Department of Endocrinology, Barts Health NHS Trust, London, United Kingdom
| | - George Paltoglou
- 2nd Department of Paediatrics, National and Kapodistrian University of Athens (NKUA), “P. & A. Kyriakou” Children’s Hospital, Athens, Greece
| | - Sophia Sakka
- Department of Paediatric Endocrinology, Evelina Children’s Hospital, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Pratik Shah
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Helen L. Storr
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ruben H. Willemsen
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Sasha R. Howard
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London (QMUL), London, United Kingdom
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
4
|
Mohanraj S, Prasad HK. Delayed Puberty. Indian J Pediatr 2023; 90:590-597. [PMID: 37127825 DOI: 10.1007/s12098-023-04577-x] [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: 11/15/2022] [Accepted: 03/17/2023] [Indexed: 05/03/2023]
Abstract
Testicular volume ≥4 ml and appearance of breast budding are the first signs of puberty. Delayed puberty is diagnosed in the absence of thelarche by 13 y or menarche by 15 y in girls and absence of testicular enlargement by 14 y in boys. Delayed puberty can be due to hypogonadotrophic hypogonadism, hypergonadotrophic hypogonadism or eugonadotrophic eugonadism characterised by low, elevated and normal gonadotrophin levels, respectively. Constitutional Delay of Growth and Puberty (CDGP) and systemic illness should be considered before pathological causes. Assessment of sexual maturity by Tanner's staging and anthropometric assessment on growth chart is pivotal. Lack of menarche in girls with thelarche suggests structural abnormalities of reproductive tract or disorders of sexual development. Measurement of bone age helps to interpret hormone measurements and decide on timing of pubertal induction. Ultrasound assessment of abdomen gives valuable clues to pubertal onset (in girls) and possible underlying etiology. Karyotyping is mandatory in all girls with delayed puberty and short stature, and delayed menarche and boys with hypergonadotrophic hypogonadism. Gonadotrophin releasing hormone analogue stimulation test may help distinguish hypogonadotrophic hypogonadism from CDGP. Pubertal induction is done with intramuscular testosterone and oral estradiol in boys and girls, respectively. Hormone replacement is begun at low doses and slowly escalated over 2 y to mimic a physiological puberty process. Short course of testosterone for 3 to 6 mo is helpful in adolescent boys with CDGP and psychological distress. Attainment of adult sexual maturity by 18 y is mandatory to rule out disorders of hypothalamic pituitary gonadal axis.
Collapse
Affiliation(s)
- Swathi Mohanraj
- Department of Pediatrics, Mehta Multispeciality Hospitals India Pvt. Ltd., Chennai, Tamil Nadu, India
| | - Hemchand Krishna Prasad
- Department of Pediatric Endocrinology, Mehta Multispeciality Hospitals India Pvt. Ltd., 2, Mc Nichol's Road, Chetpet, Chennai, Tamil Nadu, India.
| |
Collapse
|
5
|
Binder G. Anti-Müller-Hormon und Inhibin B – Marker der gonadalen Reifung und Prädiktoren der Fertilität? GYNAKOLOGISCHE ENDOKRINOLOGIE 2022. [DOI: 10.1007/s10304-022-00480-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
6
|
Abstract
Pediatric endocrinologists often evaluate and treat youth with delayed puberty. Stereotypically, these patients are 14-year-old young men who present due to lack of pubertal development. Concerns about stature are often present, arising from gradual shifts to lower height percentiles on the population-based, cross-sectional curves. Fathers and/or mothers may have also experienced later than average pubertal onset. In this review, we will discuss a practical clinical approach to the evaluation and management of youth with delayed puberty, including the differential diagnosis and key aspects of evaluation and management informed by recent review of the existing literature. We will also discuss scenarios that pose additional clinical challenges, including: (1) the young woman whose case poses questions regarding how presentation and approach differs for females vs males; (2) the 14-year-old female or 16-year-old young man who highlight the need to reconsider the most likely diagnoses, including whether idiopathic delayed puberty can still be considered constitutional delay of growth and puberty at such late ages; and finally (3) the 12- to 13-year-old whose presentation raises questions about whether age cutoffs for the diagnosis and treatment of delayed puberty should be adjusted downward to coincide with the earlier onset of puberty in the general population.
Collapse
Affiliation(s)
- Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, 5006, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, 5000, Australia
| | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
- Departments of Pediatrics and Physiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| |
Collapse
|
7
|
Harrington J, Palmert MR. Distinguishing Self-limited Delayed Puberty From Permanent Hypogonadotropic Hypogonadism: How and Why? J Clin Endocrinol Metab 2021; 106:e5264-e5266. [PMID: 34223894 DOI: 10.1210/clinem/dgab498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada
- Departments of Pediatrics and Physiology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
8
|
Saengkaew T, Patel HR, Banerjee K, Butler G, Dattani MT, McGuigan M, Storr HL, Willemsen RH, Dunkel L, Howard SR. Genetic evaluation supports differential diagnosis in adolescent patients with delayed puberty. Eur J Endocrinol 2021; 185:617-627. [PMID: 34403359 PMCID: PMC8558847 DOI: 10.1530/eje-21-0387] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/17/2021] [Indexed: 11/08/2022]
Abstract
CONTEXT Pubertal delay can be the clinical presentation of both idiopathic hypogonadotropic hypogonadism (IHH) and self-limited delayed puberty (SLDP). Distinction between these conditions is a common but important diagnostic challenge in adolescents. OBJECTIVE To assess whether gene panel testing can assist with clinical differential diagnosis and to allow accurate and timely management of delayed puberty patients. DESIGN Retrospective study. METHODS Patients presenting with delayed puberty to UK Paediatric services, followed up to final diagnosis, were included. Whole-exome sequencing was analysed using a virtual panel of genes previously reported to cause either IHH or SLDP to identify rarely predicted deleterious variants. Deleterious variants were verified by in silico prediction tools. The correlation between clinical and genotype diagnosis was analysed. RESULTS Forty-six patients were included, 54% with a final clinical diagnosis of SLDP and 46% with IHH. Red flags signs of IHH were present in only three patients. Fifteen predicted deleterious variants in 12 genes were identified in 33% of the cohort, with most inherited in a heterozygous manner. A fair correlation between final clinical diagnosis and genotypic diagnosis was found. Panel testing was able to confirm a diagnosis of IHH in patients with pubertal delay. Genetic analysis identified three patients with IHH that had been previously diagnosed as SLDP. CONCLUSION This study supports the use of targeted exome sequencing in the clinical setting to aid the differential diagnosis between IHH and SLDP in adolescents presenting with pubertal delay. Genetic evaluation thus facilitates earlier and more precise diagnosis, allowing clinicians to direct treatment appropriately.
Collapse
Affiliation(s)
- Tansit Saengkaew
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Endocrinology Unit, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Heena R Patel
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Kausik Banerjee
- Department of Paediatrics, Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Gary Butler
- Department of Paediatric and Adolescent Endocrinology, University College London Hospital NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Correspondence should be addressed to G Butler Email
| | - Mehul T Dattani
- Department of Paediatric and Adolescent Endocrinology, University College London Hospital NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Michael McGuigan
- Department of Paediatrics, Countess of Chester NHS Foundation Trust, Chester, UK
| | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Paediatric Endocrinology, Barts Health NHS Trust, London, UK
| | - Ruben H Willemsen
- Department of Paediatric Endocrinology, Barts Health NHS Trust, London, UK
| | - Leo Dunkel
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Paediatric Endocrinology, Barts Health NHS Trust, London, UK
| | - Sasha R Howard
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Paediatric Endocrinology, Barts Health NHS Trust, London, UK
| |
Collapse
|