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Bakhtiani P, Geffner M. Delayed Puberty. Pediatr Rev 2022; 43:426-435. [PMID: 35909138 DOI: 10.1542/pir.2020-005291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Priyanka Bakhtiani
- Keck School of Medicine of the University of Southern California, Los Angeles, CA.,Children's Hospital Los Angeles, Los Angeles, CA
| | - Mitchell Geffner
- Keck School of Medicine of the University of Southern California, Los Angeles, CA.,Children's Hospital Los Angeles, Los Angeles, CA.,The Saban Research Institute, Los Angeles, CA
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Mosbah H, Bouvattier C, Maione L, Trabado S, De Filippo G, Cartes A, Donzeau A, Chanson P, Brailly-Tabard S, Dwyer AA, Coutant R, Young J. GnRH stimulation testing and serum inhibin B in males: insufficient specificity for discriminating between congenital hypogonadotropic hypogonadism from constitutional delay of growth and puberty. Hum Reprod 2020; 35:2312-2322. [DOI: 10.1093/humrep/deaa185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
STUDY QUESTION
Are GnRH tests and serum inhibin B levels sufficiently discriminating to distinguish transient constitutional delay of growth and puberty (CDGP) from congenital hypogonadotropic hypogonadism (CHH) that affects reproductive health for life?
SUMMARY ANSWER
Both parameters lack the specificity to discriminate CDGP from CHH.
WHAT IS KNOWN ALREADY
GnRH tests and inhibin B levels have been proposed to differentiate CDGP from CHH. However, their diagnostic accuracies have been hampered by the small numbers of CHH included and enrichment of CHH patients with more severe forms.
STUDY DESIGN, SIZE, DURATION
The aim of this study was to assess the diagnostic performance of GnRH tests and inhibin B measurements in a large cohort of CHH male patients with the whole reproductive spectrum. From 2008 to 2018, 232 males were assessed: 127 with CHH, 74 with CDGP and 31 healthy controls.
PARTICIPANTS/MATERIALS, SETTING, METHODS
The participants were enrolled in two French academic referral centres. The following measurements were taken: testicular volume (TV), serum testosterone, inhibin B, LH and FSH, both at baseline and following the GnRH test.
MAIN RESULTS AND THE ROLE OF CHANCE
Among CHH patients, the LH response to the GnRH test was very variable and correlated with TV. Among CDGP patients, the LH peak was also variable and 47% of CHH patients had peak LH levels overlapping with the CDGP group. However, no patients with CDGP had an LH peak below 4.0 IU/l, while 53% CHH patients had LH peak below this threshold. Among CHH patients, inhibin B levels were also variable and correlated with TV and peak LH. Inhibin B was significantly lower in CHH patients than in CDGP patients but 50% of CHH values overlapped with CDGP values. Interestingly, all patients with CDGP had inhibin B levels above 35 pg/ml but 50% of CHH patients also had levels above this threshold.
LIMITATIONS, REASONS FOR CAUTION
As CHH is very rare, an international study would be necessary to recruit a larger CHH cohort and consolidate the conclusion reached here.
WIDER IMPLICATIONS OF THE FINDINGS
Peak LH and basal inhibin B levels are variable in both CHH and CDGP with significant overlap. Both parameters lack specificity and sensitivity to efficiently discriminate CHH from CDGP. This reflects the varying degree of gonadotropin deficiency inherent to CHH. These two diagnostic procedures may misdiagnose partial forms of isolated (non-syndromic) CHH, allowing them to be erroneously considered as CDGP.
STUDY FUNDING/COMPETING INTEREST(S)
This study was funded by Agence Française de Lutte contre le Dopage: Grant Hypoproteo AFLD-10 (to J.Y.); Agence Nationale de la Recherche (ANR): Grant ANR-09-GENO-017-01 (to J.Y.); European Cooperation in Science and Technology, COST Action BM1105; Programme Hospitalier de Recherche Clinique (PHRC), French Ministry of Health: PHRC-2009 HYPO-PROTEO (to J.Y.); and Programme Hospitalier de Recherche Clinique (PHRC) “Variété”, French Ministry of Health, N° P081216/IDRCB 2009-A00892-55 (to P.C.). There are no competing interests.
TRIAL REGISTRATION NUMBER
N/A
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Affiliation(s)
- Héléna Mosbah
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Reproductive Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Claire Bouvattier
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- INSERM, U1185, Le Kremlin-Bicêtre, France
- Department of Pediatric Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Luigi Maione
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Reproductive Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- INSERM, U1185, Le Kremlin-Bicêtre, France
| | - Séverine Trabado
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Hormonology and Molecular Genetics, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Gianpaolo De Filippo
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Pediatric Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Alejandra Cartes
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Reproductive Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Aurélie Donzeau
- Department of Pediatric Endocrinology, University Hospital of Angers, Angers, France
- Reference Center for Rare Pituitary Diseases (HYPO), University Hospital of Angers, Angers, France
| | - Philippe Chanson
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Reproductive Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- INSERM, U1185, Le Kremlin-Bicêtre, France
| | - Sylvie Brailly-Tabard
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Hormonology and Molecular Genetics, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Andrew A Dwyer
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA
| | - Régis Coutant
- Department of Pediatric Endocrinology, University Hospital of Angers, Angers, France
- Reference Center for Rare Pituitary Diseases (HYPO), University Hospital of Angers, Angers, France
| | - Jacques Young
- Univ Paris-Saclay, Paris-Saclay Medical School, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Reproductive Endocrinology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- INSERM, U1185, Le Kremlin-Bicêtre, France
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3
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Howard SR, Dunkel L. Delayed Puberty-Phenotypic Diversity, Molecular Genetic Mechanisms, and Recent Discoveries. Endocr Rev 2019; 40:1285-1317. [PMID: 31220230 PMCID: PMC6736054 DOI: 10.1210/er.2018-00248] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/31/2019] [Indexed: 02/07/2023]
Abstract
This review presents a comprehensive discussion of the clinical condition of delayed puberty, a common presentation to the pediatric endocrinologist, which may present both diagnostic and prognostic challenges. Our understanding of the genetic control of pubertal timing has advanced thanks to active investigation in this field over the last two decades, but it remains in large part a fascinating and mysterious conundrum. The phenotype of delayed puberty is associated with adult health risks and common etiologies, and there is evidence for polygenic control of pubertal timing in the general population, sex-specificity, and epigenetic modulation. Moreover, much has been learned from comprehension of monogenic and digenic etiologies of pubertal delay and associated disorders and, in recent years, knowledge of oligogenic inheritance in conditions of GnRH deficiency. Recently there have been several novel discoveries in the field of self-limited delayed puberty, encompassing exciting developments linking this condition to both GnRH neuronal biology and metabolism and body mass. These data together highlight the fascinating heterogeneity of disorders underlying this phenotype and point to areas of future research where impactful developments can be made.
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Affiliation(s)
- 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, United Kingdom
| | - Leo Dunkel
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Abstract
Management of patients with hypogonadism is dependent on the underlying cause. Whilst functional hypogonadism presenting as delayed puberty in adolescence is relatively common, permanent hypogonadism presenting in infancy or adolescence is unusual. The main differential diagnoses of delayed puberty include self-limited delayed puberty (DP), idiopathic hypogonadotropic hypogonadism (IHH) and hypergonadotropic hypogonadism. Treatment of self-limited DP involves expectant observation or short courses of low dose sex steroid supplementation. More complex and involved management is required in permanent hypogonadism to achieve both development of secondary sexual characteristics and to maximize the potential for fertility. This review will cover the options for management involving sex steroid or gonadotropin therapy, with discussion of benefits, limitations and specific considerations of the different treatment options.
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Affiliation(s)
- Sasha R Howard
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of 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, UK.
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Sukumar SP, Bhansali A, Sachdeva N, Ahuja CK, Gorsi U, Jarial KDS, Walia R. Diagnostic utility of testosterone priming prior to dynamic tests to differentiate constitutional delay in puberty from isolated hypogonadotropic hypogonadism. Clin Endocrinol (Oxf) 2017; 86:717-724. [PMID: 28261833 DOI: 10.1111/cen.13321] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/14/2017] [Accepted: 02/14/2017] [Indexed: 11/27/2022]
Abstract
CONTEXT Differentiation between constitutional delay in puberty (CDP) and isolated hypogonadotropic hypogonadism (IHH) during adolescence is a great clinical challenge, and the available diagnostic tests are of limited value. OBJECTIVE To study the effect of withdrawal of short-term, low-dose testosterone therapy (testosterone priming) on the discriminatory power of dynamic tests for hypothalamo-pituitary-testicular axis to differentiate CDP from IHH. DESIGN A prospective study (n = 30) consisting of 20 boys with delayed puberty (group A) and 10 patients with IHH (group B). INTERVENTION Patients in groups A and B underwent Triptorelin and hCG stimulation tests, prior to and 2 months after withdrawal of 'testosterone priming' (100 mg intramuscularly 4 weekly for 3 months) and were followed up until the onset of puberty or 18 years of age, whichever was earlier. RESULTS At baseline, Triptorelin-stimulated 4 h LH, with a cut-off of 2·8 IU/l, and hCG-stimulated day 7 testosterone with a cut-off of 3·8 nmol/l had sensitivities of 80% each, and specificities of 93% and 87%, respectively, to diagnose CDP. After withdrawal of testosterone, a 4 h LH cut-off of 14·7 IU/l and day 7 testosterone cut-off of 10·3 nmol/l had sensitivities of 93% and 88% respectively, and specificity and positive predictive value of 100% each. A basal inhibin B > 94·7 ng/l was discriminatory for diagnosing CDP after withdrawal of testosterone priming. CONCLUSIONS Inhibin B levels or 4 h LH after Triptorelin stimulation are the best discriminatory tests to differentiate CDP from IHH, when performed after withdrawal of 'testosterone priming'.
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Affiliation(s)
- Suja P Sukumar
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Kamal Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kush Dev Singh Jarial
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Varimo T, Miettinen PJ, Känsäkoski J, Raivio T, Hero M. Congenital hypogonadotropic hypogonadism, functional hypogonadotropism or constitutional delay of growth and puberty? An analysis of a large patient series from a single tertiary center. Hum Reprod 2016; 32:147-153. [PMID: 27927844 DOI: 10.1093/humrep/dew294] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/19/2016] [Accepted: 10/28/2016] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What diagnoses underlie delayed puberty (DP) and predict its outcome? SUMMARY ANSWER A multitude of different diagnoses underlie DP, and in boys a history of cryptorchidism, small testicular size and slow growth velocity (GV) predict its clinical course. WHAT IS KNOWN ALREADY DP is caused by a variety of underlying etiologies. Hormonal markers can be used in the differential diagnosis of DP but none of them have shown complete diagnostic accuracy. STUDY DESIGN, SIZE, DURATION Medical records of 589 patients evaluated for DP in a single tertiary care center between 2004 and 2014 were retrospectively reviewed. PARTICIPANTS/MATERIALS, SETTING, METHODS Clinical and biochemical data of 174 boys and 70 girls who fulfilled the criteria of DP were included in the analyses. We characterized the frequencies of underlying conditions and evaluated the predictive efficacy of selected clinical and hormonal markers. MAIN RESULTS AND THE ROLE OF CHANCE Thirty etiologies that underlie DP were identified. No markers of clinical value could be identified in the girls, whereas a history of cryptorchidism in the boys was associated with an increase in the risk of permanent hypogonadism (odds ratio 17.2 (95% CI; 3.4-85.4, P < 0.001)). The conditions that cause functional hypogonadotropic hypogonadism were more frequent in boys with a GV below 3 cm/yr than in those growing faster (19% vs 4%, P < 0.05). In this series, the most effective markers to discriminate the prepubertal boys with constitutional delay of growth and puberty (CDGP) from those with congenital hypogonadotropic hypogonadism (CHH) were testicular volume (cut-off 1.1 ml with a sensitivity of 100% and a specificity of 91%), GnRH-induced maximal LH (cut-off 4.3 IU/L; 100%, 75%) and basal inhibin B (INHB) level (cut-off 61 ng/L; 90%, 83%). LIMITATIONS, REASONS FOR CAUTION The main limitation of the study is the retrospective design. WIDER IMPLICATIONS OF THE FINDINGS Prior cryptorchidism and slow GV are two important clinical cues that may help clinicians to predict the clinical course of DP in boys, whereas markers of similar value could not be identified in girls. In prepubertal boys, testicular size appeared as effective as INHB and GnRH-induced LH levels in the differential diagnosis between CHH and CDGP. STUDY FUNDING/COMPETING INTERESTS This study was supported by the Academy of Finland (268356), Foundation for Pediatric Research (7495), Sigrid Juselius Foundation (2613) and the Finnish Medical Foundation (011115). The authors have no competing interests to report. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Tero Varimo
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi J Miettinen
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Programs Unit, Molecular Neurology, and Biomedicum Stem Cell Center, University of Helsinki, Helsinki, Finland
| | - Johanna Känsäkoski
- Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Taneli Raivio
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland .,Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Matti Hero
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Ishii T, Matsuo N, Sato S, Ogata T, Tamai S, Anzo M, Kamimaki T, Sasaki G, Inokuchi M, Hori N, Amano N, Narumi S, Shibata H, Hasegawa T. Human Chorionic Gonadotropin Stimulation Test in Prepubertal Children with Micropenis Can Accurately Predict Leydig Cell Function in Pubertal or Postpubertal Adolescents. Horm Res Paediatr 2016; 84:305-10. [PMID: 26352728 DOI: 10.1159/000439234] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/31/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM To evaluate the accuracy of the human chorionic gonadotropin (hCG) stimulation test in children with micropenis in predicting later Leydig cell function. METHODS We conducted a retrospective investigation of testosterone response to a 3-day hCG test (3,000 IU/m2/day) in prepuberty to indicate the need for hormone replacement therapy (HRT) in adolescence. RESULTS Fifty Japanese boys (range, 0.8-15.4 years of age; median, 8.9) with micropenis were enrolled. Thirty-four spontaneously developed puberty and preserved the ability of testosterone production (group 1), while 16 did not develop any pubertal signs without HRT (group 2). Serum testosterone levels after the hCG test (post-hCG T) in group 2 (range, <0.05-1.1 ng/ml; median, 0.24) were significantly lower than in group 1 (range, 0.5-8.7 ng/ml; median, 2.4; p < 0.0001). Based on true positives who required continuous HRT, the area under the receiver-operating characteristics curve for post-hCG T was 0.983 [95% confidence interval (CI), 0.90-1.00]. The post-hCG T cut-off level corresponding to the Youden index was 1.1 ng/ml (95% CI, 1.0-1.1), with a sensitivity of 100.0% (95% CI, 79.4-100.0) and a specificity of 94.1% (95% CI, 80.3-99.3). CONCLUSIONS The hCG test in prepubertal children with micropenis can be useful for predicting Leydig cell function in pubertal or postpubertal adolescents. The post-hCG T cut-off level of 1.1 ng/ml is recommended to screen for those who will likely require HRT for pubertal development.
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Affiliation(s)
- Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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8
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Abstract
Puberty is the period during which we attain adult secondary sexual characteristics and reproductive capability. Its onset depends upon reactivation of pulsative GNRH, secretion from its relative quiescence during childhood, on the background of intact potential for pituitary-gonadal function. This review is intended: to highlight those current practices in diagnosis and management that are evidence based and those that are not; to help clinicians deal with areas of uncertainty with reference to physiologic first principles; by sign-posting relevant data arising from other patient groups with shared issues; to illustrate how recent scientific advances are (or should be) altering clinician perceptions of pubertal delay; and finally, to emphasise that the management of men and women presenting in advanced adult life with absent puberty cannot simply be extrapolated from paediatric practice. There is a broad spectrum of pubertal timing that varies among different populations, separated in time and space. Delayed puberty usually represents an extreme of the normal, a developmental pattern referred to as constitutional delay of growth and puberty (CDGP), but organic defects of the hypothalamo-pituitary-gonadal axis predisposing to hypogonadism may not always be initially distinguishable from it. CDGP and organic, or congenital hypogonadotrophic hypogonadism are both significantly more common in boys than girls. Moreover, around 1/3 of adults with organic hypogonadotrophic hypogonadism had evidence of partial puberty at presentation and, confusingly, some 5-10% of these subsequently may exhibit recovery of endogenous gonadotrophin secretion, including men with Kallmann syndrome. However, the distinction is crucial as expectative ('watch-and-wait') management is inappropriate in the context of hypogonadism. The probability of pubertal delay being caused by organic hypogonadism rises exponentially both with increasing age at presentation and the presence of associated 'red flag' clinical features. These 'red flags' comprise findings indicating lack of prior 'mini-puberty' (such as cryptorchidism or micropenis), or the presence of non-reproductive congenital defects known to be associated with specific hypogonadal syndromes, e.g. anosmia, deafness, mirror movements, renal agenesis, dental/digital anomalies, clefting or coloboma would be compatible with Kallmann (or perhaps CHARGE) syndrome. In children, interventions (whether in the form or treatment or simple reassurance) have been historically directed at maximising height potential and minimising psychosocial morbidity, though issues of future fertility and bone density potential are now increasingly 'in the mix'. Apubertal adults almost invariably harbour organic hypogonadism, requiring sensitive acknowledgement of underlying personal issues and the timely introduction of sex hormone replacement therapy at more physiological doses.
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Affiliation(s)
- Leo Dunkel
- Barts and the LondonQueen Mary College, William Harvey Research Institute, Centre for Endocrinology, University of London, Charterhouse Square, London EC1M 6BQ, UKEndocrinology Research GroupInstitute of Genetic Medicine, University of Newcastle-upon-Tyne, Times Square, Newcastle NE1 3BZ, UK
| | - Richard Quinton
- Barts and the LondonQueen Mary College, William Harvey Research Institute, Centre for Endocrinology, University of London, Charterhouse Square, London EC1M 6BQ, UKEndocrinology Research GroupInstitute of Genetic Medicine, University of Newcastle-upon-Tyne, Times Square, Newcastle NE1 3BZ, UK
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9
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Zevenhuijzen H, Kelnar CJH, Crofton PM. Diagnostic utility of a low-dose gonadotropin-releasing hormone test in the context of puberty disorders. HORMONE RESEARCH 2004; 62:168-76. [PMID: 15331852 DOI: 10.1159/000080324] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Accepted: 06/14/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The 10-microg gonadotropin-releasing hormone (GnRH) test assesses pituitary gonadotroph responsiveness, whereas the 100-microg dose assesses maximal secretory capacity. Our aims were to establish normative data for the low-dose test in children and to evaluate the test in diagnosing common pubertal disorders. METHODS We retrospectively classified 107 children who underwent 10-microg GnRH tests into normal prepubertal (20 boys, 10 girls), normal early pubertal (10 boys, 16 girls), constitutional delay of puberty (CDP, 13 prepubertal boys >12 years), hypogonadotropic hypogonadism (HH, 5 prepubertal boys >12 years), central precocious puberty (CPP, 19 girls) or premature thelarche/variant (13 girls). RESULTS Peak LH response was higher in prepubertal boys >12 years compared with younger boys (p < 0.01) but showed no further change in early puberty. CDP boys had LH responses similar to prepubertal boys >12 years. HH boys showed an absent LH response which diagnosed HH with 100% sensitivity and 96% specificity. Thelarche girls had LH:FSH peak ratios lower than normal prepubertal (p = 0.001), pubertal (p < 0.05) or CPP (p = 0.001) girls. CONCLUSIONS We have established normative values for the low-dose GnRH test in children. The test successfully differentiated HH from CDP in boys, and contributed to the differential diagnosis of CPP and premature thelarche in girls.
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Affiliation(s)
- H Zevenhuijzen
- Section of Child Life and Health, Department of Reproductive and Developmental Sciences, University of Edinburgh, Edinburgh, UK
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10
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Stanhope R. Do we perform too many hCG tests? J Pediatr Endocrinol Metab 2003; 16:355-6. [PMID: 12705357 DOI: 10.1515/jpem.2003.16.3.355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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11
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Abstract
Puberty is the period of life during which reproductive capability is acquired. It is characterized clinically by the acquisition of secondary sexual characteristics associated with a growth spurt, and on average takes 3-4 years. Early maturation is defined as the development of sexual characteristics before the age of 8 years in girls and 9 years in boys. Delayed puberty is defined when there are no signs of puberty at the age of 13.4 years in girls and 14 years in boys (2 SD above the mean of chronological age for the onset of puberty). There are many forms of premature sexual maturation: gonadotrophin-dependent (central, or 'idiopathic' or 'true' precocious puberty) and gonadotrophin-independent precocious puberty (McCune-Albright syndrome in girls, testotoxicosis in boys); isolated premature thelarche (in the forms of classical, atypical and variant); premature adrenarche (characterized by the production of significant quantities of androgens between 5 and 8 years of age); premature menarche. The differential diagnosis of delayed puberty is between constitutional delay of growth and puberty, pubertal delay secondary to chronic disease and hypogonadotrophic hypogonadism.
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Affiliation(s)
- C Traggiai
- Clinica Pediatrica, University of Genova, Istituto G. Gaslini, Genova, Italy.
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Parisi MA, Kletter GB, Grady R, Mitchell M, Ramsdell LA, Pagon RA. Micropenis with testicular regression, low LH levels, and poor androgen and HCG responses: a distinct syndrome? AMERICAN JOURNAL OF MEDICAL GENETICS 2002; 109:271-7. [PMID: 11992480 DOI: 10.1002/ajmg.10350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report three boys, including two brothers, with micropenis and poor phallic growth in response to both exogenous human chorionic gonadotropin (HCG) and testosterone therapy in the newborn period. They exhibited low neonatal testosterone levels that failed to respond to HCG stimulation. These boys displayed a unique gonadotropin profile with reduced luteinizing hormone levels and elevated follicle-stimulating hormone levels. They had small, cryptorchid testes with subsequent testicular regression and atrophy. Moreover, all three boys have developed microcephaly and mild learning delays. We review the hormonal profiles and phenotypes of known causes of micropenis, and compare them to the features of our three patients. Although individuals with similar features may have been described in past series of males with micropenis, the data presented previously were insufficient for classification; thus, we propose that our patients may represent a distinct, not previously recognized, syndrome with either X-linked recessive inheritance or autosomal recessive inheritance with male sex limitation.
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Affiliation(s)
- Melissa A Parisi
- Division of Genetics and Development, Children's Hospital and Regional Medical Center, University of Washington, PO Box 5371/CH-25, Seattle, WA 98105-0371, USA.
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13
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Abstract
Puberty is the acquisition of secondary sexual characteristics associated with a growth spurt and resulting in the attainment of reproductive function. Delayed puberty is diagnosed when there is no breast development by 13.4 years of age in a girl and no testicular enlargement by 14.0 years in a boy. The aetiologies are: (i) pubertal delay, either with constitutional delay of growth and puberty or secondary to chronic illness, and (ii) pubertal failure, with hypogonadotrophic (defect in the hypothalamo-pituitary region) or hypergonadotrophic (secondary to gonadal failure) hypogonadism, or both (secondary to radio/chemotherapy). The investigation includes: history, auxological data and pubertal development examination. Boys usually require treatment and, if they do not respond, investigation. In girls it is appropriate to measure the thyroid function and karyotype first and, if necessary, to offer treatment. If they present with dysmorphic features, or positive familial history, an assessment is required before treatment.
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Al-Shaikh HA, Brook CG, Hindmarsh PC. Evaluation of the combination of GnRH and HCG tests in differentiating constitutional delay of growth and puberty from hypogonadotropic hypogonadism in males. Ann Saudi Med 2001; 21:230-3. [PMID: 17264562 DOI: 10.5144/0256-4947.2001.230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- H A Al-Shaikh
- London Centre for Paediatric Endocrinology, University College London, UK
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15
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Tanaka N, Miyamoto J, Hasegawa Y. A Response to Human Chorionic Gonadotropin Test in Boys with Normal Gonadal Function and with Hypogonadism. Clin Pediatr Endocrinol 2001. [DOI: 10.1297/cpe.10.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Junko Miyamoto
- Endocrinology, Metabolism and Genetics Unit, Tokyo Metropolitan Kiyose Children's Hospital
| | - Yukihiro Hasegawa
- Endocrinology, Metabolism and Genetics Unit, Tokyo Metropolitan Kiyose Children's Hospital
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Kaplowitz P. Delayed puberty in obese boys: comparison with constitutional delayed puberty and response to testosterone therapy. J Pediatr 1998; 133:745-9. [PMID: 9842037 DOI: 10.1016/s0022-3476(98)70144-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the results of a brief course of testosterone therapy in boys with delayed puberty and to compare the responses seen in boys with constitutional delayed puberty (CDP), boys with obesity, and boys with possible gonadotropin deficiency. DESIGN AND SETTING A retrospective chart review was done for 36 boys aged 14 years or older, seen between 1983 and 1996 because of delayed puberty, who were given 4 monthly injections of testosterone, 100 mg/mo, and had adequate follow-up. RESULTS There were 23 boys whose findings before and after treatment were consistent with a diagnosis of CDP. Testosterone treatment increased the growth rate from 4.3 cm/y to 11.2 cm/y (P <.00001), and mean testis length increased 0.6 to 0.8 cm in all (from a mean of 2.9 to 3.6 cm, P <.00001) in the 4 months after testosterone treatment. Serum testosterone 4 months after therapy was higher than that before therapy (P =.00003). Of 5 boys with growth hormone deficiency but unknown gonadotropin status, 2 had lack of progression after testosterone therapy and were believed to have permanent gonadotropin deficiency. Seven of the 36 boys were obese (body mass index, >25), and 6 had a response to testosterone similar to boys with CDP with clear pubertal progression. One obese boy and one nonobese boy were diagnosed as having isolated gonadotropin deficiency. CONCLUSIONS Monitoring the growth and genital responses to a 4-month course of testosterone injections helps to differentiate CDP from gonadotropin deficiency in boys with delayed puberty. Obese boys constitute a distinct category of boys with pubertal delay in terms of their growth, but their response to testosterone is similar to that observed in boys with classic CDP.
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Affiliation(s)
- P Kaplowitz
- Department of Pediatrics, the Medical College of Virginia of Virginia Commonwealth University, Richmond, USA
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Hashimoto N, Sakakihara Y, Miki Y, Kagawa J, Egi S, Kamoshita S. Moebius syndrome associated with pituitary dwarfism and hypoplastic optic disc. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1993; 35:144-7. [PMID: 8503272 DOI: 10.1111/j.1442-200x.1993.tb03026.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A 17 year old male patient with Moebius syndrome with pituitary dwarfism and unilateral hypoplastic optic disc is presented. Although there have been several reports of an association of Moebius syndrome and pituitary dysfunction, growth hormone deficiency has not been reported previously. These associations may give some insight into the pathogenesis of Moebius syndrome.
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Affiliation(s)
- N Hashimoto
- Department of Pediatrics, Faculty of Medicine, University of Tokyo, Japan
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Abstract
The possibility of testicular insufficiency is a common problem for the pediatric practitioner. Presentation varies with the severity of the defect, the developmental age achieved before onset, and the presence of associated other abnormalities. Most commonly, primary and secondary testicular insufficiency present at the time of puberty, but the presentation may be at birth or in the early neonatal period. Appropriate investigations may uncover the diagnosis at the time and allow intervention later at the appropriate age. Secondary testicular failure, although more difficult to diagnose and to differentiate from simple delay of development, offers the possibility of later development of spermatogenesis and the attainment of fertility through the use of gonadotropins or GnRH replacement programs. In primary testicular failure, because it implies an intrinsic abnormality of the functioning elements of the testis, spermatogenesis is not inducable by hormonal stimulation. Treatment of testicular failure in the neonatal period is unnecessary unless micropenis is associated. In the pubertal boy, testosterone replacement is the treatment of choice and should be initiated carefully, taking into consideration the age of the subject, his bone age, and the psychosocial circumstances. The goal of therapy is to achieve a normal progression of physical changes of puberty to physical maturity and the normal potential for sexual function.
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Affiliation(s)
- P A Lee
- University of Pittsburgh School of Medicine, Pennsylvania
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Cristiano AM, Munabi A, el Sabbagh H, Cassorla F, Sherins RJ. Prolactin response to metoclopramide does not distinguish patients with hypogonadotrophic hypogonadism from delayed puberty. Clin Endocrinol (Oxf) 1988; 28:75-82. [PMID: 3168303 DOI: 10.1111/j.1365-2265.1988.tb01206.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The prolactin response to metoclopramide (MCP) was studied in 23 sexually immature males, 14 with isolated hypogonadotrophic hypogonadism (IHH) and nine with constitutional delayed puberty. Six of the 14 IHH patients had not been treated prior to our study, whereas eight had received long term therapy with testosterone or hCG for variable periods ranging from 1 to 20 years. We also measured the prolactin response to chlorpromazine (CPZ) in the untreated IHH men. In these untreated subjects, we observed a greatly diminished prolactin response after CPZ by comparison to that measured following MCP administration (peak 15 ng/ml, areas 86 units vs peak 43 ng/ml, area 416 units, respectively) (P less than 0.01). Furthermore, prolactin levels following MCP were similar in untreated (peak 43 ng/ml, area 416 units) and treated (peak 55 ng/ml, area 545 units, NS) IHH males as well as in boys with constitutional delayed puberty (peak 50 ng/ml, area 532 units, NS). In addition, responses in the three groups of patients were about half (P less than 0.01) those measured in normal men (peak 81 ng/ml, area 845 units). These data indicate that, unlike CPZ, MCP is not useful in distinguishing patients with hypogonadotrophic hypogonadism from boys with constitutional delayed puberty.
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Affiliation(s)
- A M Cristiano
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development, Bethesda, Maryland 20892
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