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Gravholt CH, Andersen NH, Christin-Maitre S, Davis SM, Duijnhouwer A, Gawlik A, Maciel-Guerra AT, Gutmark-Little I, Fleischer K, Hong D, Klein KO, Prakash SK, Shankar RK, Sandberg DE, Sas TCJ, Skakkebæk A, Stochholm K, van der Velden JA, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome. Eur J Endocrinol 2024; 190:G53-G151. [PMID: 38748847 DOI: 10.1093/ejendo/lvae050] [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: 03/28/2024] [Accepted: 04/19/2024] [Indexed: 06/16/2024]
Abstract
Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.
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Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sophie Christin-Maitre
- Endocrine and Reproductive Medicine Unit, Center of Rare Endocrine Diseases of Growth and Development (CMERCD), FIRENDO, Endo ERN Hôpital Saint-Antoine, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, United States
- eXtraOrdinarY Kids Clinic, Children's Hospital Colorado, Aurora, CO 80045, United States
| | - Anthonie Duijnhouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
| | - Aneta Gawlik
- Departments of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Andrea T Maciel-Guerra
- Area of Medical Genetics, Department of Translational Medicine, School of Medical Sciences, State University of Campinas, 13083-888 São Paulo, Brazil
| | - Iris Gutmark-Little
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
| | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, Ripseweg 9, 5424 SM Elsendorp, The Netherlands
| | - David Hong
- Division of Interdisciplinary Brain Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, CA 92123, United States
| | - Siddharth K Prakash
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | - Roopa Kanakatti Shankar
- Division of Endocrinology, Children's National Hospital, The George Washington University School of Medicine, Washington, DC 20010, United States
| | - David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
| | - Theo C J Sas
- Department the Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam 3015 CN, The Netherlands
- Department of Pediatrics, Centre for Pediatric and Adult Diabetes Care and Research, Rotterdam 3015 CN, The Netherlands
| | - Anne Skakkebæk
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Janielle A van der Velden
- Department of Pediatric Endocrinology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen 6500 HB, The Netherlands
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
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de Brouwer IJ, Suijkerbuijk M, van de Grift TC, Kreukels BPC. First Adolescent Romantic and Sexual Experiences in Individuals With Differences of Sex Development/Intersex Conditions. J Adolesc Health 2022; 71:688-695. [PMID: 36088232 DOI: 10.1016/j.jadohealth.2022.07.012] [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: 03/10/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Adolescence is an important period for sexual development, including sexual debut. The purpose of this study was to assess first romantic and sexual experiences and debut age in individuals with differences of sex development (DSD/intersex) and compare these with age-matched and gender-matched population control values. METHODS Questionnaire data on sociodemographic characteristics, romantic and sexual milestones (e.g., masturbation, dating), satisfaction with sexual life and sexual activity at follow-up, self-esteem, and feelings of femininity or masculinity were collected from 976 participants in Europe with a DSD condition. Participants were divided into six diagnostic subgroups based on their diagnostic classification: women with Turner syndrome, congenital adrenal hyperplasia, 46XY-DSD nonvirilized, and 46XY-DSD female partially virilized conditions and men with 46XY-DSD male or Klinefelter syndrome. Age-specific and gender-specific reference values were retrieved from a Dutch population sample. RESULTS Individuals with DSD were less likely to reach each of the romantic and sexual milestones compared to their peers without these conditions and they were significantly older when reaching these milestones. Between clinical subgroups, individuals with Klinefelter were significantly older when reaching milestones and in the female groups and individuals with Turner were the least likely to reach milestones. Furthermore, a higher age when reaching several romantic and sexual milestones was correlated with lower self-esteem, lower satisfaction with sexual life, and lower sexual frequency at follow-up. DISCUSSION Due to a difference in biopsychosocial context, individuals with DSD often experience a different and/or delayed sexual development during adolescence. Healthcare providers should be aware of these differences in adolescents with DSD and their sexual development to optimize affirmative counseling.
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Affiliation(s)
- Iris J de Brouwer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Department of Medical Psychology, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Merel Suijkerbuijk
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands.
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
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3
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Bakker J. The role of steroid hormones in the sexual differentiation of the human brain. J Neuroendocrinol 2022; 34:e13050. [PMID: 34708466 DOI: 10.1111/jne.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/03/2021] [Accepted: 10/05/2021] [Indexed: 12/31/2022]
Abstract
Widespread sex differences in human brain structure and function have been reported. Research on animal models has demonstrated that sex differences in brain and behavior are induced by steroid hormones during specific, hormone sensitive, developmental periods. It was shown that typical male neural and behavioral characteristics develop under the influence of testosterone, mostly acting during perinatal development. By contrast, typical female neural and behavioral characteristics may actually develop under the influence of estradiol during a specific prepubertal period. This review provides an overview of our current knowledge on the role of steroid hormones in the sexual differentiation of the human brain. Both clinical and neuroimaging data obtained in patients with altered androgen levels/actions (i.e., congenital adrenal hyperplasia or complete androgen insensitivity syndrome [CAIS]), point to an important role of (prenatal) androgens in inducing typical male neural and psychosexual characteristics in humans. In contrast to rodents, there appears to be no obvious role for estrogens in masculinizing the human brain. Furthermore, data from CAIS also suggest a contribution of sex chromosome genes to the development of the human brain. The final part of this review is dedicated to a brief discussion of gender incongruence, also known as gender dysphoria, which has been associated with an altered or less pronounced sexual differentiation of the brain.
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Affiliation(s)
- Julie Bakker
- Neuroendocrinology, GIGA Neurosciences, Liège University, Liege, Belgium
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4
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Psychosocial well-being and quality of life in women with Turner syndrome. Psychoneuroendocrinology 2020; 113:104548. [PMID: 31923612 DOI: 10.1016/j.psyneuen.2019.104548] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/14/2019] [Accepted: 12/13/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Turner syndrome (TS) affects approximately one out of 2500 females. Previous research indicates that women with TS experience impairment in several psychosocial domains as well as in quality of life (QoL). Data, however, mainly focus on girls, whereas data on adult women is extremely scarce, inconsistent and mainly low in sample size. Separate analysis of adult women, however, is important since women face other challenges of TS than girls. METHODS We compared 301 women with TS aged 16-73 years (from 14 centres in six European countries) to healthy controls with regard to depression, anxiety, self-esteem, attention deficit/hyperactivity disorder (ADHD), autism, romantic relationships, social participation, amount of working hours and satisfaction with income as well as with regard to psychological, physical, environmental, social and global QoL. The influence of psychosocial well-being on the different QoL-domains was examined via multiple regression models. RESULTS Women with TS showed impairments in all psychosocial variables (anxiety, depression, ADHD, autism, self-esteem, social participation all p < 0.001) except for the amount of working hours (p = 0.062) and satisfaction with income (p = 0.369). They also showed lower social (p < 0.001), psychological (p < 0.001) and physical QoL (p < 0.001) compared to controls. Depression, satisfaction with income and self-esteem could be shown to be the best predictors for QoL. CONCLUSION In conclusion, quality of life in TS is impaired, in particular it seems to be negatively affected by depression and low self-esteem whereas satisfaction with income has a positive influence. These results implicate that medical staff needs to pay attention on possible psychosocial impairments when treating women with TS. Strengthening self-esteem and counteracting depression potentially raises their QoL.
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Lin AE, Prakash SK, Andersen NH, Viuff MH, Levitsky LL, Rivera-Davila M, Crenshaw ML, Hansen L, Colvin MK, Hayes FJ, Lilly E, Snyder EA, Nader-Eftekhari S, Aldrich MB, Bhatt AB, Prager LM, Arenivas A, Skakkebaek A, Steeves MA, Kreher JB, Gravholt CH. Recognition and management of adults with Turner syndrome: From the transition of adolescence through the senior years. Am J Med Genet A 2019; 179:1987-2033. [PMID: 31418527 DOI: 10.1002/ajmg.a.61310] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/11/2019] [Accepted: 07/18/2019] [Indexed: 12/16/2022]
Abstract
Turner syndrome is recognized now as a syndrome familiar not only to pediatricians and pediatric specialists, medical geneticists, adult endocrinologists, and cardiologists, but also increasingly to primary care providers, internal medicine specialists, obstetricians, and reproductive medicine specialists. In addition, the care of women with Turner syndrome may involve social services, and various educational and neuropsychologic therapies. This article focuses on the recognition and management of Turner syndrome from adolescents in transition, through adulthood, and into another transition as older women. It can be viewed as an interpretation of recent international guidelines, complementary to those recommendations, and in some instances, an update. An attempt was made to provide an international perspective. Finally, the women and families who live with Turner syndrome and who inspired several sections, are themselves part of the broad readership that may benefit from this review.
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Affiliation(s)
- Angela E Lin
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Siddharth K Prakash
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette H Viuff
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology, Department of Pediatrics, Mass General Hospital for Children, Boston, Massachusetts
| | - Michelle Rivera-Davila
- Division of Pediatric Endocrinology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa L Crenshaw
- Medical Genetics Services, Division of Genetics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Lars Hansen
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus, Denmark
| | - Mary K Colvin
- Psychology Assessment Center, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Frances J Hayes
- Reproductive Endocrine Unit of the Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Evelyn Lilly
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emma A Snyder
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Shahla Nader-Eftekhari
- Division of Endocrinology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa B Aldrich
- Center for Molecular Imaging, The Brown Institute for Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Ami B Bhatt
- Corrigan Minehan Heart Center, Adult Congenital Heart Disease Program, Massachusetts General Hospital, Boston, Massachusetts.,Yawkey Center for Outpatient Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura M Prager
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Ana Arenivas
- Department of Rehabilitation Psychology/Neuropsychology, TIRR Memorial Hermann Rehabilitation Network, Houston, Texas.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Anne Skakkebaek
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Marcie A Steeves
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Jeffrey B Kreher
- Department of Pediatrics and Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
| | - Claus H Gravholt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
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Kreukels BPC, Cohen-Kettenis PT, Roehle R, van de Grift TC, Slowikowska-Hilczer J, Claahsen-van der Grinten H, Lindén Hirschberg A, de Vries ALC, Reisch N, Bouvattier C, Nordenström A, Thyen U, Köhler B, Group OBOTDL. Sexuality in Adults with Differences/Disorders of Sex Development (DSD): Findings from the dsd-LIFE Study. JOURNAL OF SEX & MARITAL THERAPY 2019; 45:688-705. [PMID: 31034334 DOI: 10.1080/0092623x.2019.1610123] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
For various reasons, sexuality of individuals with differences/disorders of sex development (DSD) may be affected. The aim of the study was to describe sexual activity, satisfaction with sex life, satisfaction with genital function, and sexual problems in people with different DSD conditions. Data were collected from 1,040 participants in Europe. Many people with a variety of DSD conditions do not appear to be satisfied with their sex life, experience a variety of sexual problems, and are less sexually active than the general population; therefore sexuality should be explicitly addressed in the care of people with DSD.
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Affiliation(s)
| | - Peggy T Cohen-Kettenis
- Medische psychologie, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Robert Roehle
- Charite - Universitätsmedizin Berlin, Koordinierungszentrum fur Klinische Studien (KKS Charite) , Berlin , Germany
| | - Tim C van de Grift
- Medische psychologie, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
- Plastische, Reconstructieve en Handchirurgie, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | | | | | - Angelica Lindén Hirschberg
- Department Gynaecology and Reproductive Medicine, Karolinska University Hospital , Stockholm , Sweden
- Department of Women's and Children's Health, Karolinska Institutet , Stockholm , Sweden
| | - Annelou L C de Vries
- Kinderpsychiatrie, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Nicole Reisch
- Department of Endocrinology, University Hospital Munich , Munich , Germany
| | - Claire Bouvattier
- Department of Pediatric Endocrinology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, France , Le Kremlin Bicêtre , France
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet , Stockholm , Sweden
| | - Ute Thyen
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck , Lubeck , Germany
| | - Birgit Köhler
- Klinik fur Pädiatrie mit Schwerpunkt Endokrinologie und Diabetologie, Charite - Universitätsmedizin Berlin , Berlin , Germany
| | - On Behalf Of The Dsd-Life Group
- The dsd-LIFE group: Birgit Köhler, Berlin; Peggy Cohen-Kettenis and Annelou de Vries, Amsterdam; Wiebke Arlt, Birmingham and Claudia Wiesemann, Göttingen; Jolanta Slowikowska-Hilczer, Lodz; Aude Brac de la Perriere, Lyon; Charles Sultan and Francoise Paris, Montpellier; Claire Bouvattier, Paris; Ute Thyen, Lubeck; Nicole Reisch, Munich; Annette Richter-Unruh, Munster; Hedi Claahsen-van der Grinten, Nijmegen; Anna Nordenström, Stockholm; Catherine Pienkowski, Toulouse ; and Maria Szarras-Czapnik , Warsaw
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7
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Abstract
PURPOSE OF REVIEW Summarize the literature on the social skills and relationships of women with Turner syndrome and examine the biological and psychological factors that may contribute to social interaction difficulties. RECENT FINDINGS Turner syndrome is often associated with impaired social-cognitive processing and executive function deficits. These cognitive abnormalities, together with a range of physical differences, may adversely affect social communication skills, which typically begin to impair quality of life during early adolescence. Parental accounts of their daughter's social skills frequently highlight interaction problems, both in the home and beyond; in contrast, self-reports are usually far more positive. At present, we do not know the extent to which such self-reports reflect a lack of social awareness, or a lack of concern about social difficulties. SUMMARY Women with Turner syndrome are likely to experience social interaction challenges (especially in friendships and relationships) across the lifespan. Providing appropriate guidance and support to them demands a better understanding of their strengths and weaknesses.
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Anaki D, Zadikov-Mor T, Gepstein V, Hochberg Z. Normal Performance in Non-Visual Social Cognition Tasks in Women with Turner Syndrome. Front Endocrinol (Lausanne) 2018; 9:171. [PMID: 29780353 PMCID: PMC5946023 DOI: 10.3389/fendo.2018.00171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/03/2018] [Indexed: 12/21/2022] Open
Abstract
Turner syndrome (TS) is a chromosomal disorder in women resulting from a partial or complete absence of the X chromosome. In addition to physical and hormonal dysfunctions, along with a unique neurocognitive profile, women with TS are reported to suffer from social functioning difficulties. Yet, it is unclear whether these difficulties stem from impairments in social cognition per se or from other deficits that characterize TS but are not specific to social cognition. Previous research that has probed social functioning in TS is equivocal regarding the source of these psychosocial problems since they have mainly used tasks that were dependent on visual-spatial skills, which are known to be compromised in TS. In the present study, we tested 26 women with TS and 26 matched participants on three social cognition tasks that did not require any visual-spatial capacities but rather relied on auditory-verbal skills. The results revealed that in all three tasks the TS participants did not differ from their control counterparts. The same TS cohort was found, in an earlier study, to be impaired, relative to controls, in other social cognition tasks that were dependent on visual-spatial skills. Taken together these findings suggest that the social problems, documented in TS, may be related to non-specific spatial-visual factors that affect their social cognition skills.
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Affiliation(s)
- David Anaki
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
- Gonda Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat Gan, Israel
- *Correspondence: David Anaki,
| | - Tal Zadikov-Mor
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Vardit Gepstein
- The Ruth Rappaport Children’s Hospital, Rambam Medical Center, Haifa, Israel
| | - Ze’ev Hochberg
- Rappaport Family Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
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9
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The Sexual Differentiation of the Human Brain: Role of Sex Hormones Versus Sex Chromosomes. Curr Top Behav Neurosci 2018; 43:45-67. [PMID: 30599078 DOI: 10.1007/7854_2018_70] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Men and women differ, not only in their anatomy but also in their behavior. Research using animal models has convincingly shown that sex differences in the brain and behavior are induced by sex hormones during a specific, hormone-sensitive period during early development. Thus, male-typical psychosexual characteristics seem to develop under the influence of testosterone, mostly acting during early development. By contrast, female-typical psychosexual characteristics may actually be organized under the influence of estradiol during a specific prepubertal period. The sexual differentiation of the human brain also seems to proceed predominantly under the influence of sex hormones. Recent studies using magnetic resonance imaging have shown that several sexually differentiated aspects of brain structure and function are female-typical in women with complete androgen insensitivity syndrome (CAIS), who have a 46 XY karyotype but a female phenotype due to complete androgen resistance, suggesting that these sex differences most likely reflect androgen action, although feminizing effects of estrogens or female-typical socialization cannot be ruled out. By contrast, some male-typical neural characteristics were also observed in women with CAIS suggesting direct effects of sex chromosome genes in the sexual differentiation of the human brain. In conclusion, the sexual differentiation of the human brain is most likely a multifactorial process including both sex hormone and sex chromosome effects, acting in parallel or in combination.
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Gravholt CH, Andersen NH, Conway GS, Dekkers OM, Geffner ME, Klein KO, Lin AE, Mauras N, Quigley CA, Rubin K, Sandberg DE, Sas TCJ, Silberbach M, Söderström-Anttila V, Stochholm K, van Alfen-van derVelden JA, Woelfle J, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting. Eur J Endocrinol 2017; 177:G1-G70. [PMID: 28705803 DOI: 10.1530/eje-17-0430] [Citation(s) in RCA: 617] [Impact Index Per Article: 88.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/07/2017] [Indexed: 12/14/2022]
Abstract
Turner syndrome affects 25-50 per 100,000 females and can involve multiple organs through all stages of life, necessitating multidisciplinary approach to care. Previous guidelines have highlighted this, but numerous important advances have been noted recently. These advances cover all specialty fields involved in the care of girls and women with TS. This paper is based on an international effort that started with exploratory meetings in 2014 in both Europe and the USA, and culminated with a Consensus Meeting held in Cincinnati, Ohio, USA in July 2016. Prior to this meeting, five groups each addressed important areas in TS care: 1) diagnostic and genetic issues, 2) growth and development during childhood and adolescence, 3) congenital and acquired cardiovascular disease, 4) transition and adult care, and 5) other comorbidities and neurocognitive issues. These groups produced proposals for the present guidelines. Additionally, four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with a separate systematic review of the literature. These four questions related to the efficacy and most optimal treatment of short stature, infertility, hypertension, and hormonal replacement therapy. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with The European Society for Pediatric Endocrinology, The Endocrine Society, European Society of Human Reproduction and Embryology, The American Heart Association, The Society for Endocrinology, and the European Society of Cardiology. The guideline has been formally endorsed by the European Society for Endocrinology, the Pediatric Endocrine Society, the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology and the Endocrine Society. Advocacy groups appointed representatives who participated in pre-meeting discussions and in the consensus meeting.
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Affiliation(s)
- Claus H Gravholt
- Departments of Endocrinology and Internal Medicine
- Departments of Molecular Medicine
| | - Niels H Andersen
- Departments of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gerard S Conway
- Department of Women's Health, University College London, London, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mitchell E Geffner
- The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, California, USA
| | - Angela E Lin
- Department of Pediatrics, Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Nelly Mauras
- Division of Endocrinology, Nemours Children's Health System, Jacksonville, Florida, USA
| | | | - Karen Rubin
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - David E Sandberg
- Division of Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Theo C J Sas
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Dordrecht, The Netherlands
| | - Michael Silberbach
- Department of Pediatrics, Doernbecher Children's Hospital, Portland, Oregon, USA
| | | | - Kirstine Stochholm
- Departments of Endocrinology and Internal Medicine
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Joachim Woelfle
- Department of Pediatric Endocrinology, Children's Hospital, University of Bonn, Bonn, Germany
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Fjermestad KW, Naess EE, Bahr D, Gravholt CH. A 6-year Follow-up survey of health status in middle-aged women with Turner syndrome. Clin Endocrinol (Oxf) 2016; 85:423-9. [PMID: 27004718 DOI: 10.1111/cen.13068] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/08/2016] [Accepted: 03/18/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Studies suggest younger women with Turner syndrome (TS) have good quality of life. Less is known about everyday functioning in adults with TS. In a 6-year follow-up study, multiple areas of functioning were compared between TS women and controls. DESIGN Women with TS and controls were mailed a self-report survey 6 years after a baseline study. PATIENTS Fifty-seven women with TS (M age 40·6 ± 11·1 years) and 101 controls (M age 38·8 ± 10·6 years, ns) responded. MEASUREMENTS Measures of background information, experienced life strain and presence/impact of health conditions were developed for this study. The QPS Nordic measured perceived workload challenges. The LiSat-9 measured life satisfaction. The Rosenberg Self-Esteem Scale measured self-esteem. RESULTS More TS women lived alone, fewer had biological children, and more had adoptive children. TS women reported fewer sex partners and less sexual confidence. Controls had higher education. There was no difference in employment status. More TS women received disability pensions. TS women reported their work as more physically challenging, less positively challenging and requiring less knowledge skills. TS women experienced more life strain in school, adolescence and late working life. Controls reported higher overall life satisfaction, with no difference between samples on specific domains. TS women reported lower self-esteem. For TS women only, physical health at baseline predicted length of education and mental health at baseline predicted self-esteem. CONCLUSIONS Women with TS face more challenges than controls on several domains of functioning. Early physical and mental health may influence later educational achievement and self-esteem for women with TS.
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Affiliation(s)
- Krister W Fjermestad
- Frambu Resource Center for Rare Disorders, Siggerud, Norway
- Department of Psychology, University of Oslo, Siggerud, Norway
| | - Eva E Naess
- Frambu Resource Center for Rare Disorders, Siggerud, Norway
| | - David Bahr
- Frambu Resource Center for Rare Disorders, Siggerud, Norway
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Denmark
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Brotto L, Atallah S, Johnson-Agbakwu C, Rosenbaum T, Abdo C, Byers ES, Graham C, Nobre P, Wylie K. Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction. J Sex Med 2016; 13:538-71. [DOI: 10.1016/j.jsxm.2016.01.019] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 01/16/2016] [Accepted: 01/19/2016] [Indexed: 12/11/2022]
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Santoro N, Worsley R, Miller KK, Parish SJ, Davis SR. Role of Estrogens and Estrogen-Like Compounds in Female Sexual Function and Dysfunction. J Sex Med 2016; 13:305-16. [DOI: 10.1016/j.jsxm.2015.11.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/13/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
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Visscher K, Metcalfe KA, Semple JL. Breast deformity and reconstruction in Turner syndrome: A collection of case studies. JPRAS Open 2015. [DOI: 10.1016/j.jpra.2015.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Freriks K, Verhaak CM, Sas TCJ, Menke LA, Wit JM, Otten BJ, de Muinck Keizer-Schrama SMPF, Smeets DFCM, Netea-Maier RT, Hermus ARMM, Kessels RPC, Timmers HJLM. Long-term effects of oxandrolone treatment in childhood on neurocognition, quality of life and social-emotional functioning in young adults with Turner syndrome. Horm Behav 2015; 69:59-67. [PMID: 25562712 DOI: 10.1016/j.yhbeh.2014.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 11/28/2014] [Accepted: 12/23/2014] [Indexed: 11/24/2022]
Abstract
Turner syndrome (TS) is the result of (partial) absence of one X-chromosome. Besides short stature, gonadal dysgenesis and other physical aspects, TS women have typical psychological features. Since psychological effects of androgen exposure in childhood probably are long-lasting, we explored long-term psychological functioning after oxandrolone (Ox) therapy during childhood in adults with TS in terms of neurocognition, quality of life and social-emotional functioning. During the initial study, girls were treated with growth hormone (GH) combined with placebo (Pl), Ox 0.03 mg/kg/day, or Ox 0.06 mg/kg/day from the age of eight, and estrogen from the age of twelve. Sixty-eight women participated in the current double-blinded follow-up study (mean age 24.0 years, mean time since stopping GH/Ox 8.7 years). We found no effects on neurocognition. Concerning quality of life women treated with Ox had higher anxiety levels (STAI 37.4 ± 8.4 vs 31.8 ± 5.0, p=0.002) and higher scores on the depression subscale of the SCL-90-R (25.7 ± 10.7 vs 20.5 ± 4.7, p=0.01). Regarding social-emotional functioning, emotion perception for fearful faces was lower in the Ox-treated patients, without effect on interpersonal behavior. Our exploratory study is the first to suggest that androgen treatment in adolescence possibly has long-term effects on adult quality of life and social-emotional functioning. However, differences are small and clinical implications of our results seem limited. Therefore we would not recommend against the use of Ox in light of psychological consequences.
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Affiliation(s)
- K Freriks
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 471, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - C M Verhaak
- Department of Medical Psychology, Radboud University Medical Center, 118/925, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - T C J Sas
- Department of Pediatrics, Erasmus Medical Centre/Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands; Department of Pediatrics, Albert Schweitzer Hospital, P.O. Box 444, 3300 AK Dordrecht, The Netherlands
| | - L A Menke
- Department of Pediatrics, Leiden University Medical Center, J6S, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - J M Wit
- Department of Pediatrics, Leiden University Medical Center, J6S, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - B J Otten
- Department of Pediatrics, Radboud University Medical Center, 804, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - S M P F de Muinck Keizer-Schrama
- Department of Pediatrics, Erasmus Medical Centre/Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
| | - D F C M Smeets
- Department of Human Genetics, Radboud University Medical Center, 848, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - R T Netea-Maier
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 471, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - A R M M Hermus
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 471, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - R P C Kessels
- Department of Medical Psychology, Radboud University Medical Center, 118/925, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, The Netherlands
| | - H J L M Timmers
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 471, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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16
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Chakhtoura Z, Touraine P. [Fertility on women with Turner syndrome]. Presse Med 2013; 42:1508-12. [PMID: 24157183 DOI: 10.1016/j.lpm.2013.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 02/25/2013] [Accepted: 03/05/2013] [Indexed: 01/15/2023] Open
Abstract
Spontaneous pregnancies occur in 1.8 to 7.6% among women with Turner syndrome. A genetic counseling is required before conception because only 30 to 40% of these pregnancies lead to the birth of a healthy child. A check-up has to be done before pregnancy, and if authorized, it will be tightly followed-up. Pregnancy is contraindicated if cardiac or aortic malformations exist, except for bicuspid aortic valve. Teams advice single embryo transfer. Rates of pregnancies of 45 to 60% after oocyte donation, but 40 to 60% of spontaneous abortions are noted, due to uterine factors. A study is trying to define patients who could postulate to cryopreservation of ovarian tissue.
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Affiliation(s)
- Zeina Chakhtoura
- Groupe hospitalier La Pitié-Salpêtrière - Charles-Foix, endocrinologie et médecine de la reproduction, université Paris-6-Pierre-et-Marie-Curie, 75013 Paris, France; Centre de référence des maladies endocriniennes rares de la croissance, AP-HP, 75019 Paris, France; Centre des pathologies gynécologiques médico-chirurgicales rares, 75015 Paris, France
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Ros C, Alobid I, Balasch J, Mullol J, Castelo-Branco C. Turner's syndrome and other forms of congenital hypogonadism impair quality of life and sexual function. Am J Obstet Gynecol 2013; 208:484.e1-6. [PMID: 23313313 DOI: 10.1016/j.ajog.2013.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 12/18/2012] [Accepted: 01/07/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to assess the burden of Turner's syndrome (TS) and other congenital hypogonadisms (OCH) on quality of life (QOL) and sexual function. STUDY DESIGN An observational study was undertaken in a gynecological endocrinology unit of a teaching hospital. Three cohorts of women aged 20-50 years were compared: 26 TS patients, 21 women with OCH and wild-type karyotype, and 41 healthy age-matched women who were included as controls. All subjects filled out the Medical Outcome Study Short Form (SF-36) and the Female Sexual Function Index. RESULTS TS subjects had significantly worse QOL scores in physical functioning (P = .026) and role physical functioning (P = .032) whereas OCH showed significantly worse scores in physical functioning (P = .027) and bodily pain (P = .025) compared to controls. In all, 80% of OCH and 50% of TS patients declared sexual activity. Sexually active TS patients had poorer arousal outcomes (P = .009) and OCH women showed significantly worse scores in arousal (P = .002), orgasm (P = .007), pain (P = .001), and Female Sexual Function Index total score (P = .004) compared with healthy controls. No differences between sexually active and inactive TS women were found in SF-36 scores, clinical characteristics, or anthropomorphic characteristics. CONCLUSION TS and OCH subjects presented impaired physical domains in QOL. Women with TS are less likely to be involved in sexual activity, arousal dysfunctions being their main symptom. Conversely, arousal, orgasm, pain, and total score were significantly affected in OCH subjects.
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Clauson S, Hollins Martin C, Watt G. Anxiety as a cause of attachment avoidance in women with Turner Syndrome. SEXUAL AND RELATIONSHIP THERAPY 2012. [DOI: 10.1080/14681994.2012.748891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Burnett AC, Reutens DC, Wood AG. Social cognition in Turner’s Syndrome. J Clin Neurosci 2010; 17:283-6. [DOI: 10.1016/j.jocn.2009.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 07/20/2009] [Accepted: 09/24/2009] [Indexed: 11/30/2022]
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20
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Andrews JM, Mountifield RE, Van Langenberg DR, Bampton PA, Holtmann GJ. Un-promoted issues in inflammatory bowel disease: opportunities to optimize care. Intern Med J 2009; 40:173-82. [PMID: 19849744 DOI: 10.1111/j.1445-5994.2009.02110.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Inflammatory bowel diseases (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory disorders of the gut, which lead to significant morbidity and impaired quality of life (QoL) in sufferers, without generally affecting mortality. Despite CD and UC being chronic, life-long illnesses, most medical management is directed at acute flares of disease. Moreover, with more intensive medical therapy and the development of biological therapy, there is a risk that management will become even more narrowly focused on acute care, and be directed only at those with more severe disease, rather than encompassing all sufferers and addressing important non-acute issues. This imbalance of concentration of medical attention on 'high-end' care is in part driven by the need to perform and publish randomized clinical trials of newer therapies to obtain registration and licensing for these agents, which thus occupy a large proportion of the recent IBD treatment literature. This leads to less attention on relatively 'low-technology' issues including: (i) the psychosocial burden of chronic disease, QoL and specific psychological comorbidities; (ii) comorbidity with functional gastrointestinal disorders (FGIDs); (iii) maintenance therapy, monitoring and compliance; (iv) smoking (with regard to CD); (v) sexuality, fertility, family planning and pregnancy; and (vi) iron deficiency and anaemia. We propose these to be the 'Un-promoted Issues' in IBD and review the importance and treatment of each of these in the current management of IBD.
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Affiliation(s)
- J M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, and School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia.
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Christopoulos P, Deligeoroglou E, Laggari V, Christogiorgos S, Creatsas G. Psychological and behavioural aspects of patients with Turner syndrome from childhood to adulthood: a review of the clinical literature. J Psychosom Obstet Gynaecol 2008; 29:45-51. [PMID: 17852655 DOI: 10.1080/01674820701577078] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Turner syndrome (TS) is a chromosomal abnormality, which occurs in approximately one of every 2500 female births. Short stature, infertility, additional physical abnormalities, skeletal and medical problems may be present. Genetic, hormonal, and medical problems associated with TS are likely to affect psychosexual development of female adolescent patients, and thus influence their psychological functioning, behavior patterns, social interactions and learning ability. Although TS constitutes a chronic medical condition, with possible physical, social and psychological complications in a woman's life, hormonal and estrogen replacement therapy and assisted reproduction, are treatments that can be helpful for TS patients and improve their quality of life. Authors report on a review of the research literature clinical aspects of the syndrome as well as the beneficial effect of hormonal therapy in such patients.
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Affiliation(s)
- P Christopoulos
- 2nd Department of Obstetrics and Gynecology, Medical School, University of Athens, Aretaieion Hospital, Greece.
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