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Hoefgen HR, Benoit J, Chan S, Jayasinghe Y, Lustberg M, Pohl V, Saraf A, Schmidt D, Appiah LC. Female reproductive health in pediatric, adolescent, and young adult cancer survivors. Pediatr Blood Cancer 2023; 70 Suppl 5:e29170. [PMID: 37381166 DOI: 10.1002/pbc.29170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 05/02/2021] [Accepted: 05/11/2021] [Indexed: 06/30/2023]
Abstract
An estimated 500,000 cancer survivors of reproductive age in the United States will live to experience the long-term consequences of cancer treatment. Therefore, a focused aspect of cancer care has appropriately shifted to include quality of life in survivorship. Infertility is a late effect of therapy that affects 12% of female survivors of childhood cancer receiving any cancer treatment in large cohort studies and results in a 40% decreased likelihood of pregnancy in young adults of ages 18-39 years. Nonfertility gynecologic late effects such as hypoestrogenism, radiation-induced uterine and vaginal injury, genital graft-versus-host disease after hematopoietic stem cell transplant, and sexual dysfunction also significantly affect quality of life in survivorship but are underdiagnosed and require consideration. Several articles in the special edition "Reproductive Health in Adolescent and Young Adult Cancer Survivorship" address infertility, genital graft-versus-host disease, and psychosexual functioning in survivorship. This review article focuses on other adverse gynecologic outcomes of cancer therapies including hypogonadism and hormone replacement therapy, radiation-induced uterovaginal injury, vaccination and contraception, breast and cervical cancer screening, and pregnancy considerations in survivorship.
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Affiliation(s)
- Holly R Hoefgen
- Division of Pediatric and Adolescent Gynecology, Department of Obstet Gynecol, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Janie Benoit
- Gynecology & Reproductive Sciences, CHU Ste-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Serena Chan
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics, Gynecology & Reproductive Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yasmin Jayasinghe
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Maryam Lustberg
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Victoria Pohl
- Center for Cancer and Blood Disorders, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Amanda Saraf
- Division Pediatric Hematology Oncology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Deb Schmidt
- MACC Fund Center for Cancer and Blood Disorders, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Leslie Coker Appiah
- Division of Pediatric and Adolescent Gynecology, Department of Obstet Gynecol, Children's Hospital Colorado, University of Colorado Denver, Denver, Colorado, USA
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Dural O, Ulusoy HE, Tikiz MA, Gurbanova T, Yasa C, Ugurlucan FG, Akhan SE. Effects of Hormone Replacement Therapy on Low Bone Mineral Density in Adolescents and Young Women with Hypogonadism: Comparison of Oral and Transdermal 17 Beta-Estradiol Administration. J Pediatr Adolesc Gynecol 2022; 35:634-637. [PMID: 35644512 DOI: 10.1016/j.jpag.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To evaluate the effects of physiological dose 17 beta-estradiol (E2) replacement on low bone mineral density (BMD) and compare the results of oral and transdermal (TD) E2 administration in adolescents and young women with hypogonadism DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed the medical records of patients aged 15 to 24 years who were diagnosed with hypogonadism, who had begun receiving oral or TD E2 replacement, and whose initial dual-energy X-ray absorptiometry scan detected a lumbar spine BMD Z-score of -1 or lower between 2014 and 2018. The patients were divided into 2 groups according to the E2 route of administration as those who received 2 mg orally (Group 1) and 0.1 mg TD (Group 2). INTERVENTIONS None MAIN OUTCOME MEASURE: BMD scans of the patients at baseline and repeated within 2 years after E2 replacement RESULTS: In total, 43 patients who met the inclusion criteria were included in the study. Two groups did not differ for BMD scores at baseline. A significant improvement in BMD was observed with physiological dose E2 replacement in both groups. Mean BMD Z-score increased by +0.7 (95% CI, 0.47-0.93) in response to TD E2 administration, compared with +0.41 (95% CI, 0.25-0.58) during oral E2 replacement (P = .037). CONCLUSION We conclude that physiological dose E2 replacement, even within a short period of 2 years, has a significant beneficial effect on bone mass acquisition on the lumbar spine. Our study also demonstrates the possible superiority of TD E2 replacement over the oral route in increasing lumbar spine BMD.
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Affiliation(s)
- Ozlem Dural
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey.
| | - Hevra Ekin Ulusoy
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Muge Ates Tikiz
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Turkane Gurbanova
- Medical Park Gebze Hospital, Section of Obstetrics and Gynecology, Gebze, Kocaeli, Turkey
| | - Cenk Yasa
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Funda Gungor Ugurlucan
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Suleyman Engin Akhan
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
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Lin D, Quan H, Chen K, Lin L, Lin L, Ji Q. An adolescent girl with premature ovarian failure, Graves' disease, and chronic urticaria: a case report. J Med Case Rep 2020; 14:184. [PMID: 33038927 PMCID: PMC7548041 DOI: 10.1186/s13256-020-02491-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/07/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Premature ovarian failure is characterized by amenorrhea, hypoestrogenism, and hypergonadotropinism, and occurs in women under 40 years of age. The prevalence of premature ovarian failure in women younger than 20 years of age is only 0.01%. Immune disorders are one of the causes of premature ovarian failure. Graves' disease and chronic urticaria are also associated with immune disorders. CASE PRESENTATION We report a case of a 15-year-old Han Chinese girl with premature ovarian failure complicated by Graves' disease and chronic urticaria. She experienced menarche at 13 years of age and presented with amenorrhea after 7 months of irregular menstruation. Laboratory examinations indicated hypoestrogenism and hypergonadotropinism. Ultrasound imaging revealed that her uterus and ovaries were small in size. Gene and antibody tests related to premature ovarian failure returned negative results. Both thyroid peroxidase autoantibody and thyrotropin receptor antibody were positive. After reviewing the literature on the relationship between these three diseases and immune disorders, our patient was diagnosed as having atypical autoimmune polyglandular syndrome. After taking small doses of estrogen for 6 months, the size of her uterus increased, and her psychological anxiety was relieved. CONCLUSIONS We report a case of an unusual association of premature ovarian failure, Graves' disease, and chronic urticaria. This case presents an atypical combination of adolescent autoimmune polyglandular syndrome, which is worthy of the attention of clinicians and presents an important lesson for them. Our case highlights that premature ovarian failure in adolescents requires long-term follow-up and medical treatment as well as psychological counselling.
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Affiliation(s)
- Danhong Lin
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou City, Hainan Province, China
| | - Huibiao Quan
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou City, Hainan Province, China.
| | - Kaining Chen
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou City, Hainan Province, China
| | - Lu Lin
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou City, Hainan Province, China
| | - Leweihua Lin
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou City, Hainan Province, China
| | - Qun Ji
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou City, Hainan Province, China
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Young J, Xu C, Papadakis GE, Acierno JS, Maione L, Hietamäki J, Raivio T, Pitteloud N. Clinical Management of Congenital Hypogonadotropic Hypogonadism. Endocr Rev 2019; 40:669-710. [PMID: 30698671 DOI: 10.1210/er.2018-00116] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 10/05/2018] [Indexed: 12/12/2022]
Abstract
The initiation and maintenance of reproductive capacity in humans is dependent on pulsatile secretion of the hypothalamic hormone GnRH. Congenital hypogonadotropic hypogonadism (CHH) is a rare disorder that results from the failure of the normal episodic GnRH secretion, leading to delayed puberty and infertility. CHH can be associated with an absent sense of smell, also termed Kallmann syndrome, or with other anomalies. CHH is characterized by rich genetic heterogeneity, with mutations in >30 genes identified to date acting either alone or in combination. CHH can be challenging to diagnose, particularly in early adolescence where the clinical picture mirrors that of constitutional delay of growth and puberty. Timely diagnosis and treatment will induce puberty, leading to improved sexual, bone, metabolic, and psychological health. In most cases, patients require lifelong treatment, yet a notable portion of male patients (∼10% to 20%) exhibit a spontaneous recovery of their reproductive function. Finally, fertility can be induced with pulsatile GnRH treatment or gonadotropin regimens in most patients. In summary, this review is a comprehensive synthesis of the current literature available regarding the diagnosis, patient management, and genetic foundations of CHH relative to normal reproductive development.
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Affiliation(s)
- Jacques Young
- University of Paris-Sud, Paris-Sud Medical School, Le Kremlin-Bicêtre, France.,Department of Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hôpital, Le Kremlin-Bicêtre, France.,INSERM Unité 1185, Le Kremlin-Bicêtre, France
| | - Cheng Xu
- Service of Endocrinology, Diabetology, and Metabolism, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Georgios E Papadakis
- Service of Endocrinology, Diabetology, and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
| | - James S Acierno
- Service of Endocrinology, Diabetology, and Metabolism, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Luigi Maione
- University of Paris-Sud, Paris-Sud Medical School, Le Kremlin-Bicêtre, France.,Department of Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hôpital, Le Kremlin-Bicêtre, France.,INSERM Unité 1185, Le Kremlin-Bicêtre, France
| | - Johanna Hietamäki
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Translational Stem Cell Biology and Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Taneli Raivio
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Translational Stem Cell Biology and Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Nelly Pitteloud
- Service of Endocrinology, Diabetology, and Metabolism, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Kanj RV, Ofei-Tenkorang NA, Altaye M, Gordon CM. Evaluation and Management of Primary Ovarian Insufficiency in Adolescents and Young Adults. J Pediatr Adolesc Gynecol 2018; 31:13-18. [PMID: 28782660 DOI: 10.1016/j.jpag.2017.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/23/2017] [Accepted: 07/31/2017] [Indexed: 01/24/2023]
Abstract
STUDY OBJECTIVE To identify clinical features associated with primary ovarian insufficiency (POI) and collect data on the evaluation and treatment received. DESIGN Retrospective chart review. Data were abstracted on etiology of POI, history, laboratory evaluation, imaging results, return for clinical care, and treatment plans. SETTING Urban children's hospital in Cincinnati, Ohio. PARTICIPANTS Fifty female patients, age 11-26 years, with initial presentation of POI between January 1, 2006 and December 31, 2015. MAIN OUTCOME MEASURES Etiology of POI, bone mineral density (BMD), laboratory evaluation, and services utilized at presentation. RESULTS Three hundred thirty-one charts were reviewed, 71 with confirmed diagnosis of POI, and 50 with sufficient data for inclusion. Among the 50, 21 (42%) had Turner syndrome, 18 (36%) remained idiopathic, and 11 (22%) had another condition (eg, autoimmune polyglandular syndrome, galactosemia, etc). Thirty-six (72%) were karyotyped; in 14 (28%), 21-hydroxylase antibodies were measured; 32 (64%) underwent dual-energy x-ray absorptiometry BMD measures of lumbar spine. Eight of 50 patients (16%) reported fracture. Of these, at presentation, 4 (50%) had low BMD, and 2 (25%) had slightly low BMD. On initial spinal dual-energy x-ray absorptiometry, 9 of 32 (28%) had low BMD (Z-score ≤ -2.0) and 7 of 32 (22%) were slightly low (-1.0 to -1.9). All started estrogen therapy within 2 years of presentation. In follow-up, only 2 patients (4%) saw a mental health consultant for emotional support. CONCLUSION POI is a model of estrogen deficiency with most cases due to Turner syndrome or idiopathic causes. At presentation, many had low BMD and few were seen for psychological support as part of multidisciplinary care.
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Affiliation(s)
- Rula V Kanj
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nana Ama Ofei-Tenkorang
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Catherine M Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Dzemaili S, Tiemensma J, Quinton R, Pitteloud N, Morin D, Dwyer AA. Beyond hormone replacement: quality of life in women with congenital hypogonadotropic hypogonadism. Endocr Connect 2017; 6:404-412. [PMID: 28698240 PMCID: PMC5551425 DOI: 10.1530/ec-17-0095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Little is known about how women with isolated GnRH deficiency cope with their condition. This study aimed to examine the health and informational needs of women with congenital hypogonadotropic hypogonadism (CHH) and evaluate if their experiences differ from women with more common forms of infertility. DESIGN Cross-sectional, multiple methods study using web-based data collection to reach dispersed rare disease patients. METHODS A community-based participatory research framework was employed to develop an online survey and collect quantitative and qualitative data. Adult women diagnosed with CHH who had received at least one year of hormonal treatment completed the Morisky Medication Adherence Scale, Revised Illness Perception Questionnaire and Zung Self-Rating Depression Scale. Information on health care experiences, treatment outcomes and patient-reported challenges were also collected. RESULTS Women (n = 55) were often diagnosed late (20.7 ± 7.4, range: 10-48 years) and 16/20 patients receiving fertility treatment conceived. Poor adherence was frequently observed (34/55) while more than half (27/49) reported a gap in treatment exceeding a year. Low adherence correlated with depressive symptoms (r = 0.3, P > 0.05). Negative illness perceptions were pervasive and 30/55 exhibited some depressive symptoms - significantly greater than women with common female factor infertility (P < 0.01). Symptoms were underappreciated by providers as only 15 of 55 patients had discussions about psychological services. Women identified isolation, need for information and finding expert care as challenges to living with CHH. CONCLUSIONS Despite being a treatable form of female infertility, the presumable availability of treatment does not necessarily ensure adequate quality of life for women with isolated GnRH deficiency.
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Affiliation(s)
- Shota Dzemaili
- University of LausanneInstitute of Higher Education and Research in Healthcare, Lausanne, Switzerland
| | - Jitske Tiemensma
- University of California MercedPsychological Science, Merced, CA, USA
| | - Richard Quinton
- Department of EndocrinologyInstitute for Human Genetics, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, United Kingdom
| | - Nelly Pitteloud
- EndocrinologyDiabetes & Metabolism Service of the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Diane Morin
- University of LausanneInstitute of Higher Education and Research in Healthcare, Lausanne, Switzerland
- Faculty of Nursing ScienceLaval University, Québec City, Canada
| | - Andrew A Dwyer
- University of LausanneInstitute of Higher Education and Research in Healthcare, Lausanne, Switzerland
- EndocrinologyDiabetes & Metabolism Service of the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Webber L, Anderson RA, Davies M, Janse F, Vermeulen N. HRT for women with premature ovarian insufficiency: a comprehensive review. Hum Reprod Open 2017; 2017:hox007. [PMID: 30895225 PMCID: PMC6276684 DOI: 10.1093/hropen/hox007] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/24/2017] [Accepted: 06/08/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Premature ovarian insufficiency (POI), often and misleadingly referred to as ‘premature menopause’, is defined as a loss of ovarian activity before the age of 40 years and is characterized by irregular or absent periods and reduced fertility. Symptoms include those associated with the natural menopause (night sweats and vaginal dryness), and with the long-term adverse effects of estrogen deficiency (osteoporosis and cardiovascular disease): the latter is believed to explain the shorter life expectancy associated with POI. OBJECTIVE AND RATIONALE The objective of the current review was to collect all relevant studies supporting recommendations on the indications, treatment options, and risks of hormone replacement therapy (HRT) (estrogen, progestogens and androgens) for women with POI. SEARCH METHODS The current review was written based on the best available evidence on the topic collected for the recently published ESHRE guideline on the management of women with POI. PUBMED/MEDLINE and the Cochrane library were searched in a stepwise approach. Relevant references were summarized in evidence tables, with assessment of the quality. OUTCOMES HRT is strongly recommended for women with POI, mainly for vasomotor and genito-urinary symptom relief. In addition, HRT has been shown to have a role in bone protection and probably also in primary prevention of cardiovascular disease. There is little evidence on the optimal type, regimen and dose of HRT; patient preference for route and method of administration of each component of HRT must be considered when prescribing, as should contraceptive needs. In women with POI, physiological replacement of estrogen (and progesterone) is essential for their health, and the controversies that surround the use of HRT in postmenopausal women do not apply. LIMITATIONS, REASONS FOR CAUTION N/A. WIDER IMPLICATIONS New areas of study on HRT for women with POI should focus on life expectancy, quality of life and neurological function. Furthermore, randomized controlled trials comparing transdermal estradiol with oral estrogens with regard to efficacy, patient satisfaction and side effects are urgently needed. STUDY FUNDING/COMPETING INTERESTS The authors received no funding for the review. The costs for the development of the ESHRE guideline were covered by ESHRE. The authors have no conflicts of interest to disclose.
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Affiliation(s)
- Lisa Webber
- Department of Women's Health, University College London Hospitals, London NW1 2PG, UK
| | - Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Melanie Davies
- Department of Women's Health, University College London Hospitals, London NW1 2PG, UK
| | - Femi Janse
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht 3584 CX, The Netherlands
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology (ESHRE), Grimbergen B-1852, Belgium
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De Sanctis V, Soliman AT, Elsedfy H, Albu A, Al Jaouni S, Anastasi S, Bisconte MG, Canatan D, Christou S, Daar S, Di Maio S, El Kholy M, Khater D, Elshinawy M, Kilinc Y, Mattei R, Mosli HH, Quota A, Roberti MG, Sobti P, Yaarubi SAL, Canpisi S, Kattamis C. Review and Recommendations on Management of Adult Female Thalassemia Patients with Hypogonadism based on Literature Review and Experience of ICET-A Network Specialists. Mediterr J Hematol Infect Dis 2017; 9:e2017001. [PMID: 28101307 PMCID: PMC5224811 DOI: 10.4084/mjhid.2017.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/14/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Multi-transfused thalassemia major (TM) patients frequently develop severe endocrine complications, mainly due to iron overload, anemia, and chronic liver disease, which require prompt diagnosis, treatment and follow-up by specialists. The most common endocrine complication documented is hypogonadotropic hypogonadism which increases with age and associated comorbidities. It is thus important for physicians to have a clear understanding of the pathophysiology and management of this disorder. Also to be aware of the side effects, contraindications and monitoring of sex steroid therapy. In this paper, practical ICET-A recommendations for the management of hypogonadism in adult females with TM are addressed. METHODS In March 2015, the Coordinator of the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) conducted a two-step survey to assess the attitudes and practices of doctors in the ICET-A network taking care of adult female TM patients with hypogonadism. They were clinically characterized by the absence of pubertal development or discontinuation or regression of the maturation of secondary sex characteristics, and biochemically by persistent low FSH, LH and estradiol levels. Recently a supplementary survey on adult female hypogonadism in TM was undertaken within the ICET-A network. RESULTS The completed questionnaires were returned by 16 of 27 specialists (59.2%) following 590 female TM patients over the age of 18 years; 315 patients (53.3%) had hypogonadism, and only 245 (74.6%) were on hormone replacement therapy (HRT). Contraceptive oral pills (COC) were the first treatment choice in 11 centers (68.7%). A wide range of COCs was used with different progestin contents. In general, the patients' compliance to treatment was reported as good in 81.2 % of centers. The frequency of required tests for follow-up HRT, in addition to the regular check-up for thalassemia, was variable in the participating centers. CONCLUSIONS Doctors taking care of TM patients should have sound knowledge of the pathophysiology of hypogonadism in adult females with TM. They should know the potential effects of HRT including advantages and disadvantages of estrogen and progestins. Moreover, they should keep in consideration the emotional needs of these patients dreaming of attaining a full pubertal development.
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Affiliation(s)
- Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy
| | - Ashraf T. Soliman
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital Doha, Qatar and Department of Pediatrics, Division of Endocrinology, Alexandria University Children’s Hospital, Alexandria, Egypt
| | - Heba Elsedfy
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Alice Albu
- Endocrinology and Diabetes Department of Elias Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Soad Al Jaouni
- Head Division of Pediatric Hematology Oncology, Deputy Chair of Hematology & Head Section of Hematology Research Lab, King Fahd Medical Research Center Department of Hematology Faculty of Medicine, King Abdulaziz University Jeddah, Kingdom of Saudi Arabia
| | - Salvatore Anastasi
- Thalassemia Unit, Maternal and Child Department, Garibaldi Hospital, Catania, Italy
| | | | - Duran Canatan
- Director of Thalassemia Diagnosis Center of Mediterranean Blood Diseases Foundation Antalya, Turkey
| | | | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Sultanate of Oman & Visiting Scholar, Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch 7600, South Africa
| | - Salvatore Di Maio
- Emeritus Director in Pediatrics, Children’s Hospital “Santobono-Pausilipon”, Naples, Italy
| | | | - Doaa Khater
- Department of Pediatrics, Endocrinology Unit, Alexandria University Children’s Hospital, Egypt and Child Health Department, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Mohamed Elshinawy
- Department of Pediatrics, Hematology Unit, Faculty of Medicine, University of Alexandria, Egypt and Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yurdanur Kilinc
- Çukurova University, Medical Faculty, Department of Pediatric Hematology, Adana, Turkey
| | | | - Hala H. Mosli
- Internal Medicine, Endocrinology and Metabolism, Department of Medicine King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | | | | | - Praveen Sobti
- Pediatric Hemato-Oncology Unit, Christian Medical College and Hospital, Ludhiana Punjab, India
| | - Saif AL Yaarubi
- Head of Pediatric Endocrine Unit, Department of Child Health, Sultan Qaboos University Hospital, Al-Khoud, Sultanate of Oman
| | | | - Christos Kattamis
- First Department of Paediatrics, University of Athens, Athens, Greece
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Vern-Gross TZ, Bradley JA, Rotondo RL, Indelicato DJ. Fertility in childhood cancer survivors following cranial irradiation for primary central nervous system and skull base tumors. Radiother Oncol 2015; 117:195-205. [DOI: 10.1016/j.radonc.2015.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/21/2015] [Accepted: 10/03/2015] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW We provide an overview of new insights into the genetic causes of primary ovarian insufficiency (POI) and address the challenges faced by clinicians who care for adolescents with this condition. RECENT FINDINGS In most cases, the cause of POI remains a mystery after appropriate clinical testing has been completed. Large-scale genomic sequencing approaches are uncovering new mechanisms underlying the disorder. Gene variants that affect the normal processes of primordial germ-cell proliferation and migration, oocyte meiosis, and ovarian follicle formation/activation are plausible mechanisms. Whole exome sequencing has been used to associate many of these variants with human POI. POI is a serious chronic condition with no cure. It qualifies as a rare disease and as such presents special challenges to patients, parents, and clinicians. Although the diagnosis of POI is often delayed because of the assumption that irregular menses are common among adolescents, early detection is critical for the maintenance of bone and cardiovascular health. Treatment options have focused on hormonal therapy and fertility preservation. However, many studies prove the increasing need to incorporate mental health support and a family systems approach into the management plan. SUMMARY Large-scale genomic sequencing has recently identified new mechanisms of POI. However, at present this testing is not clinically indicated as routine. Practice will change as genomic medicine is integrated into standard care. Adolescents with POI are best served by an integrated personal care approach centered on the patient and provided by a primary care clinician who has support from a multidisciplinary team.
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Quigley CA, Wan X, Garg S, Kowal K, Cutler GB, Ross JL. Effects of low-dose estrogen replacement during childhood on pubertal development and gonadotropin concentrations in patients with Turner syndrome: results of a randomized, double-blind, placebo-controlled clinical trial. J Clin Endocrinol Metab 2014; 99:E1754-64. [PMID: 24762109 PMCID: PMC4154082 DOI: 10.1210/jc.2013-4518] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
CONTEXT The optimal approach to estrogen replacement in girls with Turner syndrome has not been determined. OBJECTIVE The aim of the study was to assess the effects of an individualized regimen of low-dose ethinyl estradiol (EE2) during childhood from as early as age 5, followed by a pubertal induction regimen starting after age 12 and escalating to full replacement over 4 years. DESIGN This study was a prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING The study was conducted at two US pediatric endocrine centers. SUBJECTS Girls with Turner syndrome (n = 149), aged 5.0-12.5 years, were enrolled; data from 123 girls were analyzable for pubertal onset. INTERVENTION(S) Interventions comprised placebo or recombinant GH injections three times a week, with daily oral placebo or oral EE2 during childhood (25 ng/kg/d, ages 5-8 y; 50 ng/kg/d, ages >8-12 y); after age 12, all patients received escalating EE2 starting at a nominal dosage of 100 ng/kg/d. Placebo/EE2 dosages were reduced by 50% for breast development before age 12 years, vaginal bleeding before age 14 years, or undue advance in bone age. MAIN OUTCOME MEASURES The main outcome measures for this report were median ages at Tanner breast stage ≥2, median age at menarche, and tempo of puberty (Tanner 2 to menarche). Patterns of gonadotropin secretion and impact of childhood EE2 on gonadotropins also were assessed. RESULTS Compared with recipients of oral placebo (n = 62), girls who received childhood low-dose EE2 (n = 61) had significantly earlier thelarche (median, 11.6 vs 12.6 y, P < 0.001) and slower tempo of puberty (median, 3.3 vs 2.2 y, P = 0.003); both groups had delayed menarche (median, 15.0 y). Among childhood placebo recipients, girls who had spontaneous breast development before estrogen exposure had significantly lower median FSH values than girls who did not. CONCLUSIONS In addition to previously reported effects on cognitive measures and GH-mediated height gain, childhood estrogen replacement significantly normalized the onset and tempo of puberty. Childhood low-dose estrogen replacement should be considered for girls with Turner syndrome.
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Affiliation(s)
- Charmian A Quigley
- Indiana University School of Medicine (C.A.Q.), Indianapolis, Indiana 46202; Novartis Pharmaceuticals (X.W.), East Hanover, New Jersey 07936; GCE Solutions Inc (S.G.), Bloomington, Illinois 61701; Thomas Jefferson University (K.K.), Philadelphia, Pennsylvania 19107; Gordon Cutler Consultancy, LLC (G.B.C.), Deltaville, Virginia 23043; and Thomas Jefferson University (J.L.R.), Philadelphia, Pennsylvania 19107
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Kenigsberg L, Balachandar S, Prasad K, Shah B. Exogenous pubertal induction by oral versus transdermal estrogen therapy. J Pediatr Adolesc Gynecol 2013; 26:71-9. [PMID: 22112543 DOI: 10.1016/j.jpag.2011.09.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/28/2011] [Indexed: 11/26/2022]
Abstract
Hypogonadal adolescent girls need estrogen therapy for the induction of puberty. For years, oral conjugated estrogens have been used for this purpose, starting at a very low dose, with gradual increments over time, to allow for the maturation of the reproductive organs, in order to mimic physiologic conditions. Several concerns, mainly due to first pass through the liver, are manifest with oral estrogen therapy. With the advent of transdermal estrogens and its improved efficacy profile as well as reduced side effects, it seems reasonable to consider it for pubertal induction. The primary objective of this study was to compare and contrast oral versus transdermal estrogen with regard to metabolism and physiology and to review current available data on transdermal estrogens with respect to exogenous pubertal induction.
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Affiliation(s)
- Lisa Kenigsberg
- Department of Pediatrics, Division of Pediatric Endocrinology, NYU School of Medicine, New York, NY 10016, USA
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Sanfilippo JS. The editor's workshop. J Pediatr Adolesc Gynecol 2013; 26:69-70. [PMID: 23518188 DOI: 10.1016/j.jpag.2013.01.059] [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: 11/17/2022]
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Metzger ML, Meacham LR, Patterson B, Casillas JS, Constine LS, Hijiya N, Kenney LB, Leonard M, Lockart BA, Likes W, Green DM. Female reproductive health after childhood, adolescent, and young adult cancers: guidelines for the assessment and management of female reproductive complications. J Clin Oncol 2013; 31:1239-47. [PMID: 23382474 PMCID: PMC4500837 DOI: 10.1200/jco.2012.43.5511] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE As more young female patients with cancer survive their primary disease, concerns about reproductive health related to primary therapy gain relevance. Cancer therapy can often affect reproductive organs, leading to impaired pubertal development, hormonal regulation, fertility, and sexual function, affecting quality of life. METHODS The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) are evidence-based recommendations for screening and management of late effects of therapeutic exposures. The guidelines are updated every 2 years by a multidisciplinary panel based on current literature review and expert consensus. RESULTS This review summarizes the current task force recommendations for the assessment and management of female reproductive complications after treatment for childhood, adolescent, and young adult cancers. Experimental pretreatment as well as post-treatment fertility preservation strategies, including barriers and ethical considerations, which are not included in the COG-LTFU Guidelines, are also discussed. CONCLUSION Ongoing research will continue to inform COG-LTFU Guideline recommendations for follow-up care of female survivors of childhood cancer to improve their health and quality of life.
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Pantelis T, Nikolaos V, Zoe I, Efthymios D. Long-term followup of adolescent and young adult females with hypergonadotropic hypogonadism. Int J Endocrinol 2012; 2012:862892. [PMID: 22190931 PMCID: PMC3235457 DOI: 10.1155/2012/862892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/18/2011] [Indexed: 11/18/2022] Open
Abstract
The condition characterized by elevated gonadotrophins (gonadotropins elevated into the menopausal range), low sex steroids, and menstrual disorders was previously termed Premature Ovarian Failure (POF). However, over the last two years an effort has been made by many authors to have the term Primary Ovarian Insufficiency (POI) exclusively applied. Irrespective of the term, the condition concerns adolescent and young adult women under 40 years who experience cessation of menstruation for more than 3 cycles (whereas these women in the past had a rhythmic menstrual cycle) or amenorrhea for 4-6 months against the background of a previously disturbed menstrual cycle. Determining the cause of POI is difficult, and it is even harder to deal with problems arising from the paucity of estrogen as well as to draw up the plan for long-term monitoring of these patients. This paper presents long-term therapeutic management strategies concerning emotional health, hormone replacement therapy, maintenance of bone health, family planning, other associated disorders as well as possible research options for the future.
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