Estrogen treatment in tall girls

Estrogen-mediated Height Control in Girls with Marfan Syndrome

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

Looking back in time: conducting a cohort study of the long-term effects of treatment of adolescent tall girls with synthetic hormones

Objective

Public health research is an endeavour that often involves multiple relationships, far-reaching collaborations, divergent expectations and various outcomes. Using the Tall Girls Study as a case study, this paper will present and discuss a number of methodological, ethical and legal challenges that have implications for other public health research.

Approach

The Tall Girls Study was the first study to examine the long-term health and psychosocial effects of oestrogen treatment for tall stature.

Results

In undertaking this study the research team overcame many hurdles: in maintaining collaboration with treating clinicians and with the women they had treated as girls - groups with opposing points of view and different expectations; using private practice medical records to trace women who had been patients up to forty years earlier; and exploring potential legal issues arising from the collection of data related to treatment.

Conclusion

While faced with complex challenges, the Tall Girls Study demonstrated that forward planning, ongoing dialogue between all stakeholders, transparency of processes, and the strict adherence to group-developed protocols were keys to maintaining rigour while undertaking pragmatic research.

Implications

Public health research often occurs within political and social contexts that need to be considered in the planning and conduct of studies. The quality and acceptability of research findings is enhanced when stakeholders are engaged in all aspects of the research process.

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MEASUREMENTS

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

CONCLUSION

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

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

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

Height reduction in 539 tall girls treated with three different dosages of ethinyloestradiol

During the period 1970 to 1985, 539 constitutionally tall girls were treated with ethinyloestradiol in varying dosages to reduce final height. They all had a predicted final height above 181 cm (greater than +2.5 SD). The girls were all healthy and were treated with three different dosages of ethinyloestradiol. Throughout these 15 years recommended treatment regimens changed, and the treatments described followed these guidelines. Girls in group 1 (n = 263) were treated with 0.5 mg of ethinyloestradiol, group 2 (n = 178) with 0.25 mg, and group 3 (n = 98) with 0.1 mg. The total mean (SEM) reduction of final height was 5.9 (0.2), 5.3 (0.1), and 4.4 (0.2) cm when treated with 0.5, 0.25, and 0.1 mg respectively. Group 1 was treated for 2.02 (0.03) years and group 2 and 3 for 1.85 (0.04) and 1.63 (0.05) years respectively. When expressed in relation to the treatment period the reduction of final height was 3.0 (0.1), 3.1 (0.1), and 2.9 (0.2) cm/year of treatment respectively. All the girls were treated with ethinyloestradiol as a daily single dose, while progestogen was given daily the first 10 days of every month. In conclusion we found that a daily dose of ethinyloestradiol 0.1 mg for about 20 months is sufficient to reduce final height. We recommend starting treatment at a bone age of about 12 years.

Oestrogen treatment of tall girls: effect decreases with age

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

Estrogen treatment of tall girls: dose dependency of effects on subsequent growth and IGF-I levels in blood

Three groups of girls with mean final height predictions of 185.3 cm were treated in 3-week cycles with 0.25, 0.5, or 1.0 mg of ethinylestradiol. The three groups were comparable with regard to chronological age, bone age, height prediction, and duration of treatment. Reduction in final height of 5.5-5.9 cm/group in comparison with the initial prediction was observed in all treated groups. This reduction appeared independent of estrogen dose. Subsequent height increases were limited to about 50% of the predicted gain in all cases. In a comparable group of untreated tall girls the prediction method overestimated the final height by 1.2 cm. In the groups receiving 1.0 and 0.5 mg EtE2 a significant reduction in IGF-I levels was achieved within three to six months after the start of estrogen therapy.

Effect of different oestrogen doses on final height reduction in girls with constitutional tall stature

The effects of different doses of oestrogens in constitutionally tall girls were evaluated in two centres for paediatric endocrinology. In one centre, 38 girls were treated with a high oestrogen dose of 0.3 to 0.5 mg ethinyloestradiol (EE) daily. In the other, 44 girls received a comparably low dose of 0.1 mg EE per day. Height prediction (HP), chronological age (CA), and height at the onset of treatment were comparable in both groups. Although the duration of treatment was significantly longer in those receiving the low dose, the cumulative oestrogen dose was still significantly lower. The dose of EE had no effect on final height reduction (high dose group: 4.9 +/- 2.6 cm, low dose group: 5.1 +/- 2.4 cm). Final height was more reduced in both groups when treatment was started at an early bone age (BA) (less than or equal to 13 years). No serious side effects were observed in either group, however weight gain was more pronounced in girls receiving the higher dose. We conclude that treatment of constitutionally tall girls with low doses of oestrogens is equally effective in reducing the final height as the usually administered high doses. The lowest effective dose has to be determined in a randomized, prospective clinical trial.

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

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

Critical analysis of height reduction in oestrogen-treated tall girls

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

Haemostatic changes in tall girls treated with high doses of ethinyloestradiol

Haemostasis was studied in 8 tall girls during treatment with high doses of synthetic oestrogens for a period of 1 to 28 months. The girls received 0.5 mg ethinyloestradiol daily from day 1 to day 25 and 15 mg norethisteron daily from day 21 to day 25. All were without clinical signs of thromboembolism. Factors of the prothrobmin complex were significantly elevated in the tall girls compared to healthy controls of the same age. Fibrinogen was also significantly elevated. Factor VIII-related antigen was significantly higher in the tall girls and the ratio between factor VIII activity and factor VIII-related antigen was significantly decreased in the tall girls, as compared to the controls. Thrombin time was significantly shortened. Tests of primary haemostasis showed an increased tendency for thrombocytes to adhere to glass and to aggregate spontaneously and after stimulation with ADP or collagen. Whether these in vitro signs of hypercoagulability indicate an enhanced risk of throbmoembolic complications in tall girls treated with high doses of oestrogens remains to be established. However, these girls should be watched carefully for clinical signs of throbmoembolic complications during treatment.

Reduction of adult height in tall girls

Assessment of the results of treatment of tall girls with estrogens by comparing actual mature height with predicted mature height is unreliable, unless the accuracy of prediction has been tested in untreated tall girls. We report such an investigation in 14 tall girls who were treated with estrogens and in 14 untreated tall girls. Of the three prediction methods, those of Bayley and Tanner were reliable in our hands, whereas the method of Roche was less adequate. The mean reduction of height by treatment was about 7 cm using Tanner's method of prediction, 10 cm when Bayley's method was used. The standard deviation of the difference between actual and predicted height as found in untreated girls makes it hazardous to assess the amount of height reduction in the individual treated case with any certainty.