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Torres-Santiago L, Mauras N. Approach to the Peripubertal Patient With Short Stature. J Clin Endocrinol Metab 2024; 109:e1522-e1533. [PMID: 38181434 DOI: 10.1210/clinem/dgae011] [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: 11/15/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/07/2024]
Abstract
CONTEXT The assessment and treatment of children with growth retardation is increasingly complex, and due to availability of targeted genetic sequencing, an ever-expanding number of conditions impeding growth are being identified. Among endocrine-related etiologies of short stature amenable to hormonal treatment, defects in the growth hormone (GH)-insulin-like growth factor I axis remain pre-eminent, with a multiplicity of disorders causing decreased secretion or insensitivity to GH action. Sex steroids in puberty increase epiphyseal senescence and eventual growth plate closure. This is mediated mostly via estrogen receptor (ER)α in males and females, effects that can greatly limit time available for growth. EVIDENCE ACQUISITION Extensive literature review through PubMed and other search engines. EVIDENCE SYNTHESIS Therapeutic strategies to be considered in peripubertal and pubertal children with disordered growth are here discussed, including daily and weekly GH, low-dose sex steroids, gonadotropin hormone releasing hormone (GnRH) analogues in combination with GH, aromatase inhibitors (AIs) alone and in combination with GH in boys. When used for at least 2 to 3 years, GnRH analogues combined with GH can result in meaningful increases in height. AIs used with GH permit puberty to progress in boys without hindrance, selectively decreasing estrogen, and resulting in taller height. With more than 20 years of cumulative experience in clinical use of these medications, we discuss the safety profile of these treatments. CONCLUSION The approach of growth retardation in the peripubertal and pubertal years must consider the sex steroid milieu and the tempo of bone acceleration. Treatment of affected children in this period must be individualized.
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Affiliation(s)
- Lournaris Torres-Santiago
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health, Jacksonville, FL 32207, USA
| | - Nelly Mauras
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health, Jacksonville, FL 32207, USA
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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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Woelfle J, Schnabel D, Binder G. The Treatment of Growth Disorders in Childhood and Adolescence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:96-106. [PMID: 38051162 PMCID: PMC11002441 DOI: 10.3238/arztebl.m2023.0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND 3% of all children are unusually short, and 3% are unusually tall. New approaches have broadened the range of therapeutic options in treating growth disorders. METHODS This review is based on publications retrieved by a selective review of the literature and on the authors' clinical experience. RESULTS Pituitary growth hormone deficiency is treated with recombinant growth hormone. Long-acting preparations of this type became available recently, but their long-term safety and efficacy are still unknown. Vosoritide, a CNP analogue, has also been approved for the treatment of achondroplasia, and severe primary deficiency of insulin-like growth factor 1 (IGF-1) can be treated with recombinant IGF-1. In the treatment of excessively tall stature, new information on the safety of growth-attenuating treatment and an altered perception of above-average height in society have led to a change in management. CONCLUSION There are new options for the treatment of rare causes of short stature, while new information on the safety of treatment strategies for excessive tallness have led to a reconsideration of surgical intervention. There is insufficient evidence on the benefits and risks of supraphysiological GH therapy and of newer treatment options for which there are as yet no robust data on adult height. Therefore, before any treatment is provided, physicians should give patients and their families detailed information and discuss their expectations from treatment and the goals that treatment can be expected to achieve.
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Affiliation(s)
- Joachim Woelfle
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen; Centre for Chronic Sick Children, Paediatric Endocrinology, Charité, University Medicine Berlin, Berlin; Pediatric Endocrinology, University Children's Hospital, Universiy of Tuebingen, Tuebingen
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Kriström B, Ankarberg-Lindgren C, Barrenäs ML, Nilsson KO, Albertsson-Wikland K. Normalization of puberty and adult height in girls with Turner syndrome: results of the Swedish Growth Hormone trials initiating transition into adulthood. Front Endocrinol (Lausanne) 2023; 14:1197897. [PMID: 37529614 PMCID: PMC10389045 DOI: 10.3389/fendo.2023.1197897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/12/2023] [Indexed: 08/03/2023] Open
Abstract
Objective To study the impact of GH dose and age at GH start in girls with Turner syndrome (TS), aiming for normal height and age at pubertal onset (PO) and at adult height (AH). However, age at diagnosis will limit treatment possibilities. Methods National multicenter investigator-initiated studies (TNR 87-052-01 and TNR 88-072) in girls with TS, age 3-16 years at GH start during year 1987-1998, with AH in 2003-2011. Of the 144 prepubertal girls with TS, 132 girls were followed to AH (intention to treat), while 43 girls reduced dose or stopped treatment prematurely, making n=89 for Per Protocol population. Age at GH start was 3-9 years (young; n=79) or 9-16 years (old; n=53). Treatment given were recombinant human (rh)GH (Genotropin® Kabi Peptide Hormones, Sweden) 33 or 67 µg/kg/day, oral ethinyl-estradiol (2/3) or transdermal 17β-estradiol (1/3), and, after age 11 years, mostly oxandrolone. Gain in heightSDS, AHSDS, and age at PO and at AH were evaluated. Results At GH start, heightSDS was -2.8 (versus non-TS girls) for all subgroups and mean age for young was 5.7 years and that of old was 11.6 years. There was a clear dose-response in both young and old TS girls; the mean difference was (95%CI) 0.66 (-0.91 to -0.26) and 0.57 (-1.0 to -0.13), respectively. The prepubertal gainSDS (1.3-2.1) was partly lost during puberty (-0.4 to -2.1). Age/heightSDS at PO ranged from 13 years/-0.42 for GH67young to 15.2 years/-1.47 for GH33old. At AH, GH67old group became tallest (17.2 years; 159.9 cm; -1.27 SDS; total gainSDS, 1.55) compared to GH67young group being least delayed (16.1 years; 157.1 cm; -1.73 SDS; total, 1.08). The shortest was the GH33young group (17.3 years; 153.7 cm: -2.28 SDS; total gainSDS, 0.53), and the most delayed was the GH33old group, (18.5 years; 156.5 cm; -1.82 SDS; total gainSDS, 0.98). Conclusion For both young and old TS girls, there was a GH-dose growth response, and for the young, there was less delayed age at PO and at AH. All four groups reached an AH within normal range, despite partly losing the prepubertal gain during puberty. Depending on age at diagnosis, low age at start with higher GH dose resulted in greater prepubertal height gain, permitting estrogen to start earlier at normal age and attaining normal AH at normal age, favoring physiological treatment and possibly also bone health, hearing, uterine growth and fertility, psychosocial wellbeing during adolescence, and the transition to adulthood.
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Affiliation(s)
- Berit Kriström
- Department of Clinical Science, Pediatrics, Umeå University, Umeå, Sweden
| | - Carina Ankarberg-Lindgren
- Department of Pediatrics, Institute of Clinical Sciences, Göteborg Pediatric Growth Research Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marie-Louise Barrenäs
- Department of Physiology/Endocrinology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karl Olof Nilsson
- Department of Clinical Sciences, University Hospital Malmö, Lund University, Malmö, Sweden
| | - Kerstin Albertsson-Wikland
- Department of Physiology/Endocrinology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Mauras N, Ross J, Mericq V. Management of Growth Disorders in Puberty: GH, GnRHa, and Aromatase Inhibitors: A Clinical Review. Endocr Rev 2023; 44:1-13. [PMID: 35639981 DOI: 10.1210/endrev/bnac014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Indexed: 01/14/2023]
Abstract
Pubertal children with significant growth retardation represent a considerable therapeutic challenge. In growth hormone (GH) deficiency, and in those without identifiable pathologies (idiopathic short stature), the impact of using GH is significantly hindered by the relentless tempo of bone age acceleration caused by sex steroids, limiting time available for growth. Estrogen principally modulates epiphyseal fusion in females and males. GH production rates and growth velocity more than double during puberty, and high-dose GH use has shown dose-dependent increases in linear growth, but also can raise insulin-like growth factor I concentrations supraphysiologically, and increase treatment costs. Gonadotropin-releasing hormone analogs (GnRHas) suppress physiologic puberty, and when used in combination with GH can meaningfully increase height potential in males and females while rendering adolescents temporarily hypogonadal at a critical time in development. Aromatase inhibitors (AIs) block androgen to estrogen conversion, slowing down growth plate fusion, while allowing normal virilization in males and stimulating longitudinal bone growth via androgen receptor effects on the growth plate. Here, we review the physiology of pubertal growth, estrogen and androgen action on the epiphyses, and the therapeutic impact of GH, alone and in combination with GnRHa and with AIs. The pharmacology of potent oral AIs, and pivotal work on their efficacy and safety in children is also reviewed. Time-limited use of AIs is a viable alternative to promote growth in pubertal males, particularly combined with GH. Use of targeted growth-promoting therapies in adolescence must consider the impact of sex steroids on growth plate fusion, and treatment should be individualized.
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Affiliation(s)
| | - Judith Ross
- Nemours Children's Health Wilmington, DE, USA
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Turner Syndrome. ENDOCRINES 2022. [DOI: 10.3390/endocrines3020022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Turner syndrome (TS) affects approximately 1 out of every 1500–2500 live female births, with clinical features including short stature, premature ovarian failure, dysmorphic features and other endocrine, skeletal, cardiovascular, renal, gastrointestinal and neurodevelopmental organ system involvement. TS, a common genetic syndrome, is caused by sex chromosome aneuploidy, mosaicism or abnormalities with complete or partial loss of function of the second X chromosome. Advances in genetic and genomic testing have further elucidated other possible mechanisms that contribute to pathogenic variability in phenotypic expression that are not necessarily explained by monosomy or haploinsufficiency of the X chromosome alone. The role of epigenetics in variations of gene expression and how this knowledge can contribute to more individualized therapy is currently being explored. TS is established as a multisystemic condition, with several endocrine manifestations of TS affecting growth, puberty and fertility having significant impact on quality of life. Treatment guidelines are in place for the management of these conditions; however, further data on optimal management is needed.
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Bamba V, Kanakatti Shankar R. Approach to the Patient: Safety of Growth Hormone Replacement in Children and Adolescents. J Clin Endocrinol Metab 2022; 107:847-861. [PMID: 34636896 DOI: 10.1210/clinem/dgab746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Indexed: 02/07/2023]
Abstract
The use of recombinant human growth hormone (rhGH) in children and adolescents has expanded since its initial approval to treat patients with severe GH deficiency (GHD) in 1985. rhGH is now approved to treat several conditions associated with poor growth and short stature. Recent studies have raised concerns that treatment during childhood may affect morbidity and mortality in adulthood, with specific controversies over cancer risk and cerebrovascular events. We will review 3 common referrals to a pediatric endocrinology clinic, followed by a summary of short- and long-term effects of rhGH beyond height outcomes. Methods to mitigate risk will be reviewed. Finally, this information will be applied to each clinical case, highlighting differences in counseling and clinical outcomes. rhGH therapy has been used for more than 3 decades. Data are largely reassuring, yet we still have much to learn about pharmaceutical approaches to growth in children and the lifelong effect of treatment.
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Affiliation(s)
- Vaneeta Bamba
- The Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Roopa Kanakatti Shankar
- The George Washington University School of Medicine, Children's National Hospital, Washington, DC 20010, USA
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Backeljauw P, Kanumakala S, Loche S, Schwab KO, Pfäffle RW, Höybye C, Lundberg E, Battelino T, Kriström B, Giemza T, Zouater H. Safety and Effectiveness of Recombinant Human Growth Hormone in Children with Turner Syndrome: Data from the PATRO Children Study. Horm Res Paediatr 2021; 94:133-143. [PMID: 34350858 PMCID: PMC8491505 DOI: 10.1159/000515875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/15/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION PATRO Children is an international, observational, postmarketing surveillance study for a biosimilar recombinant human growth hormone (rhGH; somatropin, Omnitrope®; Sandoz), approved by the European Medicines Agency in 2006. We report safety and effectiveness data for patients with Turner syndrome (TS). METHODS The study population included infants, children, and adolescents with TS who received Omnitrope® treatment according to standard clinical practice. Adverse events (AEs) were monitored for safety evaluation, and height velocity (HV), height standard deviation score (HSDS), and HVSDS were calculated to evaluate treatment effectiveness. RESULTS As of August 2019, 348 TS patients were enrolled from 130 centers. At baseline, 314 patients (90.2%) were prepubertal and 284 patients (81.6%) were rhGH treatment naïve. The mean (range) age at baseline was 9.0 (0.7-18.5) years, and mean (SD) treatment duration in the study was 38.5 (26.8) months. Overall, 170 patients (48.9%) reported AEs, which were considered treatment related in 25 patients (7.2%). One treatment-related serious AE was reported (intracranial hypertension). Mean ΔHSDS after 3 years of therapy was +1.17 in treatment-naïve prepubertal patients and +0.1 in pretreated prepubertal patients. In total, 51 patients (31.1%) reached adult height (AH), 35 of whom were rhGH treatment naïve; in these patients, mean (SD) HSDS was -2.97 (1.03) at the start of Omnitrope® treatment, and they achieved a mean (SD) AHSDS of -2.02 (0.9). CONCLUSION These data suggest that biosimilar rhGH is well tolerated and effective in TS patients managed in real-life clinical practice. Optimization of rhGH dose may contribute to a higher AH.
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Affiliation(s)
| | | | - Sandro Loche
- Hospital for Children Microcitemico “A. Cao”, Cagliari, Italy
| | | | | | - Charlotte Höybye
- Department of Endocrinology, Karolinska University Hospital, Solna, Sweden,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Elena Lundberg
- Institute of Clinical Science/Pediatrics, Umeå University, Umeå, Sweden
| | - Tadej Battelino
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre-University Children's Hospital, and University of Ljubljana, Ljubljana, Slovenia
| | - Berit Kriström
- Institute of Clinical Science/Pediatrics, Umeå University, Umeå, Sweden
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Bertelli E, DI Frenna M, Cappa M, Salerno M, Wasniewska M, Bizzarri C, DE Sanctis L. Hypogonadism in male and female: which is the best treatment? Minerva Pediatr (Torino) 2021; 73:572-587. [PMID: 34309345 DOI: 10.23736/s2724-5276.21.06534-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Subjects with hypo-or hypergonadotropic hypogonadism need hormone replacement therapy (HRT) to initiate puberty and maintain it with a normal hormonal status. While general recommendations for the management of HRT in adults have been published, no systematic suggestions focused on adolescents and young adults. The focus of this review is the HRT in males and females with hypogonadism, from puberty to late reproductive age, covering the different management options, encompassing sex steroid or gonadotropin therapy, with discussion of benefits, limitations and specific considerations of the different treatments. METHODS We conducted an extensive search in the 3 major scientific databases (PubMed, EMBASE and Google Scholar) using the keywords "hormonal replacement therapy", "hypogonadism", "bone mineral density", "estradiol/testosterone", "puberty induction", "delayed puberty". Case-control studies, case series, reviews and meta-analysis published in English from 1990 to date were included. RESULTS By considering the available opportunities for fertility induction and preservation, we hereby present the proposals of practical schemes to induce puberty, and a decisional algorithm to approach HRT in post-pubertal adolescents. CONCLUSIONS A condition of hypogonadism can underlie different etiologies involving the hypothalamic-pituitary-gonadal axis at different levels. Since the long-terms effects of hypogonadism may vary and include not only physical outcomes related to sex hormone deficiencies, but also psychological problems and implications on fertility, the initiation, maintenance and consolidation of puberty with different pharmaceutical options is of utmost importance and beside pubertal development, optimal uterine and testicular growth and adequate bone health should consider also the psychosocial wellbeing and the potential fertility.
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Affiliation(s)
- Enrica Bertelli
- Pediatric and Pediatric Emergency Unit, Children's Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Marianna DI Frenna
- Pediatric Department, V. Buzzi Children's Hospital, ASST Fatebenefratelli - SACCO, University of Milan, Milan, Italy
| | - Marco Cappa
- Unit of Endocrinology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Mariacarolina Salerno
- Paediatric Endocrinology Unit, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Malgorzata Wasniewska
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Carla Bizzarri
- Unit of Endocrinology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Luisa DE Sanctis
- Pediatric Endocrinology Unit, Department of Public Health and Pediatric Sciences, Regina Margherita Children Hospital, University of Turin, Turin, Italy -
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10
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Metformin reduces oxandrolone- induced depression-like behavior in rats via modulating the expression of IL-1β, IL-6, IL-10 and TNF-α. Behav Brain Res 2021; 414:113475. [PMID: 34280460 DOI: 10.1016/j.bbr.2021.113475] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 01/22/2023]
Abstract
Oxandrolone (OXA) is an androgen and anabolic steroid (AAS) that is used to reverse weight loss associated with some medical conditions. One of the side effects of OXA is its potential to induce depressive symptoms. Growing evidence suggested that neuroinflammation and cytokines play crucial roles in sickness behavioral and associated mood disturbances. Previous studies showed that metformin attenuated neuroinflammation. This study investigated the potential protective role of metformin against OXA-induced depression-like behavior and neuroinflammation. Twenty- four Wistar male rats were randomly grouped into four groups: the control group (Control) received only vehicle; the oxandrolone group (OXA) received oxandrolone (0.28 mg/kg, i.p); the metformin group (MET) received metformin (100 mg/kg, i.p); and the oxandrolone / metformin group (OXA + MET) received both oxandrolone (0.28 mg/kg, i.p) and metformin (100 mg/kg, i.p). These treatments were administered for fourteen consecutive days. Behavioral tests to measure depression-like behavior were conducted before and after treatments. qRT-PCR was used to measure the relative expression of proinflammatory and anti-inflammatory cytokines in the hippocampus and hypothalamus. The results showed that oxandrolone induced depression-like behavior and dysregulated pro-/anti-inflammatory cytokines, while metformin attenuated these effects. These findings suggest that metformin is a potential treatment to reverse the depressive effects induced by oxandrolone that involve neuroinflammatory effects.
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11
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Bernardina NRD, de Lima RMS, Ronchi SN, Wan Der Mass EM, Souza GJ, Rodrigues LC, Bissoli NS, Brasil GA. Oxandrolone treatment in juvenile rats induced anxiety-like behavior in young adult animals. Neurosci Lett 2021; 761:136104. [PMID: 34256105 DOI: 10.1016/j.neulet.2021.136104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 06/29/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
AIMS Oxandrolone (OXA) is a synthetic steroid used for the treatment of clinical conditions associated with catabolic states in humans, including children. However, its behavioral effects are not well known. Our goal was to evaluate the anxiety-like behavior induced in young adult rats after the treatment of juvenile animals with OXA. METHODS Four-week-old male rats were separated into three groups: Control (CON), therapeutic-like OXA dose (TD), and excessive OXA dose (ED), in which 2.5 and 37.5 mg/kg/day of OXA were administered via gavage for four weeks for TD and ED, respectively. Behavior was evaluated through the elevated plus maze (EPM) and open field (OF) tests. Protein expression of catalase (CAT), superoxide dismutase (SOD), Tumor necrosis factor-α (TNF-α), and dopamine receptor 2 (DrD2) were analyzed in tissue samples of the hippocampus, amygdala, and prefrontal cortex by Western Blot. RESULTS OXA induced anxiety-like behaviors in both TD and ED animals; it decreased the time spent in the open arms of the EPM in both groups and reduced the time spent in the central zone of the OF in the TD group. In the hippocampus, CAT expression was higher in TD compared with both control and ED animals. No differences were found in the amygdala and prefrontal cortex. TNF-α, SOD, and DrD2 levels were not altered in any of the assessed areas. CONCLUSIONS Treatment of juvenile rats with OXA led to anxiety-like behavior in young adult animals regardless of the dose used, with minor changes in the antioxidant machinery located in the hippocampus.
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Affiliation(s)
- Nara Rubia D Bernardina
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | | | - Silas N Ronchi
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Edgar M Wan Der Mass
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Glauciene J Souza
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Livia C Rodrigues
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Nazaré S Bissoli
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Girlandia A Brasil
- Pharmaceutical Sciences Graduate Program, University Vila Velha, Vila Velha, ES, Brazil.
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12
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Ronchi SN, Mass EMSW, Bernardina NRD, de Melo Júnior AF, Dos Santos WC, de Andrade TU, Brasil GA, Bissoli NS. Low and high doses of oxandrolone promote pathological cardiac remodeling in young male rats. Steroids 2021; 170:108814. [PMID: 33727119 DOI: 10.1016/j.steroids.2021.108814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/18/2021] [Accepted: 02/24/2021] [Indexed: 01/09/2023]
Abstract
Oxandrolone (OXA) used in clinical practice, however, its misuse is frequent, including by adolescents pursuing an aesthetic goal. However, the impacts of noxious doses on the cardiovascular system remain unknown. AIM To investigate cardiac effects of OXA in low (LD) and high (HD) doses. METHODS Male Wistar prepubescent rats were separated into 3 experimental groups: control (CON), LD, and HD. Only the CON group received the carrier (carboxymethylcellulose, 0.5%), while the LD and HD groups received, respectively, 2.5 and 37.5 mg/kg/day of OXA via gavage for 4 weeks. The hemodynamic parameters (+dP/dtmax, -dP/dtmin, and Tau) and cardiac autonomic tonus were assessed. Hearts were retrieved for histological analyses and oxidative stress evaluation. Expression levels of calcium-handling proteins were measured by western blot. RESULTS The OXA treatment changed neither the cardiac contractility nor the cardiac autonomic tonus. However, cardiac hypertrophy, collagen deposition, and increased angiotensin-converting enzyme (ACE) expression were observed in a dose-dependent way. Also, the p-phospholamban (p-PLB)/PLB ratio was observed to decrease and increase, respectively, in the LD and HD groups; the sarcoplasmic/endoplasmic reticulum calcium ATPase 2a (SERCA2a)/PLB ratio being higher in both groups. OXA increased SOD1 expression and decreased catalase expression only in the LD group, and protein oxidation was increased in HD. CONCLUSION Both doses of OXA could promote pathological cardiac remodeling, probably via increased ACE, and these effects were exacerbated in the HD treatment, but cardiac contractility was not affected regardless of the dose.
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Affiliation(s)
- Silas Nascimento Ronchi
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | | | | | | | | | | | | | - Nazaré Souza Bissoli
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
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13
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Grimstad FW, Knoll MM, Jacobson JD. Oxandrolone Use in Trans-Masculine Youth Appears to Increase Adult Height: Preliminary Evidence. LGBT Health 2021; 8:300-306. [PMID: 33819432 DOI: 10.1089/lgbt.2020.0355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: Early use of oxandrolone and gonadotropin-releasing hormone analogs has been shown to increase adult height in patients at risk for short stature, but use in trans-masculine (TM) youth to augment height has not been explored. The purpose of this study was to identify the impact of oxandrolone on adult height in TM youth. Methods: This was a single-center, retrospective chart review of TM patients seen between 2013 and 2018. Hormone regimens, heights, mid-parental height, and bone ages were recorded. We examined correlations between adult height and age at the initiation of treatment or with the age of referral (in untreated patients). Results: Of TM patients, 154 had achieved adult height, including 34 who received oxandrolone, 42 who reached adult height before starting gender-affirming hormone therapy (GAHT), and 14 who received no treatment. Adult height correlated inversely with age at hormone initiation in oxandrolone-treated patients only (p = 0.001). Each earlier year of treatment yielded a 2.3 cm increase in adult height. Those who started oxandrolone younger than the median age achieved an adult height of 169.6 ± 6.4 cm compared to 162.1 ± 6.0 cm in those starting later than the median age (p < 0.001), 164.6 ± 4.8 cm in those receiving no treatment (p = 0.02), and 163.9 ± 6.5 cm in those receiving all other regimens (p < 0.001). Conclusions: Early use of oxandrolone may augment adult height in TM youth. Height discussions should be part of comprehensive GAHT counseling.
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Affiliation(s)
- Frances W Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle M Knoll
- Division of Endocrinology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Jill D Jacobson
- Division of Endocrinology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
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14
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Gault EJ, Cole TJ, Casey S, Hindmarsh PC, Betts P, Dunger DB, Donaldson MDC. Effect of oxandrolone and timing of pubertal induction on final height in Turner syndrome: final analysis of the UK randomised placebo-controlled trial. Arch Dis Child 2021; 106:74-76. [PMID: 31862699 DOI: 10.1136/archdischild-2019-317695] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The UK Turner syndrome (TS) study examined the effect on final height of oxandrolone 0.05 mg/kg/day (maximum dose 2.5 mg) versus placebo from 9 years of age; and delaying ethinylestradiol induction of puberty by 2 years from 12 (E12) to 14 (E14) years in growth hormone-treated girls with TS. The study ran from 1999 to 2013. By 2011, eighty-two of 92 participants had reached final height and an interim analysis using the Super-Imposition by Translation And Rotation model showed significant increases in final height with both oxandrolone and E14. The analysis has been repeated now that all 92 patients have reached final height. Oxandrolone still significantly increased final height by 4.1 cm (95% CI 1.6 to 6.6, n=92) compared with 4.6 cm previously. However, the E14 effect was no longer significant at 2.7 cm (95% CI -0.8 to 6.1, n=56) compared with 3.8 cm previously.
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Affiliation(s)
- Emma Jane Gault
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
| | - Tim J Cole
- Policy and Practice Programme, UCL Great Ormond Street, Institute of Child Health, London, UK
| | - Sarah Casey
- Pharmacy (Clinical Trials) Department, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Peter C Hindmarsh
- Clinical and Molecular Genetics Unit, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Peter Betts
- Paediatrics, Southampton University Hospitals NHS Trust, Southampton, UK
| | | | - Malcolm D C Donaldson
- Section of Child Health, Royal Hospital for Sick Children, University of Glasgow School of Medicine, Glasgow, UK
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15
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van de Grift TC, Kreukels BPC. Breast development and satisfaction in women with disorders/differences of sex development. Hum Reprod 2020; 34:2410-2417. [PMID: 31774116 PMCID: PMC6936743 DOI: 10.1093/humrep/dez230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/23/2019] [Indexed: 02/04/2023] Open
Abstract
STUDY QUESTION What are the levels of breast development and satisfaction in women with a Disorder/Difference of Sex Development (DSD)? SUMMARY ANSWER Compared with normative data, women with DSD reached lower Tanner stages and reported less breast satisfaction. WHAT IS KNOWN ALREADY Women with DSD may have chromosomal and hormonal variations that can impact typical breast development. While much emphasis is placed on genital development in this group, little is known about breast development, satisfaction and their association. STUDY DESIGN, SIZE, DURATION Data collection was part of the cross-sectional European multicenter dsd-LIFE study. Fourteen recruiting sites included 1040 participants between February 2014 and September 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 695 female-identifying participants were included (Turner n = 332, 46,XY DSD n = 141 and congenital adrenal hyperplasia n = 222), with a median age of 28 years. Clinical (i.e. history of hormone and surgical treatments, Tanner breast examination) and patient-reported (i.e. breast satisfaction, relationship status, sexual satisfaction and experienced femininity) data was collected by independent trained research staff. The relationship between breast development, satisfaction and femininity was assessed. Control data on breast development and satisfaction in women without DSD was retrieved from the literature. MAIN RESULTS AND THE ROLE OF CHANCE Of the 695 participants, 61% had received estrogen replacement and 51% puberty induction therapy, whereas 2% had received breast augmentation surgery. Approximately 65% of participants had reached Tanner breast stage 5, which is substantially less than the general population (90%). Breast satisfaction was lower than normative data as well (P < 0.001, Cohen’s d = 0.45). Breast size and breast satisfaction were associated with feelings of femininity. LIMITATIONS, REASONS FOR CAUTION Limitations include the sample representativeness (e.g. regarding the clinical heterogeneity) and the limited in-depth knowledge on (prior) hormonal regimens. Furthermore, no (matched) control data was collected as part of this study. WIDER IMPLICATIONS OF THE FINDINGS In order to support the psychosexual well-being of women with DSD, enhancing breast development by sufficient hormone replacement and possible augmentation surgery is advocated. The scope of DSD management should be beyond genital development only and consider breasts as well. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by the European Union Seventh Framework Program (FP7/2007–2013) under grant agreement no. 305 373. There are no competing interests. TRIAL REGISTRATION NUMBER German Clinical Trials Register: Registration identification number: DRKS00006072.
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Affiliation(s)
- Tim C van de Grift
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam UMC (VU University Medical Center), Amsterdam, the Netherlands.,Department of Medical Psychology (Gender and Sexology), Amsterdam UMC (VU University Medical Center), Amsterdam, the Netherlands.,Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology (Gender and Sexology), Amsterdam UMC (VU University Medical Center), Amsterdam, the Netherlands.,Amsterdam Public Health Institute, Amsterdam, the Netherlands
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16
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Tanaka T. Perspectives on growth promoting treatment for patients with Turner syndrome in Japan. Clin Pediatr Endocrinol 2020; 29:91-97. [PMID: 32694884 PMCID: PMC7348636 DOI: 10.1297/cpe.29.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/18/2020] [Indexed: 11/04/2022] Open
Abstract
In Japan, anabolic steroid hormone (ASH) treatment for Turner syndrome (TS) to promote growth had been provided before GH therapy for TS was approved. ASH effectively improved the adult height (AH) of TS patients without spontaneous puberty but decreased the AH of TS patients with spontaneous puberty. Although GH therapy for TS was approved in 1991, the approved dosage remained 0.5 IU/kg/wk for GH-deficient TS patients and improved AH by approximately 7 cm. However, AH did not reach -2 standard deviations in healthy girls. In 1999, the requirement of GH deficiency was removed and a dose of 1.0 IU/kg/wk was approved. Although an increase in AH was expected, no reports showed significant improvements in AH at a high dose of GH. GH + ASH combination therapy was reevaluated and recommended for TS patients with gonadal failure and an extremely short stature or those who respond poorly to GH therapy. Although early estrogen replacement therapy is recommended to improve psychological quality of life and prevent osteoporosis, it lowered AH even at a low dose of ethinyl estradiol (25 ng/kg/d). The initiation of ethynyl estradiol at an extremely low dose (1-5 ng/kg/d) at a relatively young age successfully improved AH.
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17
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Donaldson M, Kriström B, Ankarberg-Lindgren C, Verlinde S, van Alfen-van der Velden J, Gawlik A, van Gelder MMHJ, Sas T. Optimal Pubertal Induction in Girls with Turner Syndrome Using Either Oral or Transdermal Estradiol: A Proposed Modern Strategy. Horm Res Paediatr 2019; 91:153-163. [PMID: 31167218 DOI: 10.1159/000500050] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 03/29/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Most girls with Turner syndrome (TS) require pubertal induction with estrogen, followed by long term replacement. However, no adequately powered prospective studies comparing transdermal with oral 17β-estradiol administration exist. This reflects the difficulty of securing funding to study a rare condition with relatively low morbidity/mortality when competing against conditions such as cancer and vascular disease. Protocol Consensus: The TS Working Group of the European Society for Paediatric Endocrinology (ESPE) has agreed to both a 3-year oral and a 3-year transdermal regimen for pubertal induction. Prerequisites include suitable 17β-estradiol tablets and matrix patches to allow the delivery of incremental doses based on body weight. Study Proposal: An international prospective cohort study with single centre analysis is proposed in which clinicians and families are invited to choose either of the agreed regimens, usually starting at 11 years. We hypothesise that pubertal induction with transdermal estradiol will result in better outcomes for some key parameters. The primary outcome measure chosen is height gain during the induction period. ANALYSIS Assessment of the demographics and drop-out rates of patients choosing either oral or transdermal preparations; and appropriate analysis of outcomes including pubertal height gain, final height, liver enzyme and lipid profile, adherence/acceptability, cardiovascular health, including systolic and diastolic blood pressure and aortic root diameter and bone health. CONCLUSION The proposed model of prospective data collection according to internationally agreed protocols aims to break the current impasse in obtaining evidence-based management for TS and could be applied to other rare paediatric endocrine conditions.
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Affiliation(s)
| | - Berit Kriström
- Institution of Clinical Science, Pediatrics, Umeå University, Umeå, Sweden
| | - Carina Ankarberg-Lindgren
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Siska Verlinde
- Belgian Study Group of Paediatric Endocrinology and Diabetes, Brussels, Belgium
| | | | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Marleen M H J van Gelder
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Theo Sas
- Department of Pediatric Endocrinology, Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Diabeter, National Diabetes Care and Research Center, Rotterdam, The Netherlands
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18
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Grinspon RP, Freire AV, Rey RA. Hypogonadism in Pediatric Health: Adult Medicine Concepts Fail. Trends Endocrinol Metab 2019; 30:879-890. [PMID: 31471249 DOI: 10.1016/j.tem.2019.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/19/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023]
Abstract
The classical definition of hypogonadism, used in adult medicine, as gonadal failure resulting in deficient steroid and gamete production, and its classification into hypergonadotropic and hypogonadotropic refer to primary gonadal and hypothalamic-pituitary disorders respectively and may lead to under- or misdiagnosis in pediatrics. Indeed, in children with primary gonadal failure, gonadotropin levels may be within the reference range for age. Conversely, since gonadotropins and steroids are normally low during childhood, it may prove impossible to show the existence of a hypogonadotropic state before pubertal age. Anti-Müllerian hormone (AMH) and inhibin B arise as more adequate biomarkers to assess gonadal function and increase the possibility of making an earlier diagnosis of hypogonadism in children, which may positively impact on timely management.
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Affiliation(s)
- Romina P Grinspon
- Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá' (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Gallo 1330 - C1425EFD Buenos Aires, Argentina
| | - Analía V Freire
- Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá' (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Gallo 1330 - C1425EFD Buenos Aires, Argentina
| | - Rodolfo A Rey
- Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá' (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Gallo 1330 - C1425EFD Buenos Aires, Argentina.
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19
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Wit JM, Deeb A, Bin-Abbas B, Al Mutair A, Koledova E, Savage MO. Achieving Optimal Short- and Long-term Responses to Paediatric Growth Hormone Therapy. J Clin Res Pediatr Endocrinol 2019; 11:329-340. [PMID: 31284701 PMCID: PMC6878339 DOI: 10.4274/jcrpe.galenos.2019.2019.0088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023] Open
Abstract
It is over sixty years since the first administration of human growth hormone (GH) to children with GH deficiency, and over thirty years since recombinant human GH has been available for treatment of GH deficiency and a wider range of non-GH deficiency disorders. From a diagnostic perspective, genetic analysis, using single gene or Sanger sequencing and more recently next generation or whole exome sequencing, has brought advances in the diagnosis of specific causes of short stature, which has enabled therapy to be targeted more accurately. Genetic discoveries have ranged from defects of pituitary development and GH action to abnormalities in intracellular mechanisms, paracrine regulation and cartilage matrix formation. The strategy of GH therapy using standard doses has evolved to individualised GH dosing, depending on diagnosis and predictors of growth response. Evidence of efficacy of GH in GH deficiency, Turner syndrome and short children born small for gestational age is reviewed. The importance of critical assessment of growth response is discussed, together with the recognition and management of a poor or unsatisfactory growth response and the organisational issues related to prevention, detection and intervention regarding suboptimal adherence to GH therapy.
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Affiliation(s)
- Jan M. Wit
- Leiden University Medical Centre, Department of Paediatrics, Leiden, Netherlands
| | - Asma Deeb
- Mafraq Hospital, Clinic of Paediatric Endocrinology, Abu Dhabi, United Arab Emirates
| | - Bassam Bin-Abbas
- King Faisal Specialist Hospital and Research Center, Department of Paediatrics, Riyadh, Saudi Arabia
| | - Angham Al Mutair
- King Abdullah Specialised Children’s Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research, Clinic of Paediatrics, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Science, Clinic of Paediatrics, Riyadh, Saudi Arabia
| | | | - Martin O. Savage
- William Harvey Research Institute, Barts and the London Faculty of Medicine and Dentistry, London, United Kingdom
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20
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Mohamed S, Alkofide H, Adi YA, Amer YS, AlFaleh K. Oxandrolone for growth hormone-treated girls aged up to 18 years with Turner syndrome. Cochrane Database Syst Rev 2019; 2019:CD010736. [PMID: 31684688 PMCID: PMC6820693 DOI: 10.1002/14651858.cd010736.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The final adult height of untreated girls aged up to 18 years with Turner syndrome (TS) is approximately 20 cm shorter compared with healthy females. Treatment with growth hormone (GH) increases the adult height of people with TS. The effects of adding the androgen, oxandrolone, in addition to GH are unclear. Therefore, we conducted this systematic review to investigate the benefits and harms of oxandrolone as an adjuvant therapy for people with TS treated with GH. OBJECTIVES To assess the effects of oxandrolone on growth hormone-treated girls aged up to 18 years with Turner syndrome. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was October 2018. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled clinical trials (RCTs) that enrolled girls aged up to 18 years with TS who were treated with GH and oxandrolone compared with GH only treatment. DATA COLLECTION AND ANALYSIS Three review authors independently screened titles and abstracts for relevance, selected trials, extracted data and assessed risk of bias. We resolved disagreements by consensus, or by consultation with a fourth review author. We assessed trials for overall certainty of the evidence using the GRADE instrument. MAIN RESULTS We included six trials with 498 participants with TS, 267 participants were randomised to oxandrolone plus GH treatment and 231 participants were randomised to GH only treatment. The individual trial sample size ranged between 22 and 133 participants. The included trials were conducted in 65 different paediatric endocrinology healthcare facilities including clinics, centres, hospitals and academia in the USA and Europe. The duration of interventions ranged between 3 and 7.6 years. The mean age of participants at start of therapy ranged from 9 to 12 years. Overall, we judged only one trial at low risk of bias in all domains and another trial at high risk of bias in most domains. We downgraded the level of evidence mainly because of imprecision (low number of trials, low number of participants or both). Comparing oxandrolone plus GH with GH only for final adult height showed a mean difference (MD) of 2.7 cm in favour of oxandrolone plus GH treatment (95% confidence interval (CI) 1.3 to 4.1; P < 0.001; 5 trials, 270 participants; moderate-quality evidence). The 95% prediction interval ranged between 0.3 cm and 5.1 cm. For adverse events, we based our main analysis on reliable date from two trials with overall low risk of bias. There was no evidence of a difference between oxandrolone plus GH and GH for adverse events (RR 1.81, 95% CI 0.83 to 3.96; P = 0.14; 2 trials, 170 participants; low-quality evidence). Six out of 86 (18.6%) participants receiving oxandrolone plus GH compared with 8/84 (9.5%) participants receiving GH only reported adverse events, mainly signs of virilisation (e.g. deepening of the voice). One trial each investigated the effects of treatments on speech (voice frequency; 88 participants), cognition (51 participants) and psychological status (106 participants). The overall results for these comparisons were inconclusive (very low-quality evidence). No trial reported on health-related quality of life or all-cause mortality. AUTHORS' CONCLUSIONS Addition of oxandrolone to the GH therapy led to a modest increase in the final adult height of girls aged up to 18 years with TS. Adverse effects identified included virilising effects such as deepening of the voice, but reporting was inadequate in some trials.
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Affiliation(s)
- Sarar Mohamed
- Prince Sultant Military Medical CityGenetics and Metabolic Medicine Division, Department of PediatricsRiyadhSaudi Arabia
- Alfaisal UniversityDepartment of Pediatrics, College of MedicineRiyadhSaudi Arabia
| | - Hadeel Alkofide
- College of Pharmacy King Saud University KSADepartment of Clinical PharmacyRiyadhSaudi Arabia
| | - Yaser A Adi
- King Faisal Specialist Hospital & Research CenterAcademic & Training AffairsRiyadhRiyadhSaudi Arabia11211 Riyadh
| | - Yasser Sami Amer
- King Saud University College of Medicine and King Khalid University HospitalResearch Chair for Evidence Based Health Care and Knowledge Translation, CPG Steering Committee, Quality Management DepartmentP.O.Box 71470 Al DiriyahRiyadhAr‐Riyad (Riyadh)Saudi Arabia11587
| | - Khalid AlFaleh
- King Saud UniversityDepartment of Pediatrics (Division of Neonatology)King Khalid University Hospital and College of MedicineDepartment of Pediatrics (39), P.O. Box 2925RiyadhSaudi Arabia11461
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21
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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: 20] [Impact Index Per Article: 4.0] [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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22
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23
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Kosteria I, Kanaka-Gantenbein C. Turner Syndrome: transition from childhood to adolescence. Metabolism 2018; 86:145-153. [PMID: 29309748 DOI: 10.1016/j.metabol.2017.12.016] [Citation(s) in RCA: 10] [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: 07/03/2017] [Revised: 12/29/2017] [Accepted: 12/31/2017] [Indexed: 01/15/2023]
Abstract
Transition from pediatric to adult care for young women with Turner Syndrome (TS) is characterized by high drop-out rates and inadequate follow-up, leading to increased morbidity and mortality. The complexity of the health issues young women with TS face or new problems that may arise warrants a well-structured and efficiently coordinated gradual transition plan, which is adapted to the individual needs of the emerging young adult and is based on interdisciplinary communication between physicians. In order to achieve a high level of care, it is important for the patient to be sincerely informed about her condition but also supported throughout this critical period of rising responsibility and autonomy by an experienced, multidisciplinary team. In this review, we present the basic concepts that should characterize transition and the major health issues that should be thoroughly addressed, including growth, Hormone Replacement Treatment and fertility options, cardiovascular disease, bone health, gastrointestinal disorders, autoimmunity, orthopaedic and ENT issues, as well as the overall psychological well-being of the young adult with TS.
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Affiliation(s)
- Ioanna Kosteria
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece.
| | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece
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Klein KO, Rosenfield RL, Santen RJ, Gawlik AM, Backeljauw PF, Gravholt CH, Sas TCJ, Mauras N. Estrogen Replacement in Turner Syndrome: Literature Review and Practical Considerations. J Clin Endocrinol Metab 2018; 103:1790-1803. [PMID: 29438552 DOI: 10.1210/jc.2017-02183] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/02/2018] [Indexed: 01/15/2023]
Abstract
CONTEXT Most girls with Turner syndrome (TS) have hypergonadotropic hypogonadism and need hormonal replacement for induction of puberty and then for maintaining secondary sex characteristics, attaining peak bone mass, and uterine growth. The optimal estrogen replacement regimen is still being studied. EVIDENCE ACQUISITION We conducted a systematic search of PubMed for studies related to TS and puberty. EVIDENCE SYNTHESIS The goals of replacement are to mimic normal timing and progression of physical and social development while minimizing risks. Treatment should begin at age 11 to 12 years, with dose increases over 2 to 3 years. Initiation with low-dose estradiol (E2) is crucial to preserve growth potential. Delaying estrogen replacement may be deleterious to bone and uterine health. For adults who have undergone pubertal development, we suggest transdermal estrogen and oral progestin and discuss other approaches. We discuss linear growth, lipids, liver function, blood pressure, neurocognition, socialization, and bone and uterine health as related to hormonal replacement. CONCLUSION Evidence supports the effectiveness of starting pubertal estrogen replacement with low-dose transdermal E2. When transdermal E2 is unavailable or the patient prefers, evidence supports use of oral micronized E2 or an intramuscular preparation. Only when these are unavailable should ethinyl E2 be prescribed. We recommend against the use of conjugated estrogens. Once progestin is added, many women prefer the ease of use of a pill containing both an estrogen and a progestin. The risks and benefits of different types of preparations, with examples, are discussed.
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Affiliation(s)
- Karen O Klein
- University of California, San Diego, California
- Rady Children's Hospital, San Diego, California
| | | | | | - Aneta M Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Theo C J Sas
- Erasmus Medical Center and Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Nelly Mauras
- Nemours Children's Health System, Jacksonville, Florida
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Shankar RK, Backeljauw PF. Current best practice in the management of Turner syndrome. Ther Adv Endocrinol Metab 2018; 9:33-40. [PMID: 29344338 PMCID: PMC5761955 DOI: 10.1177/2042018817746291] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/24/2017] [Indexed: 01/15/2023] Open
Abstract
Turner syndrome (TS) is characterized by partial or complete loss of the second X-chromosome in phenotypic females resulting in a constellation of clinical findings that may include lymphedema, cardiac anomalies, short stature, primary ovarian failure and neurocognitive difficulties. Optimizing health care delivery is important to enable these individuals achieve their full potential. We review the current best practice management recommendations for individuals with TS focusing on the latest consensus opinion in regard to genetic diagnosis, treatment of short stature, estrogen supplementation, addressing psychosocial issues, as well screening for other comorbidities. A multidisciplinary approach and a well-planned transition to adult follow-up care will improve health care delivery significantly for this population.
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Affiliation(s)
- Roopa Kanakatti Shankar
- Assistant Professor, Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Philippe F Backeljauw
- Cincinnati Center for Pediatric and Adult Turner Syndrome Care, Professor, Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Yang S. Diagnostic and therapeutic considerations in Turner syndrome. Ann Pediatr Endocrinol Metab 2017; 22:226-230. [PMID: 29301182 PMCID: PMC5769837 DOI: 10.6065/apem.2017.22.4.226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/21/2017] [Accepted: 12/10/2017] [Indexed: 12/26/2022] Open
Abstract
Newly developed genetic techniques can reveal mosaicism in individuals diagnosed with monosomy X. Noninvasive prenatal diagnosis using maternal blood can detect most fetuses with X chromosome abnormalities. Low-dose and ultralow-dose estrogen replacement therapy can achieve a more physiological endocrine milieu. However, many complicated and controversial issues with such treatment remain. Therefore, lifetime observation, long-term studies of health problems, and optimal therapeutic plans are needed for women with Turner syndrome. In this review, we discuss several diagnostic trials using recently developed genetic techniques and studies of physiological hormone replacement treatment over the last 5 years.
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Affiliation(s)
- Seung Yang
- Department of Pediatrics, Kangdong Sacred Hear t Hospital, Hallym University College of Medicine, Seoul, Korea
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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: 588] [Impact Index Per Article: 84.0] [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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Mauras N, Ross JL, Gagliardi P, Yu YM, Hossain J, Permuy J, Damaso L, Merinbaum D, Singh RJ, Gaete X, Mericq V. Randomized Trial of Aromatase Inhibitors, Growth Hormone, or Combination in Pubertal Boys with Idiopathic, Short Stature. J Clin Endocrinol Metab 2016; 101:4984-4993. [PMID: 27710241 PMCID: PMC5155684 DOI: 10.1210/jc.2016-2891] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/03/2016] [Indexed: 11/19/2022]
Abstract
CONTEXT Growth of short children in puberty is limited by the effect of estrogen on epiphyseal fusion. OBJECTIVES To compare: 1) the efficacy and safety of aromatase inhibitors (AIs) vs GH vs AI/GH on increasing adult height potential in pubertal boys with severe idiopathic short stature (ISS); and 2) differences in body composition among groups. DESIGN Randomized three-arm open-label comparator. SETTING Outpatient clinical research. PATIENTS Seventy-six pubertal boys [mean (SE) age, 14.1 (0.1) years] with ISS [height SD score (SDS), -2.3 (0.0)]. INTERVENTION Daily AIs (anastrozole or letrozole), GH, or AI/GH for 24-36 months. OUTCOMES Anthropometry, bone ages, dual x-ray absorptiometry, spine x-rays, hormones, safety labs. RESULTS Height gain [mean (SE)] at 24 months was: AI, +14.0 (0.8) cm; GH, +17.1 (0.9) cm; AI/GH, +18.9 (0.8) cm (P < .0006, analysis of covariance). Height SDS was: AI, -1.73 (0.12); GH, -1.43 (0.14); AI/GH, -1.25 (0.12) (P < .0012). Those treated through 36 months grew more. Regardless of treatment duration, height SDS at near-final height [n = 71; age, 17.4 (0.2) years; bone age, 15.3 (0.1) years; height achieved, ∼97.6%] was: AI, -1.4 (0.1); GH, -1.4 (0.2); AI/GH, -1.0 (0.1) (P = .06). Absolute height change was: AI, +18.2 (1.6) cm; GH, +20.6 (1.5) cm; AI/GH, +22.5 (1.4) cm (P = .01) (expected height gain at -2.0 height SDS, +13.0 cm). AI/GH had higher fat free mass accrual. Measures of bone health, safety labs, and adverse events were similar in all groups. Letrozole caused higher T and lower estradiol than anastrozole. CONCLUSIONS Combination therapy with AI/GH increases height potential in pubertal boys with ISS more than GH and AI alone treated for 24-36 months with a strong safety profile.
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Affiliation(s)
- Nelly Mauras
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Judith L Ross
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Priscila Gagliardi
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Y Miles Yu
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Jobayer Hossain
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Joseph Permuy
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Ligeia Damaso
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Debbie Merinbaum
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Ravinder J Singh
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Ximena Gaete
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
| | - Veronica Mericq
- Nemours Children's Health System, Division of Endocrinology (N.M., P.G., J.P., L.D.), Jacksonville, Florida 32207; (J.L.R.), Philadelphia, Pennsylvania 19107; and (Y.M.Y.), Orlando, Florida 32827; Nemours Children's Health System, Division of Biostatistics (J.H.), Wilmington, Delaware 19803; and Nemours Children's Health System, Department of Radiology (D.M.), Jacksonville, Florida 32207; Mayo Clinic (R.J.S.), Department of Biochemistry, Rochester, Minnesota 55905; and University of Chile (X.G., V.M.), Division of Endocrinology, 1058 Santiago, Chile
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Al Herbish AS, Almutair A, Bin Abbas B, Alsagheir A, Alqahtani M, Kaplan W, Deeb A, El-Awwa A, Al Khawari M, Koledova E, Savage MO. Diagnosis and management of growth disorders in Gulf Cooperation Council (GCC) countries: Current procedures and key recommendations for best practice. Int J Pediatr Adolesc Med 2016; 3:91-102. [PMID: 30805477 PMCID: PMC6372455 DOI: 10.1016/j.ijpam.2016.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/04/2016] [Accepted: 07/04/2016] [Indexed: 11/26/2022]
Abstract
Diagnosis and management of growth disorders comprises an important area of pediatric practice. Current procedures in the different stages of the identification, referral, investigation, and treatment of growth disorders in the Gulf Cooperation Council (GCC) countries have been summarized. Evidence-based procedures, relating specifically to height screening for identification of short stature, auxological criteria for patient referral from primary to secondary pediatric care, and general and endocrine investigations and diagnosis have been discussed and outlined. The management issues related to key disorders that are licensed for growth hormone (hGH) therapy, namely GH deficiency, Turner syndrome, short stature related to birth size small for gestational age (SGA), and idiopathic short stature are discussed with recommendations described for best practice. Finally, two key components of short stature management, namely transitional care for the transfer of patients from pediatric to adult endocrinology services and adherence to recommended therapy with hGH, have been addressed with current practice outlines and recommendations presented.
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Affiliation(s)
| | - Angham Almutair
- King Abdullah Specialist Children's Hospital, King Saud bin Abdulaziz University for Health Science, Saudi Arabia
| | - Bassam Bin Abbas
- King Faisal Specialist Hospital and Research Centre, Saudi Arabia
| | - Afaf Alsagheir
- King Faisal Specialist Hospital and Research Centre, Saudi Arabia
| | | | | | - Asma Deeb
- Mafraq Hospital, Abu Dhabi, United Arab Emirates
| | - Ahmed El-Awwa
- Hamad Medical Corporation, Qatar and Alexandria Children's Hospital, Cairo, Egypt
| | | | | | - Martin O. Savage
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, UK
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30
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Update on Common Childhood Endocrine Disorders. Curr Probl Pediatr Adolesc Health Care 2015; 45:250-80. [PMID: 26356799 DOI: 10.1016/j.cppeds.2015.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/23/2015] [Indexed: 11/21/2022]
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Sheanon NM, Backeljauw PF. Effect of oxandrolone therapy on adult height in Turner syndrome patients treated with growth hormone: a meta-analysis. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:18. [PMID: 26322078 PMCID: PMC4551522 DOI: 10.1186/s13633-015-0013-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/07/2015] [Indexed: 11/10/2022]
Abstract
Turner syndrome is a chromosomal abnormality in which there is complete or partial absence of the X chromosome. Turner syndrome effects 1 in every 2000 live births. Short stature is a cardinal feature of Turner Syndrome and the standard treatment is recombinant human growth hormone. When growth hormone is started at an early age a normal adult height can be achieved. With delayed diagnosis young women with Turner Syndrome may not reach a normal height. Adjuvant therapy with oxandrolone is used but there is no consensus on the optimal timing of treatment, the duration of treatment and the long term adverse effects of treatment. The objective of this review and meta-analysis is to examine the effect of oxandrolone on adult height in growth hormone treated Turner syndrome patients. Eligible trials were identified by a literature search using the terms: Turner syndrome, oxandrolone. The search was limited to English language randomized-controlled trials after 1980. Twenty-six articles were reviewed and four were included in the meta-analysis. A random effects model was used to calculate an effect size and confidence interval. The pooled effect size of 2.0759 (95 % CI 0.0988 to 4.0529) indicates that oxandrolone has a positive effect on adult height in Turner syndrome when combined with growth hormone therapy. In conclusion, the addition of oxandrolone to growth hormone therapy for treatment of short stature in Turner syndrome improves adult height. Further studies are warranted to investigate if there is a subset of Turner syndrome patients that would benefit most from growth hormone plus oxandrolone therapy, and to determine the optimal timing and duration of such therapy.
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Affiliation(s)
- Nicole M Sheanon
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 7012, Cincinnati, OH 45229 USA
| | - Philippe F Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 7012, Cincinnati, OH 45229 USA ; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
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32
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Gawlik A. Management of Turner Syndrome. EUROPEAN ENDOCRINOLOGY 2015; 11:100-101. [PMID: 29632579 PMCID: PMC5819065 DOI: 10.17925/ee.2015.11.02.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/10/2015] [Indexed: 12/03/2022]
Abstract
Turner syndrome is one of the most common genetic disorders, affecting one in 2,000–2,500 live-born girls. In order to provide appropriate healthcare, a multi-disciplinary team of closely cooperating endocrinologists, gynaecologists, geneticists, cardiologists, otolaryngologists, fertility specialists, psychologists, nurse educators and social workers is needed.
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Affiliation(s)
- Aneta Gawlik
- Assistant Professor, Pediatric Endocrinology and Diabetes, Department of Pediatrics, Medical University of Silesia, School of Medicine in Katowice, Poland
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33
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Abstract
Congenital disruptions of sex hormone production lead to wide-ranging developmental and physiological effects in individuals who have atypical chromosomal, gonadal or anatomic sex. Aberrant developmental sex hormone exposure causes disorders of genital anatomy, attainment of secondary sexual characteristics and has long-term effects on metabolism, fertility and psychological functioning. Principles in the management of disorders of sex development (DSD) aim to improve physiological health and long-term outcome, as well as development of male or female sexual anatomy. Concerns raised by DSD patient advocacy groups about beneficence and autonomy with respect to prescribed hormone treatments and avoidance of unnecessary genital and gonadal surgery have demanded greater informed consent and attention to long-term outcome. Hormone treatment is influenced by underlying clinical diagnosis and by factors such as sex of rearing and gender identity of the affected individual. We describe diagnostic criteria for different DSDs, clinical considerations in management protocols, together with current concepts and detailed practical hormone treatments for male and female individuals with DSD. Gender identity issues requiring multidisciplinary consensus, ethical consideration and informed consent or assent from the young person are also addressed.
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Affiliation(s)
- Jacqueline Hewitt
- Department of Endocrinology, Royal Children's Hospital, 3 West Clinical Offices, 50 Flemington Road, Parkville, Victoria 3052, Australia.
| | - Margaret Zacharin
- Department of Endocrinology, Royal Children's Hospital, 3 West Clinical Offices, 50 Flemington Road, Parkville, Victoria 3052, Australia
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Abstract
Besides growth hormone, several pharmaceutical products have been investigated for efficacy and safety in increasing short term growth or adult height. Short-term treatment with testosterone esters in boys with constitutional delay of growth and puberty is efficacious in generating secondary sex characteristics and growth acceleration. The addition of oxandrolone to growth hormone (GH) in Turner syndrome has an additive effect on adult height gain. Treatment with GnRH analogs is the established treatment of central precocious puberty, and its addition to GH therapy appears effective in increasing adult height in GH deficient children, and possibly short children born SGA or with SHOX deficiency, who are still short at pubertal onset. Aromatase inhibitors appear effective in several rare disorders, but their value in increasing adult height in early pubertal boys with GH deficiency or idiopathic short stature is uncertain. A trial with a C-natriuretic peptide analog offers hope for children with achondroplasia.
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Affiliation(s)
- Jan M Wit
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Wilma Oostdijk
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Levitsky LL, Luria AHO, Hayes FJ, Lin AE. Turner syndrome: update on biology and management across the life span. Curr Opin Endocrinol Diabetes Obes 2015; 22:65-72. [PMID: 25517026 DOI: 10.1097/med.0000000000000128] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW We review recent understanding of the pathophysiology, molecular biology, and management of Turner syndrome. RECENT FINDINGS Sophisticated genetic techniques are able to detect mosaicism in one-third of individuals previously thought to have monosomy X. Prenatal detection using maternal blood should permit noninvasive detection of most fetuses with an X chromosome abnormality. Disproportionate growth with short limbs has been documented in this condition, and a target gene of short stature homeobox, connective tissue growth factor (Ctgf), has been described. Liver disease is more common in Turner syndrome than previously recognized. Most girls have gonadal failure. Spontaneous puberty and menarche is more commonly seen in girls with XX mosaicism. Low-dose estrogen replacement therapy may be given early to induce a more normal onset and tempo of puberty. Oocyte donation for assisted reproduction carries a substantial risk, particularly if the woman has known cardiac or aortic disease. Neurodevelopmental differences in Turner syndrome are beginning to be correlated with differences in brain anatomy. SUMMARY An increased understanding of the molecular basis for aspects of this disorder is now developing. In addition, a renewed focus on health maintenance through the life span should provide better general and targeted healthcare for these girls and women.
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Affiliation(s)
- Lynne L Levitsky
- aPediatric Endocrine Unit, Department of Pediatrics, Massachusetts General Hospital bGenetics Residency Program, Harvard Medical School cBoston Children's Hospital dReproductive Endocrine Unit, Department of Medicine, Massachusetts General Hospital eGenetics Unit, Mass General Hospital for Children, Massachusetts, Boston, USA
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