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Glodowski MB, Parra CM, Xin MK, Fino ME. Reproductive Considerations in the Transgender and Gender Diverse Population: A Review. Endocrinol Metab Clin North Am 2024; 53:471-482. [PMID: 39084820 DOI: 10.1016/j.ecl.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Many transgender and gender diverse (TGD) individuals will be considering gender-affirming treatments during their reproductive lifespan. These medically necessary treatments have a negative impact on reproductive potential. All TGD individuals should be counseled regarding fertility. Options for fertility preservation for individuals who have undergone puberty include mature oocyte, embryo, and sperm cryopreservation. In prepubertal individuals, ovarian tissue cryopreservation may be considered, but testicular tissue cryopreservation remains experimental only. While there have been advances in the technology and standardization of reproductive health care for this population, many gaps remain in our knowledge which require further research.
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Affiliation(s)
- Michele B Glodowski
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, New York University Langone Health, 111 Broadway, 2nd Floor, New York, NY 10006, USA.
| | - Carlos M Parra
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, New York University Langone Prelude Fertility Center, 159 East 53rd Street, 3rd Floor, New York, NY 10022, USA
| | - Madeline K Xin
- NYU Grossman School of Medicine, 550 First Avenue, New York, NY 10016, USA
| | - Mary Elizabeth Fino
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, New York University Langone Prelude Fertility Center, 159 East 53rd Street, 3rd Floor, New York, NY 10022, USA
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Murano-Kinney S. Banning Puberty-Pausing Medications Endangers Transgender Adolescents. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:4-8. [PMID: 39158419 DOI: 10.1080/15265161.2024.2371117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
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3
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Eitel KB, Hodax JK. Evaluation and medical care of intersex and gender diverse youth. Pediatr Radiol 2024; 54:1352-1362. [PMID: 38782777 DOI: 10.1007/s00247-024-05948-y] [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: 03/18/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
While there is considerable overlap in the treatment of patients with intersex traits and differences in sex development (I/DSD) with transgender and gender diverse (TGD) youth, the initial medical evaluation varies significantly. I/DSD youth often present due to differences in genitalia development in infancy or pubertal development in adolescence, and this leads to comprehensive biochemical, radiologic, and genetic evaluation. TGD youth, however, tend to have typical development noted at birth and during puberty, but present with a gender identity that does not align with their sex assigned at birth and do not require evaluation for underlying pathology. For both I/DSD and TGD youth, the mainstays of treatment are to better align one's physical appearance to their gender identity. This review discusses the non-medical and medical interventions utilized in gender affirming care. A multidisciplinary team of mental health providers, pediatric medical providers, and surgeons is recommended for providing gender affirming care to both I/DSD youth and TGD youth and their families. Radiologists have an important role in initial evaluation of I/DSD youth and in ongoing monitoring of growth and bone mineral density during puberty induction in I/DSD and TGD youth.
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Affiliation(s)
- Kelsey B Eitel
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S OC.7.920, PO Box 5371, Seattle, 98105, WA, USA
| | - Juanita K Hodax
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S OC.7.920, PO Box 5371, Seattle, 98105, WA, USA.
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Yaman K, Unal E, Beştaş A, Aktar Karakaya A, Beyazıt N, Kolbaşı B. Retrospective evaluation of patients diagnosed with central precocious puberty who reached the final height. J Pediatr Endocrinol Metab 2024; 0:jpem-2024-0124. [PMID: 38881279 DOI: 10.1515/jpem-2024-0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/01/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVES Central precocious puberty (CPP) is the onset of puberty before the age of 8 in girls and 9 in boys. The primary goal of CPP treatment is control and arrest of puberty development. In this study, it was aimed to determine the factors associated with final height in patients who received gonadotropin-releasing hormone analogs (GnRHa) treatment and reached their final height. METHODS From the medical records of the patients, age on admission, bone age (BA), weight-standard deviation score (SDS), height-SDS, BMI-SDS, target height-SDS, basal LH, FSH, E2, age at menarche, and pelvic USG findings were obtained. RESULTS The mean age on admission of the 67 female patients was 7.5 ± 0.60 years. On admission, 4.5 % of the patients were obese and 19.4 % were overweight. There was no difference between BMI-SDS at admission and after treatment. The mean age at menarche was 11.57 ± 0.78 years. About 58.2 % of the patients reached the target height, 35.8 % exceeded the target height, and 6 % were below the target height. The mean height-SDS and predicted adult height (PAH) on admission were better in patients who exceeded the target height. It was determined that target height-SDS had a positive effect on delta height-SDS, while BA/CA ratio had a negative effect. CONCLUSIONS It was found that GnRHa treatment did not have a negative effect on BMI-SDS. It was shown that 94 % of the patients who received GnRHa treatment reached the target height, and in fact, 35.8 % exceeded the target height. A greater final height may be associated with good height-SDS and PAH values on admission.
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Affiliation(s)
- Kadri Yaman
- Department of Pediatric Endocrinology, 2064056 Faculty of Medicine, Dicle University , Diyarbakır, Türkiye
| | - Edip Unal
- Department of Pediatric Endocrinology, 2064056 Faculty of Medicine, Dicle University , Diyarbakır, Türkiye
| | - Aslı Beştaş
- Department of Pediatric Endocrinology, 2064056 Faculty of Medicine, Dicle University , Diyarbakır, Türkiye
| | - Amine Aktar Karakaya
- Department of Pediatric Endocrinology, 2064056 Faculty of Medicine, Dicle University , Diyarbakır, Türkiye
| | - Nurcan Beyazıt
- Department of Pediatric Endocrinology, 2064056 Faculty of Medicine, Dicle University , Diyarbakır, Türkiye
| | - Barış Kolbaşı
- Department of Pediatric Endocrinology, 2064056 Faculty of Medicine, Dicle University , Diyarbakır, Türkiye
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Betsi G, Goulia P, Sandhu S, Xekouki P. Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications. Front Endocrinol (Lausanne) 2024; 15:1309904. [PMID: 38988996 PMCID: PMC11235884 DOI: 10.3389/fendo.2024.1309904] [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: 10/08/2023] [Accepted: 05/17/2024] [Indexed: 07/12/2024] Open
Abstract
Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.
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Affiliation(s)
- Grigoria Betsi
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Heraklion, Greece
| | - Panagiota Goulia
- Department of Psychiatry, Cambridgeshire and Peterborough National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Sophia Sandhu
- General Practice, Bridge Street Medical Practice, Cambridge, United Kingdom
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Heraklion, Greece
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Bakhtiani P. Gonadotropin-Releasing Hormone Agonists and Bone Density in Congenital Adrenal Hyperplasia: A Call for Further Research. J Clin Endocrinol Metab 2024; 109:e1458-e1459. [PMID: 37997392 DOI: 10.1210/clinem/dgad687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Priyanka Bakhtiani
- Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Children's Hospital Los Angeles/Keck School of Medicine at the University of Southern California, Los Angeles, CA 90026, USA
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Zepf FD, König L, Kaiser A, Ligges C, Ligges M, Roessner V, Banaschewski T, Holtmann M. [Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2024; 52:167-187. [PMID: 38410090 DOI: 10.1024/1422-4917/a000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria Abstract: Objective: The suppression of physiological puberty using puberty-blocking pharmacological agents (PB) and prescribing cross-sex hormones (CSH) to minors with gender dysphoria (GD) is a current matter of discussion, and in some cases, PB and CSH are used in clinical practice for this particular population. Two systematic reviews (one on PB, one on CSH treatment) by the British National Institute for Clinical Excellence (NICE) from 2020 indicated no clear clinical benefit of such treatments regarding critical outcome variables. In particular, these two systematic NICE reviews on the use of PB and CSH in minors with GD detected no clear improvements of GD symptoms. Moreover, the overall scientific quality of the available evidence, as discussed within the above-mentioned two NICE reviews, was classified as "very low certainty" regarding modified GRADE criteria. Method: The present systematic review presents an updated literature search on this particular topic (use of PB and CSH in minors with GD) following NICE principles and PICO criteria for all relevant new original research studies published since the release of the two above-mentioned NICE reviews (updated literature search period was July 2020-August 2023). Results: The newly conducted literature search revealed no newly published original studies targeting NICE-defined critical and important outcomes and the related use of PB in minors with GD following PICO criteria. For CSH treatment, we found two new studies that met PICO criteria, but these particular two studies had low participant numbers, yielded no significant additional clear evidence for specific and clearly beneficial effects of CSH in minors with GD, and could be classified as "low certainty" tfollowing modified GRADE criteria. Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn't suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data. The electronic supplement (ESM) 1 is an adapted and abreviated English version of this work.
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Affiliation(s)
- Florian D Zepf
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Laura König
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Anna Kaiser
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Carolin Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Marc Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Veit Roessner
- Department of Child and Adolescent Psychiatry, TU Dresden, Dresden, Germany
- German Center for Child and Adolescent Health (DZJK), partner site Leipzig-Dresden, Germany
| | - Tobias Banaschewski
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- German Center for Mental Health (DZPG), partner site Mannheim-Heidelberg-Ulm, Germany
| | - Martin Holtmann
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Hamm, Germany
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Flokas ME, Wakim P, Kollender S, Sinaii N, Merke DP. Gonadotropin-Releasing Hormone Agonist Therapy and Longitudinal Bone Mineral Density in Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2024; 109:498-504. [PMID: 37643900 PMCID: PMC10795903 DOI: 10.1210/clinem/dgad514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Children with congenital adrenal hyperplasia (CAH) are at risk for early puberty. Gonadotropin-releasing hormone analog (GnRHa) is frequently used and can decrease bone mineral density (BMD). OBJECTIVE Our aim was to investigate the effect of GnRHa therapy on BMD in a longitudinal study of patients with CAH spanning both childhood and adulthood. DESIGN AND SETTING Sixty-one patients with classic CAH due to 21-hydroxylase deficiency (20 treated with GnRHa) were followed with dual-energy X-ray absorptiometry (DXA) scans at puberty onset, attainment of adult height, and during early adulthood. MAIN OUTCOME MEASURES Whole body, lumbar spine, femoral neck, total hip, and distal radius BMD z-score at adult height. Longitudinal BMD and adult height were also assessed. RESULTS Twenty patients received GnRHa for an average of 4.5 ± 2 years. There were no differences in BMD between GnRHa-treated and -untreated groups at adult height for all sites. Overall, the follow-up DXA during early adulthood showed decreases in BMD z-scores for whole body (P = .01), lumbar spine (P < .0001), femoral neck (P = .06), total hip (P = .009), and distal radius (P = .05). GnRHa treatment correlated with improved height outcomes compared to predicted height at puberty onset after adjusting for midparental height (P = .02). Patients in both groups achieved similar adult height. CONCLUSION In children with CAH, GnRHa does not compromise BMD. However, BMD decreases with time and during the second and third decades of life is a possible effect of chronic supraphysiologic glucocorticoids. Children with CAH who experience early puberty benefit from GnRHa treatment as evidenced by the positive effect on height.
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Affiliation(s)
- Myrto Eleni Flokas
- Children's National Hospital, Washington, DC 20010, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
| | - Paul Wakim
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Sarah Kollender
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Ninet Sinaii
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Deborah P Merke
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
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Zevin EL, Eugster EA. Central precocious puberty: a review of diagnosis, treatment, and outcomes. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:886-896. [PMID: 37973253 DOI: 10.1016/s2352-4642(23)00237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/23/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
Central precocious puberty (CPP) refers to early activation of the hypothalamic-pituitary-gonadal (HPG) axis and is manifested by breast development in girls or testicular enlargement in boys before the normal physiological age ranges. CPP can be precipitated by intracranial pathology, exposure to high levels of sex steroids, or environmental risk factors, but most cases are idiopathic. Monogenic causes have also been identified. In this Review, we summarise pathophysiology, risk factors, diagnosis, and management of CPP. Concern for CPP should prompt referral to paediatric endocrinology where diagnosis is confirmed by clinical, biochemical, radiological, and genetic testing. CPP is treated with a gonadotropin-releasing hormone analogue, the primary aims of which are to increase adult height and postpone development of secondary sexual characteristics to an age that is more commensurate with peers. Although long-term outcomes of treatment with gonadotropin-releasing hormone analogues are reassuring, additional research on the psychological effect of CPP is needed.
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Affiliation(s)
- Erika L Zevin
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Erica A Eugster
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Buyukyilmaz G, Koca SB, Adiguzel KT, Gurbuz F, Boyraz M. Body mass index evolution and ovarian function in adolescent girls who received GnRH agonist treatment for central precocious puberty or early and fast puberty. J Pediatr Endocrinol Metab 2023; 36:1044-1051. [PMID: 37735929 DOI: 10.1515/jpem-2023-0232] [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: 05/16/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES Gonadotropin-releasing hormone agonist (GnRHa) has been used for central precocious puberty (CPP) or early and fast puberty. It was aimed to assess changes in body mass index (BMI), polycystic ovary syndrome (PCOS) frequency, and anti-Müllerian hormone (AMH) in girls who had been treated with GnRHa. METHODS Fifty-eight adolescent girls treated with GnRHa for CPP or early and fast puberty (3.75 mg/28 days), between 2011 and 2015, were re-evaluated in 2020-2022 at least 2 years after menstruation. Hormonal analyses were compared with 51 healthy adolescents. RESULTS In the GnRHa-treated group, a statistically significant increase was observed when the BMI standard deviation score (SDS) at the beginning of the treatment was compared with the BMI SDS at the end of the treatment (p=0.038). A statistically significant decrease was observed when the BMI SDS at the end of the treatment was compared with the BMI SDS in late adolescence (p=0.012). When the BMI SDS at the beginning of the treatment was compared with the BMI SDS in late adolescence, it was observed that there was no statistically significant difference (p=0.196). Of the 58 girls in the GnRHa-treated group, 8 (14 %) had PCOS. Serum AMH levels did not differ between the GnRHa-treated and the control group. CONCLUSIONS GnRHa treatment causes no adverse effect on BMI, at least in late adolescence. Girls treated with GnRHa were not found to be prone to developing PCOS. AMH levels were similar in the GnRHa-treated group as in the control group.
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Affiliation(s)
- Gonul Buyukyilmaz
- Department of Pediatric Endocrinology, Ankara City Hospital, Ankara, Türkiye
| | - Serkan Bilge Koca
- Department of Pediatrics, Division of Pediatric Endocrinology, Health Sciences University, Kayseri City Hospital, Kayseri, Türkiye
| | | | - Fatih Gurbuz
- Department of Pediatric Endocrinology, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara, Türkiye
| | - Mehmet Boyraz
- Department of Pediatric Endocrinology, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara, Türkiye
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Tseng CH, Lee YJ, Huang CY, Wu YL, Wang LT, Lin CH, Cheng BW, Lo FS, Chang YJ, Ting WH. The effects of gonadotropin-releasing hormone agonist on final adult height among girls with early and fast puberty. Front Endocrinol (Lausanne) 2023; 14:1271395. [PMID: 38027198 PMCID: PMC10655081 DOI: 10.3389/fendo.2023.1271395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction This study aimed to explore the impact of gonadotropin-releasing hormone agonists (GnRHa) on final adult height (FAH) in girls with early and fast puberty. Methods A retrospective study was conducted by reviewing data from the medical records of the Pediatric Endocrinology Clinics between January 1, 2010, and December 31, 2020, at MacKay Children's Hospital. The treatment group included 109 patients who received 3.75 mg monthly for at least 1 year, whereas the control group consisted of 95 girls who received no treatment. Results The treatment group was significantly older at the time of inclusion(chronological age (CA1), treatment vs. control, 8.7 vs. 8.4 years, p < 0.001), had a more advanced bone age (BA) (BA1, 11.5 vs. 10.8 years, p < 0.001), BA1-CA1 (2.7 vs. 2.2 years, p < 0.001), and shorter predicted adult height (PAH1) (153.3 vs. 157.1 cm, p = 0.005) that was significantly lower than their target height (Tht)(PAH1-Tht, -3.9 vs. -1.3 cm, p = 0.039). The FAHs of the GnRHa and the control group were similar (157.0 vs. 156.7 cm, p = 0.357) and were not significantly different from their Tht (FAH vs. Tht in the GnRHa group, 157.0 vs. 157.0 cm; control group, 156.7 vs. 157.0 cm). In the subgroup analysis, FAH was significantly higher after GnRHa treatment in those with PAH1 less than 153 cm and Tht (154.0 vs. 152.0 cm, p = 0.041), and those whose CA1 was between 8 and 9 years (158.0 vs. 155.4 cm, p = 0.004). We defined satisfactory FAH outcome as FAH-PAH1≥5 cm and significant factors were GnRHa therapy, PAH1 shorter than their Tht, age younger than 9 years, and faster growth velocity during the first year. Discussion GnRHa is effective in restoring the Tht in some early and fast pubertal girls, especially in those with poorly PAH (PAH lower than 153 cm and shorter than their target height). A younger age at initiation of treatment and a faster growth velocity during treatment are associated with a better height gain.
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Affiliation(s)
- Chin-Hui Tseng
- Department of Pediatric Endocrinology, MacKay Children’s Hospital, Taipei, Taiwan
- Department of Pediatric Endocrinology and Metabolism, Chuanghua Christian Childrens Hospital, Changhua, Taiwan
| | - Yann-Jinn Lee
- Department of Pediatric Endocrinology, MacKay Children’s Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Department of Medical Research, Tamsui MacKay Memorial Hospital, New Taipei City, Taiwan
- Institute of Biomedical Sciences, MacKay Medical College, New Taipei City, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chi-Yu Huang
- Department of Pediatric Endocrinology, MacKay Children’s Hospital, Taipei, Taiwan
| | - Yi-Lei Wu
- Department of Pediatric Endocrinology and Metabolism, Chuanghua Christian Childrens Hospital, Changhua, Taiwan
| | - Lu-Ting Wang
- Department of Pediatric Endocrinology, MacKay Children’s Hospital, Taipei, Taiwan
| | - Chao-Hsu Lin
- Department of Pediatric Endocrinology, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Bi-Wen Cheng
- Department of Pediatric Endocrinology, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Fu-Sung Lo
- Department of Pediatric Endocrinology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Jun Chang
- Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Hsin Ting
- Department of Pediatric Endocrinology, MacKay Children’s Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
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Mason A, Crowe E, Haragan B, Smith S, Kyriakou A. Gender Dysphoria in Young People: A Model of Chronic Stress. Horm Res Paediatr 2023; 96:54-65. [PMID: 34673639 DOI: 10.1159/000520361] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gender dysphoria (GD) refers to the distress that may accompany gender incongruence, often heightened at the onset of puberty, with the development of secondary sex characteristics. Children and adolescents may be especially vulnerable to severe stressors, including GD, with potentially irreversible effects if these exposures occur during critical periods of development and brain maturation. SUMMARY We describe the evidence for GD as a chronic stressor, drawing parallels to other established models of stress, activating both innate psychological and biological stress responses. As well as being an inherently distressing experience, a person who experiences GD may also experience minority stress. Minority stress has been demonstrated in young people who experience GD with higher rates of social rejection and internalized stigma and shame. The biological stress response in young people with GD is illustrated through the activation of the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and pro-inflammatory response. The number of young people who report experiencing GD has increased exponentially worldwide in the past decade, demanding a change in the clinic infrastructure. Paediatric endocrinologists and specialists in mental health work together to both support psychosocial well-being and offer individualized treatment to align the phenotype with gender identity with the aim of alleviating the distress of GD. Medical interventions may include puberty suppression and gender-affirming hormones. Ongoing monitoring is required prior to initiation and during treatment to ensure that the goals of treatment are being achieved.
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Affiliation(s)
- Avril Mason
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK
| | - Eimear Crowe
- Young People's Gender Service, Sandyford Services, Glasgow, UK
| | - Beccy Haragan
- Young People's Gender Service, Sandyford Services, Glasgow, UK
| | - Simon Smith
- Young People's Gender Service, Sandyford Services, Glasgow, UK
| | - Andreas Kyriakou
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK.,Department of Paediatric Endocrinology, Makarios Children's Hospital, Nicosia, Cyprus
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Stolk THR, Asseler JD, Huirne JAF, van den Boogaard E, van Mello NM. Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 87:102312. [PMID: 36806443 DOI: 10.1016/j.bpobgyn.2023.102312] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/30/2022] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
The decision to pursue one's desire for children is a basic human right. For transgender and gender-diverse (TGD) people, gender-affirming care may alter the possibilities to fulfill one's desire for children due to the impact of this treatment on their reproductive organs. We systematically included 76 studies of varying quality describing the desire for children and parenthood; fertility counseling and utilization; and fertility preservation options and outcomes in TGD people. The majority of TGD people expressed a desire for children. Fertility preservation utilization rates were low as there are many barriers to pursue fertility preservation. The most utilized fertility preservation strategies include oocyte vitrification and sperm banking through masturbation. Oocyte vitrification showed successful outcomes, even after testosterone cessation. Sperm analyses when banking sperm showed a lower quality compared to cis male samples even prior to gender-affirming hormone treatment and an uncertain recovery of spermatogenesis after discontinuing treatment.
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Affiliation(s)
- T H R Stolk
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - J D Asseler
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - E van den Boogaard
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N M van Mello
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
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Dela Cruz C, Kinnear HM, Hashim PH, Wandoff A, Nimmagadda L, Chang FL, Padmanabhan V, Shikanov A, Moravek MB. A mouse model mimicking gender-affirming treatment with pubertal suppression followed by testosterone in transmasculine youth. Hum Reprod 2023; 38:256-265. [PMID: 36484619 PMCID: PMC10167862 DOI: 10.1093/humrep/deac257] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/04/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Can mice serve as a translational model to examine the reproductive consequences of pubertal suppression with GnRH agonist (GnRHa) followed by testosterone (T) administration, a typical therapy in peripubertal transmasculine youth? SUMMARY ANSWER An implanted depot with 3.6 mg of GnRHa followed by T enanthate at 0.45 mg weekly can be used in peripubertal female mice for investigating the impact of gender-affirming hormone therapy in transmasculine youth. WHAT IS KNOWN ALREADY There is limited knowledge available in transgender medicine to provide evidence-based fertility care, with the current guidelines being based on the assumption of fertility loss. We recently successfully developed a mouse model to investigate the reproductive consequences of T therapy given to transgender men. On the other hand, to our knowledge, there is no mouse model to assess the reproductive outcomes in peripubertal transmasculine youth. STUDY DESIGN, SIZE, DURATION A total of 80 C57BL/6N female mice were used in this study, with n = 7 mice in each experimental group. PARTICIPANTS/MATERIALS, SETTING, METHODS We first assessed the effectiveness of GnRHa in arresting pubertal development in the female mice. In this experiment, 26-day-old female mice were subcutaneously implanted with a GnRHa (3.6 mg) depot. Controls underwent a sham surgery. Animals were euthanized at 3, 9, 21 and 28 days after the day of surgery. In the second experiment, we induced a transmasculine youth mouse model. C57BL/6N female mice were subcutaneously implanted with a 3.6 mg GnRHa depot on postnatal day 26 for 21 days and this was followed by weekly injections of 0.45 mg T enanthate for 6 weeks. The control for the GnRH treatment was sham surgery and the control for T treatment was sesame oil vehicle injections. Animals were sacrificed 0.5 weeks after the last injection. The data collected included the day of the vaginal opening and first estrus, daily vaginal cytology, weekly and terminal reproductive hormones levels, body/organ weights, ovarian follicular distribution and corpora lutea (CL) counts. MAIN RESULTS AND THE ROLE OF CHANCE GnRHa implanted animals remained in persistent diestrus and had reduced levels of FSH (P = 0.0013), LH (P = 0.0082) and estradiol (P = 0.0155), decreased uterine (P < 0.0001) and ovarian weights (P = 0.0002), and a lack of CL at 21 days after GnRHa implantation. T-only and GnRHa+T-treated animals were acyclic throughout the treatment period, had sustained elevated levels of T, suppressed LH levels (P < 0.0001), and an absence of CL compared to controls (P < 0.0001). Paired ovarian weights were reduced in the T-only and GnRHa+T groups compared with the control and GnRHa-only groups. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION Although it is an appropriate tool to provide relevant findings, precaution is needed to extrapolate mouse model results to mirror human reproductive physiology. WIDER IMPLICATIONS OF THE FINDINGS To our knowledge, this study describes the first mouse model mimicking gender-affirming hormone therapy in peripubertal transmasculine youth. This model provides a tool for researchers studying the effects of GnRHa-T therapy on other aspects of reproduction, other organ systems and transgenerational effects. The model is supported by GnRHa suppressing puberty and maintaining acyclicity during T treatment, lower LH levels and absence of CL. The results also suggest GnRHa+T therapy in peripubertal female mice does not affect ovarian reserve, since the number of primordial follicles was not affected by treatment. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Michigan Institute for Clinical and Health Research grants KL2 TR 002241 and UL1 TR 002240 (C.D.C.); National Institutes of Health grants F30-HD100163 and T32-HD079342 (H.M.K.); University of Michigan Office of Research funding U058227 (A.S.); American Society for Reproductive Medicine/Society for Reproductive Endocrinology and Infertility grant (M.B.M.); and National Institutes of Health R01-HD098233 (M.B.M.). The University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core Facility was supported by the Eunice Kennedy Shriver NICHD/NIH grants P50-HD028934 and R24-HD102061. The authors declare that they have no competing interests.
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Affiliation(s)
- Cynthia Dela Cruz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Postdoctoral Translational Scholar Program, Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Hadrian M Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, USA
| | - Prianka H Hashim
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Abigail Wandoff
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Likitha Nimmagadda
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Faith L Chang
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Ariella Shikanov
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Wu W, Zhu X, Chen Y, Yang X, Zhang Y, Chen R. Development and validation of a model for predicting the adult height of girls with idiopathic central precocious puberty. Eur J Pediatr 2023; 182:1627-1635. [PMID: 36708384 DOI: 10.1007/s00431-023-04842-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/07/2023] [Accepted: 01/21/2023] [Indexed: 01/29/2023]
Abstract
UNLABELLED The aim was to develop a model to predict the adult height (AH) of idiopathic central precocious puberty (ICPP) girls who underwent gonadotropin-releasing hormone analog (GnRHa) treatment. Data analysis included 258 girls with ICPP. Among them, 101 girls who reached final AH (FAH) with GnRHa treatment were analyzed to verify three previous prediction models and develop a unique model based on multiple linear regression. The control group consisted of 41 untreated ICPP girls. Moreover, 116 girls treated with GnRHa who almost attained FAH were included for external validation. Based on our cohorts, all of the three previously published models underestimated the FAH with an R of 0.667, 0.793, and 0.664. The AH prediction model was built as follows: Calculated AH (cm) = 1.89630 * Height SDS + 2.29927 * Height SDS for bone age + 0.40776 * Target height + 100.16684 (R2 = 0.66 and adjusted R2 = 0.65). Internal validation showed a mean root mean squared error (RMSE) of 2.16 cm and a mean absolute error (MAE) of 1.64 cm. External validation showed that a significant error (> 1 SD) appeared only in 7 of 116 girls (6.0%). The model is displayed on the website: http://cpppredict.shinyapps.io/dynnomapp . CONCLUSION A model for predicting the AH of girls with ICPP was developed incorporating the variables of height SDS, height SDS for bone age, and target height. The internal and external validation ensures an appropriate degree of discrimination and calibration of the prediction model. WHAT IS KNOWN • Uncertainty prevails as how to predict the adult height of patients with central precocious puberty following gonadotropin-releasing hormone analog treatment. • Previous models for predicting adult height of girls with idiopathic central precocious puberty have not been proven translational to the Chinese population. WHAT IS NEW • This study develops a new model for predicting the adult height of idiopathic central precocious puberty girls who underwent gonadotropin-releasing hormone analog treatment. • The internal and external validation assures a good degree of discrimination and calibration of the prediction model in this study.
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Affiliation(s)
- Wenyong Wu
- Fuzhou Children's Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaoyun Zhu
- Fuzhou Children's Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yun Chen
- Fuzhou Children's Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaohong Yang
- Fuzhou Children's Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Ying Zhang
- Fuzhou Children's Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Ruimin Chen
- Fuzhou Children's Hospital of Fujian Medical University, Fuzhou, Fujian, China.
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Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review. Eur Urol Focus 2023; 9:35-41. [PMID: 36396559 DOI: 10.1016/j.euf.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/16/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT Gonadotropin-releasing hormone analogues (GnRHAs) delay the progression of puberty in transgender and nonbinary (TGNB) adolescents and reduce the impact of dysphoria due to ongoing physical development. The intervention remains contentious despite growing evidence to support this practice. OBJECTIVE To stimulate discussion on this topical issue in the urological and gynaecological community given potential ramifications for future fertility, physical development, and options for gender affirmation surgery (GAS). EVIDENCE ACQUISITION We conducted searches of the MEDLINE (from 1946) and Embase (from 1974) databases for the benefits and potential challenges of hormone blockade in TGNB adolescents on February 1, 2022. Evidence with a primary focus on clinical issues of interest to urologists and gynaecologists was objectively synthesised and reported. EVIDENCE SYNTHESIS The onset of puberty represents a period of distress for TGNB adolescents as secondary sexual characteristics develop. GnRHAs are prescribed to inhibit sex hormone production, but the decision to treat should be balanced against the known (and unknown) adverse effects. Fertility preservation is more likely to be successful if GnRHA treatment is delayed for as long as possible. Some adolescents may decide to stop GnRHA use to harvest spermatozoa or oocytes before starting gender-affirming hormone treatment. Transfeminine individuals should consider that options for genital GAS may become more limited, as vaginoplasty with penile skin inversion requires an adequate stretched penile length. Transmasculine individuals may no longer require chest reconstruction for breast development. CONCLUSIONS Offers of GnRHA treatment to TGNB adolescents should be balanced by careful preparation and counselling. Urologists and gynaecologists can complement the expertise of specialist psychosocial and adolescent endocrinology teams, and should be involved early in and throughout the treatment pathway to maximise future functional and surgical outcomes. PATIENT SUMMARY Puberty blockers for transgender and nonbinary adolescents have benefits, but timing is important to preserve fertility and surgical options.
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Zurita-Cruz JN, Villasís-Keever MA, Manuel-Apolinar L, Damasio-Santana L, Garrido-Magaña E, Rivera-Hernández ADJ. Leptin/adiponectin ratio as a prognostic factor for increased weight gain in girls with central precocious puberty. Front Endocrinol (Lausanne) 2023; 14:1101399. [PMID: 36967781 PMCID: PMC10036755 DOI: 10.3389/fendo.2023.1101399] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
OBJECTIVE To determine if the leptin, adiponectin, and leptin/adiponectin ratio (LAR) can predict weight gain at the end of GnRH analogs (GnRHa) treatment in girls with central precocious puberty (CPP). MATERIAL AND METHODS Study design: prospective cohort. Serum levels of leptin and adiponectin were determined at diagnosis of CPP. Anthropometry was performed at diagnosis of CPP and every six-months, until treatment with GnRHa was discontinued and they presented menarche. Patients were divided according to BMI<94 and BMI>95 percentile at diagnosis of CPP. The outcome was the increased in weight gain (e.g., from normal weight to overweight) at the end of follow-up. Statistical analysis: repeated measures ANOVA test and Student's t-test were used to compare groups. Logistic regression analysis was used to evaluate the association of leptin and adiponectin levels, as well as LAR values with increased weight gain. RESULTS Fifty-six CPP patients were studied, 18 had BMI >95 percentile and 38 BMI <94 percentile. Of the 18 patients who initially had BMI >95th, two patients went from obesity to overweight, while among the 38 patients who started with BMI <94th, 21 (55.2%) increased their weight gain at the end of follow-up. This last group had higher leptin levels (8.99 ± 0.6 vs 6.14 ± 0.8, p=0.005) and higher LAR values compared to those who remained in the same weight (1.3 ± 0.5 vs 0.96 ± 0.56, p=0.01). In the logistic regression analysis, it was found that higher leptin levels and higher LAR values were associated with increased weight gain (RR 1.31, 95%CI 1.03-1.66, RR 4.86, 95%CI 1.10-21.51, respectively), regardless of birth weight, pubertal stage, age, and bone/chronological age ratio. CONCLUSIONS In patients with CPP, leptin levels and higher LAR values appear to be associated with significantly greater weight gain during GhRHa treatment, particularly in girls starting with BMI < 94 percentile.
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Affiliation(s)
- Jessie Nallely Zurita-Cruz
- Medicine Faculty of Autonomous National University, Clinical Research Department, Hospital Infantil de México Federico Gómez, Ciudad de Mexico, Mexico
| | - Miguel Angel Villasís-Keever
- Unit of Analysis and Synthesis of the Evidence, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
- *Correspondence: Miguel Angel Villasís-Keever,
| | - Leticia Manuel-Apolinar
- Department of Endocrinology Research, Hospital of Medical Specialties, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - Leticia Damasio-Santana
- Department of Endocrinology Research, Hospital of Medical Specialties, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - Eulalia Garrido-Magaña
- Department of Pediatric Endocrinology, Children’s Hospital, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - Aleida de Jesús Rivera-Hernández
- Department of Pediatric Endocrinology, Children’s Hospital, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
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The Role of Genetics in Central Precocious Puberty: Confirmed and Potential Neuroendocrine Genetic and Epigenetic Contributors and Their Interactions with Endocrine Disrupting Chemicals (EDCs). ENDOCRINES 2022. [DOI: 10.3390/endocrines3030035] [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
Despite the growing prevalence of central precocious puberty (CPP), most cases are still diagnosed as “idiopathic” due to the lack of identifiable findings of other diagnostic etiology. We are gaining greater insight into some key genes affecting neurotransmitters and receptors and how they stimulate or inhibit gonadotropin-releasing hormone (GnRH) secretion, as well as transcriptional and epigenetic influences. Although the genetic contributions to pubertal regulation are more established in the hypogonadotropic hypogonadism (HH) literature, cases of CPP have provided the opportunity to learn more about its own genetic influences. There have been clinically confirmed cases of CPP associated with gene mutations in kisspeptin and its receptor (KISS1, KISS1R), Delta-like noncanonical Notch ligand 1 (DLK1), and the now most commonly identified genetic cause of CPP, makorin ring finger protein (MKRN3). In addition to these proven genetic causes, a number of other candidates continue to be evaluated. After reviewing the basic clinical aspects of puberty, we summarize what is known about the various genetic and epigenetic causes of CPP as well as discuss some of the potential effects of endocrine disrupting chemicals (EDCs) on some of these processes.
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Marwa A, Misra M, Lopez X. Determinants of Bone Mineral Density in Transgender Youth. Transgend Health 2022; 7:213-218. [PMID: 36643057 PMCID: PMC9831245 DOI: 10.1089/trgh.2020.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Purpose We aimed to study determinants of bone health in transgender youth in anticipation of or shortly after initiating puberty suppression and/or gender-affirming hormone therapy. Methods This was a retrospective review of records of transgender adolescents in our institution between June 2014 and June 2019. Dual energy X-ray absorptiometry was used to assess bone mineral density (BMD). Baseline characteristics were collected and included in a multilinear regression model to assess determinants of lumbar spine (LS) BMD Z-scores adjusted for age and height and accounting for race. Welch's t-test was used to compare characteristics across genders. Results One hundred nineteen patient records were analyzed. Forty-six patients (38.7%) were assigned male at birth (AMAB) and 73 patients (61.3%) were assigned female at birth (AFAB). Mean (±standard deviation [SD]) age (years) was 14.7±2.6 for AMAB and 15.0±2.2 for AFAB. The adjusted LS BMD Z-score was lower in the AMAB population with a mean (+SD) of -0.605±1.42 compared with 0.043±1.09 in AFAB (p=0.010). In a multivariate model, AMAB gender, vitamin D deficiency, and lower body mass index (BMI) z-scores were determinants of lower LS BMD Z-scores (R 2=0.206). Age, race, ethnicity, insurance status, and Tanner stage were not determinants of BMD. However, post hoc analysis did show that pubertal status modified the results. Conclusion AMAB transgender adolescents have lower BMD compared with AFAB patients, before or shortly after starting puberty suppression and/or gender-affirming hormone therapy. Lower BMI and vitamin D deficiency were determinants of lower BMD. Further studies are needed to explore etiology for bone health discrepancy in this population.
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Affiliation(s)
- Albara Marwa
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ximena Lopez
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
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de Souza KBF, Veiga MSP, Martins GRF, da Silva AP, Fujita LGA, Tomé JM, Palhares HMDC, Borges MDF. Assessment of Gonadotropin Concentrations Stimulated by Gonadotropin-Releasing Hormone Analog by Electrochemiluminescence in Girls with Precocious Puberty and Premature Thelarche. Horm Res Paediatr 2022; 94:433-440. [PMID: 34933304 DOI: 10.1159/000521593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/18/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study is to determine the cutoff values of gonadotropin response to gonadotropin-releasing hormone analogs (GnRHas) corresponding to the activation of the hypothalamic-pituitary-gonadal axis that could differentiate central precocious puberty (CPP) from premature thelarche (PT) and using the electrochemiluminescence assay method. METHODS A total of 49 girls underwent the stimulation test with an intramuscular injection of 3.75 mg leuprolide acetate. Based on the clinical and laboratory characteristics, they were divided into two groups: CPP (n = 22) and PT (n = 27). Baseline estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were collected before GnRHa administration and LH and FSH at 60 and 120 min, respectively, after GnRHa administration. RESULTS The girls with CPP presented an increased height Z-score, advanced bone age, and higher baseline LH, FSH, estradiol, and LH/FSH ratio in relation to PT (p < 0.001). Stimulated LH differed significantly between the two groups, and the LH cutoff values were ≥4.29 IU/L (p < 0.001) and ≥3.95 IU/L at 60 and 120 min, respectively (p < 0.001). The LH peak was found at 60 min after stimulation. CONCLUSIONS The GnRHa test is effective in distinguishing CPP from PT, and a single sampling, at 60 min, with LH concentrations above 4.29 may be the parameter of choice with the advantage of greater convenience and practicality.
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Affiliation(s)
- Kamila Botelho Fernandes de Souza
- Medical Endocrinologist, Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Melyna Shayanne Pessôa Veiga
- Medical Endocrinologist, Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Gabriela Ráina Ferreira Martins
- Pediatric Endocrinologist Physician, Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Adriana Paula da Silva
- Nutritionist Collaborator, Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Lívia Grimaldi Abud Fujita
- Endocrinologist, Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Janaíne Machado Tomé
- Biomedical Collaborator, Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Heloísa Marcelina da Cunha Palhares
- Physician Collaborator in Pediatric Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
| | - Maria de Fátima Borges
- Associated Professor of Endocrinology, Department of Endocrinology and Metabology, Federal University of Triângulo Mineiro, Clinical Hospital, Uberaba, Brazil
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Abstract
PURPOSE OF REVIEW In this review, we have summarized the current data on the effect of sexual precocity and treatment with gonadotropin-releasing hormone analogues (GnRHa) on body composition. RECENT FINDINGS Higher body weight and weight gain in infancy and childhood may increase the risk of early puberty in girls. The relation between BMI and pubertal onset in boys is controversial. Current studies draw attention to the fact that a similar relationship may exist in boys too. Obesity prevalence is high among girls with central precocious puberty (CPP) and treatment with GnRHa has a different effect on BMI according to baseline body composition. Although BMI values of normal weight girls tend to increase under treatment, they return to normal following treatment. The few studies that have followed up body composition longitudinally in girls show a gradual increase in adiposity, decrease in muscle mass and bone mineral density during GnRHa treatment, whereas bone mass was preserved after treatment. Adequate data are not available in boys to determine the effect of GnRHa therapy on body composition. SUMMARY Body composition and fat distribution should be monitored longitudinally in patients with CPP treated with GnRHa to ascertain the long-term effects of therapy.
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Affiliation(s)
- Elmas Nazli Gonc
- Hacettepe University, Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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22
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Knific T, Lazarevič M, Žibert J, Obolnar N, Aleksovska N, Šuput Omladič J, Battelino T, Avbelj Stefanija M. Final adult height in children with central precocious puberty - a retrospective study. Front Endocrinol (Lausanne) 2022; 13:1008474. [PMID: 36531464 PMCID: PMC9757689 DOI: 10.3389/fendo.2022.1008474] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND/AIMS Central precocious puberty (CPP) is due to premature activation of the hypothalamic-pituitary-gonadal axis. It predominantly affects girls. CPP leads to lower final height (FH), yet the treatment benefit in girls between 6 and 8 years is equivocal. Our main goal was to evaluate the effects of gonadotropin-releasing hormone analog (GnRHa) on FH and identify factors that predict FH. METHODS In a retrospective study, children with CPP (12 boys, 81 girls) that reached FH were included. Their clinical data at diagnosis and up to their final height was compared by descriptive statistics among idiopathic (iCPP) (n=68) and non-idiopathic CPP (nCPP) and between GnRHa treated (n=48) and untreated (n=15) girls with iCPP. The treatment effect of body weight (BW) adjusted GnRHa dosing was evaluated. Univariate linear regression and step-wise multivariable regression including 48 girls with iCPP treated with GnRHa were performed to identify predicting factors for FH. RESULTS Children with idiopathic CPP (iCPP) reached higher FH (p=0.002) than children with non-idiopathic CPP. After the diagnosis, the treated group gained 7.0 cm more than the untreated group. Yet, attributable to individualized decision-making, the FH in both groups was comparable (161.5 cm in treated, 161.0 cm in untreated girls with iCPP), although the onset of menarche was 2.5 years earlier among untreated girls. BW-adjusted dosing suppressed peak luteinizing hormone (LH) below 4.5 IU/L in 95% of children; however, bone age further advanced during therapy in 38% of patients. Predicting factors revealed by multivariable regression were bone age at diagnosis, BMI SDS at diagnosis, LH basal, age at start and cessation of treatment, predicted adult height and target height. (R2 = 0.72). CONCLUSION Children with nCPP had worse FH outcome compared to iCPP despite similar CPP onset and therapeutic characteristics. Treatment by GnRHa using BW-adjusted dosing was effective in delaying menarche onset and reaching target height in girls with iCPP. Multiple factors affecting FH outcome indicated individualized decision-making regarding therapeutic intervention remains challenging. In the treated patients, among the factors that can be influenced, height at treatment cessation most significantly influenced the outcome.
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Affiliation(s)
- Taja Knific
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Melisa Lazarevič
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janez Žibert
- Centre for Health Informatics and Statistics, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Nika Obolnar
- Department of Infectious Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Nataša Aleksovska
- Department of Vascular Surgery, Izola General Hospital, Izola, Slovenia
| | - Jasna Šuput Omladič
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Magdalena Avbelj Stefanija
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- *Correspondence: Magdalena Avbelj Stefanija,
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23
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Popovic J, Geffner ME, Rogol AD, Silverman LA, Kaplowitz PB, Mauras N, Zeitler P, Eugster EA, Klein KO. Gonadotropin-releasing hormone analog therapies for children with central precocious puberty in the United States. Front Pediatr 2022; 10:968485. [PMID: 36268040 PMCID: PMC9577333 DOI: 10.3389/fped.2022.968485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
Gonadotropin-releasing hormone agonists (GnRHa's) are the standard treatment for children with central precocious puberty (CPP). We aim to present data on available GnRHa options with an easy-to-review table and discuss factors that influence treatment selection. Five GnRHa's are currently FDA-approved and prescribed in the US and published data suggest similar safety and efficacy profiles over the first year of treatment. One- and 3-month intramuscular (IM) leuprolide acetate (LA) have long-term safety and efficacy data and allow for flexible dosing. Six-month IM triptorelin pamoate offers a longer duration of treatment, but without long-term efficacy and outcome data. Six-month subcutaneous (SQ) LA combines a SQ route of injection and long duration of action but lacks long-term efficacy and outcome data. The 12-month SQ histrelin acetate implant avoids injections and offers the longest duration of action, but requires a minor surgical procedure with local or general anesthesia. Factors in treatment selection include route of administration, needle size, injection volume, duration of action, and cost. The current GnRHa landscape provides options with varying benefits and risks, allowing physicians and caregivers to select the most appropriate therapy based on the specific needs and concerns of the child and the caregiver. Agents have different advantages and disadvantages for use, with no one agent displaying superiority.
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Affiliation(s)
- Jadranka Popovic
- Department of Pediatric Endocrinology, Pediatric Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Mitchell E Geffner
- Department of Pediatric Endocrinology, Diabetes and Metabolism, The Saban Research Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Alan D Rogol
- Department of Pediatric Diabetes and Endocrinology, University of Virginia, Charlottesville, VA, United States
| | - Lawrence A Silverman
- Department of Pediatric Endocrinology, Goryeb Children's Hospital Atlantic Health, Morristown, NJ, United States
| | - Paul B Kaplowitz
- Department of Endocrinology, Children's National Hospital, Washington, DC, United States
| | - Nelly Mauras
- Department of Pediatrics, Nemours Children's Health System, Jacksonville, FL, United States
| | - Philip Zeitler
- Department of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Erica A Eugster
- Department of Pediatric Endocrinology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States
| | - Karen O Klein
- Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, San Diego, CA, United States
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24
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Beattie C. High court should not restrict access to puberty blockers for minors. JOURNAL OF MEDICAL ETHICS 2022; 48:71-76. [PMID: 33593872 DOI: 10.1136/medethics-2020-107055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 06/12/2023]
Abstract
Gender dysphoria (GD) is a clinically significant incongruence between expressed gender and assigned gender, with rapidly growing prevalence among children. The UK High Court recently conducted a judicial review regarding the service provision at a youth-focussed gender identity clinic in Tavistock. The high court adjudged it 'highly unlikely' that under-13s, and 'doubtful' that 14-15 years old, can be competent to consent to puberty blocker therapy for GD. They based their reasoning on the limited evidence regarding efficacy, the likelihood of progressing to cross-sex hormone therapy and the 'life-changing consequences' of puberty blockers. In this article, I offer two concurrent arguments to dispute their reasoning. First, I argue that minors can be competent to consent to puberty blockers for GD, because the decision to undergo puberty blocker therapy is no more complex or far-reaching than other medical decisions that we accept a child should be able to make. Second, I argue that-irrespective of competence-such legal restriction for all children fundamentally contradicts the central ethical tenet of child healthcare: best interests. For these two reasons, the high court should not restrict access to puberty blockers for competent GD children.
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Affiliation(s)
- Cameron Beattie
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
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25
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Luo X, Hou L, Zhong Y, You C, Yang Y, Wu X, Li P, Zhou S, Qiu W, Zhang H, Liu Y, Qian Y, Luo F, Cheng R, Hu Y, Gong H, Wang Q, Xu Z, Du H, Lu F, Fu J, Chen X, Wang W, Guo Z. An open label, multicenter clinical trial that investigated the efficacy and safety of leuprorelin treatment of central precocious puberty in Chinese children. Medicine (Baltimore) 2021; 100:e28158. [PMID: 34941067 PMCID: PMC8702188 DOI: 10.1097/md.0000000000028158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/18/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Leuprorelin is an analog of gonadotropin-releasing hormone that is used for the therapy of central precocious puberty (CPP). The aims of this prospective, open label, multicenter clinical trial were to establish its efficacy and safety during long-term use. METHODS Patients, who were all children, were treated with 1.88 to 3.75 mg leuprorelin subcutaneously once every 4 weeks for a total of 96 weeks between 2015 and 2018. The primary endpoint was the rate of occurrence of adverse events (AEs) and the secondary endpoint was no progression in the Tanner stage or regression by week 96 compared to baseline. RESULTS A total of 307 CPP patients, 305 (99.3%) females and 2 males (0.7%), completed the 96-weeks of treatment. Due to limited data for male patients, they are not discussed in the efficacy results. Treatment-emergent AEs (TEAEs) were reported for 252 (82.1%) patients, mostly (79.5%) being mild or moderate and only 33 (10.7%) of patients experienced TEAEs related to leuprorelin therapy. The most frequent (>2%) drug-related TEAEs were injection site induration (4.6%, 14/307) and vaginal bleeding (2.3%, 7/305). After treatment, 83.5% of patients had regression or no progression in the Tanner stage (95% confidence interval: 78.68%, 87.62%) and the majority had decreased gonadotropin-releasing hormone-stimulated peak luteinizing hormone and follicle-stimulating hormone concentrations, as well as reduced sex hormone concentrations and a reduction in the bone age/chronological age ratio compared to baseline. CONCLUSIONS The trial revealed that CPP was effectively treated in most patients who received leuprorelin for nearly 2 years. Any drug-related AEs were reported with low incidence (<5%) and were consistent with the known safety profile of leuprorelin. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (registration number: NCT02427958).
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Affiliation(s)
- Xiaoping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Ling Hou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Yan Zhong
- Department of Child Healthcare, Hunan Children's Hospital, Changsha, China
| | - Cheng You
- Department of Child Healthcare, Hunan Children's Hospital, Changsha, China
| | - Yu Yang
- Department of Endocrinology, Metabolism and Genetics, The Affiliated Children's Hospital of Nanchang University, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Xian Wu
- Department of Endocrinology, Metabolism and Genetics, The Affiliated Children's Hospital of Nanchang University, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shasha Zhou
- Department of Endocrinology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjuan Qiu
- Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Huiwen Zhang
- Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Ying Liu
- Department of Endocrinology, Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Ye Qian
- Department of Endocrinology, Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Feihong Luo
- Department of Endocrinology, Metabolism and Genetics, Children's Hospital of Fudan University, Shanghai, China
| | - Ruoqian Cheng
- Department of Endocrinology, Metabolism and Genetics, Children's Hospital of Fudan University, Shanghai, China
| | - Yuhua Hu
- Department of Pediatrics, Jiangsu Province Hospital, Nanjing, China
| | - Haihong Gong
- Department of Pediatrics, Jiangsu Province Hospital, Nanjing, China
| | - Qing Wang
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Zhuangjian Xu
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Hongwei Du
- Department of Pediatric Endocrinology, The First Bethune Hospital of Jilin University, Changchun, China
| | - Feiyu Lu
- Department of Pediatric Endocrinology, The First Bethune Hospital of Jilin University, Changchun, China
| | - Junfen Fu
- Department of Endocrinology, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xuefeng Chen
- Department of Endocrinology, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | | | - Ziheng Guo
- Takeda Medical Affairs, Takeda (China) International Trading Co., Ltd, Shanghai, China
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26
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Wilde M, Huguelet P, Alaniz VI. Transgender Medicine and Hormone Therapy: What the Gynecologist Needs to Know. Clin Obstet Gynecol 2021; 64:739-756. [PMID: 34292172 DOI: 10.1097/grf.0000000000000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The transgender community comprises individuals with diverse identities in both gender and sexual orientation. Unfortunately, many face discrimination and harassment within our society-including within the medical system. There is an overall lack of provider training in transgender specific health which has led to health disparities and inequities within this population. This chapter aims to elucidate the medical needs unique to transgender and gender nonconforming individuals and thus enable medical providers to meet those needs with competency and compassion.
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Affiliation(s)
- Melyssa Wilde
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
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27
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Chu ZL, Jiang H, Wu Q. Effect of gonadotropin-releasing hormone analogue treatment in improving final adult height of children with central precocious puberty or early and fast puberty: a Meta analysis. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1161-1168. [PMID: 34753549 PMCID: PMC8580025 DOI: 10.7499/j.issn.1008-8830.2108078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/26/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To systematically evaluate the effect of gonadotropin-releasing hormone analogue (GnRHa) treatment on the final adult height of children over 6 years of age with central precocious puberty (CPP) or early and fast puberty (EFP). METHODS PubMed, MEDLINE, Embase, Cochrane Library, CNKI, and Wanfang Data were searched for related articles on GnRHa treatment for children with CPP or EFP. Stata 12.0 software was used to perform a Meta analysis of related data. RESULTS A total of 10 studies were included, and the total sample size was 720 children, with 475 children in the GnRHa treatment group and 245 children in the control group. The Meta analysis showed that compared with the control group, the GnRHa treatment group had significantly better final adult height (WMD=3.30, 95%CI: 2.49-4.12, P<0.001), standard deviation score of final adult height (WMD=0.51, 95%CI: 0.29-0.73, P<0.001), and height gain (WMD=2.89, 95%CI: 2.17-3.60, P<0.001). No severe adverse events were reported in these studies. CONCLUSIONS GnRHa treatment is safe and effective in improving the final adult height of children over 6 years of age with CPP or EFP.
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Affiliation(s)
- Zhao-Le Chu
- Department of Pediatrics, Tongcheng People's Hospital of Anhui Province, Tongcheng, Anhui 231400, China
| | - Hui Jiang
- Department of Pediatrics, Tongcheng People's Hospital of Anhui Province, Tongcheng, Anhui 231400, China
| | - Qian Wu
- Department of Pediatrics, Tongcheng People's Hospital of Anhui Province, Tongcheng, Anhui 231400, China
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28
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Wu V, Zhao V, Issa R, Wilkes M, Wallach E, Rapaport R, Romero C, Yau M. Clinical findings influencing time to menarche post gonadotropin-releasing hormone agonist therapy in central precocious puberty. Ann Pediatr Endocrinol Metab 2021; 26:185-191. [PMID: 34015904 PMCID: PMC8505034 DOI: 10.6065/apem.2040220.110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/02/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study aimed to evaluate the time interval to menarche after gonadotropin-releasing hormone agonist (GnRHa) treatment in females with central precocious puberty (CPP) and to identify factors contributing to timing of menarche. METHODS We retrospectively reviewed medical records of 39 females with CPP who reached menarche after GnRHa treatment (leuprolide or histrelin). CPP diagnostic criteria were breast development at <8 years old, measurable pubertal luteinizing hormone and/or estradiol concentrations, and bone age advancement. Indications to treat were advanced bone age and psychosocial concerns. Descriptive summaries were reported as frequency and proportion for categorical variables and mean and standard deviation for continuous measures. Linear regression models were developed to evaluate the associations of clinical factors with the time interval to menarche. RESULTS Mean age was 9.4±1.6 years at treatment onset, and treatment duration was 2.2±1.4 years. Menarche occurred at 12.6±1.1 years, which was 1.04±0.5 years after treatment discontinuation. This was negatively associated with Tanner stage of breast development and bone age at treatment onset and change in bone age during treatment. No association was seen between time interval to menarche and treatment duration, medication, or body mass index. CONCLUSION We found the average time interval to menarche after GnRHa treatment in our population of female patients with CPP to be 1.04±0.5 years; this is in agreement with other reports. Tanner stage of breast development, bone age at treatment onset, and change in bone age were negatively associated with time interval to menarche. These data provide clinical correlates that assist providers during anticipatory guidance of patients with CPP after GnRHa treatment.
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Affiliation(s)
- Vickie Wu
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Address for correspondence: Vickie Wu Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1512, New York, NY 10029, USA
| | - Victoria Zhao
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rula Issa
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meredith Wilkes
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth Wallach
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Rapaport
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Romero
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mabel Yau
- Department of Pediatric Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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29
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Varimo T, Iivonen AP, Känsäkoski J, Wehkalampi K, Hero M, Vaaralahti K, Miettinen PJ, Niedziela M, Raivio T. Familial central precocious puberty: two novel MKRN3 mutations. Pediatr Res 2021; 90:431-435. [PMID: 33214675 DOI: 10.1038/s41390-020-01270-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Paternally inherited loss-of-function mutations in MKRN3 underlie central precocious puberty (CPP). We describe clinical and genetic features of CPP patients with paternally inherited MKRN3 mutations in two independent families. METHODS The single coding exon of MKRN3 was analyzed in three patients with CPP and their family members, followed by segregation analyses. Additionally, we report the patients' responses to GnRH analog treatment. RESULTS A paternally inherited novel heterozygous c.939C>G, p.(Ile313Met) missense mutation affecting the RING finger domain of MKRN3 was found in a Finnish girl with CPP (age at presentation 6 years). Two Polish siblings (a girl presenting with B2 at the age of 4 years and a boy with adult size testes at the age of 9 years) had inherited a novel heterozygous MKRN3 mutation c.1237_1252delGGAGACACATGCTTTT p.(Gly413Thrfs*63) from their father. The girls were treated with GnRH analogs, which exhibited suppression of the hypothalamic-pituitary-gonadal axis. In contrast, the male patient was not treated, yet he reached his target height. CONCLUSIONS We describe two novel MKRN3 mutations in three CPP patients. The first long-term data on a boy with CPP due to an MKRN3 mutation questions the role of GnRH analog treatment in augmenting adult height in males with this condition. IMPACT We describe the genetic cause for central precocious puberty (CPP) in two families. This report adds two novel MKRN3 mutations to the existing literature. One of the mutations, p.(Ile313Met) affects the RING finger domain of MKRN3, which has been shown to be important for repressing the promoter activity of KISS1 and TAC3. We describe the first long-term observation of a male patient with CPP due to a paternally inherited MKRN3 loss-of-function mutation. Without GnRH analog treatment, he achieved an adult height that was in accordance with his mid-parental target height.
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Affiliation(s)
- Tero Varimo
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
| | - Anna-Pauliina Iivonen
- Stem Cells and Metabolism Research Program, Research Program Unit, University of Helsinki, Helsinki, Finland
| | - Johanna Känsäkoski
- Stem Cells and Metabolism Research Program, Research Program Unit, University of Helsinki, Helsinki, Finland
| | - Karoliina Wehkalampi
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
| | - Matti Hero
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Vaaralahti
- Stem Cells and Metabolism Research Program, Research Program Unit, University of Helsinki, Helsinki, Finland
| | - Päivi J Miettinen
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
| | - Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Karol Jonscher's Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Taneli Raivio
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland. .,Stem Cells and Metabolism Research Program, Research Program Unit, University of Helsinki, Helsinki, Finland.
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30
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Zurita-Cruz JN, Villasís-Keever MA, Manuel-Apolinar L, Damasio-Santana L, Gutierrez-Gonzalez A, Wakida-Kusunoki G, Padilla-Rojas M, Maldonado-Rivera C, Garrido-Magaña E, Rivera-Hernández ADJ, Nishimura-Meguro E. Altered cardiometabolic profile in girls with central precocious puberty and adipokines: A propensity score matching analysis. Cytokine 2021; 148:155660. [PMID: 34334260 DOI: 10.1016/j.cyto.2021.155660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare cardiometabolic factors and adipokines between patients with recently diagnosed CPP and controls without CPP, paired by BMI Z scores (BMIz) and classified into girls with adequate nutritional status and girls who are overweight or obese. METHODS This cross-sectional study was performed from January 2012 to May 2015 at two tertiary care pediatric centers in Mexico City. We included female patients with idiopathic CPP without other chronic pathology and healthy controls. Patients were divided into groups, BMI < 85th and BMI ≥ 85th percentile, according to 2000 CDC Growth Charts. Anthropometric data and fasting plasma concentrations of lipids, glucose, insulin, and leptin were assessed. RESULTS There were 73 patients with CPP and 82 without CPP. Sixty-six patients were matched between the groups; no significant difference was noted between the groups according to zBMI. However, differences in the bone/chronological age relationship, birth weight and proportions in different Tanner stages were observed. Among girls with normal BMI, the percentage of body fat (24.6% vs 18.9%, p < 0.001), serum triglycerides (102.9 vs 54.3 mg/dl, p < 0.001), leptin (7.46 vs 5.4 ng/ml, p = 0.010) and free leptin (0.44 vs 0.29 ng/ml, p = 0.044) were higher in those with CPP; additionally, girls with CPP presented a higher proportion of hypertriglyceridemia. In the overweight/obese group, adiponectin levels were lower in girls with CPP (6.23 vs 7.28 pg/ml, p = 0.011). CONCLUSIONS Girls with CPP and normal BMI at diagnosis had a worse cardiometabolic profile, as reflected by higher levels of free leptin, and higher proportion of hypertriglyceridemia than girls without CPP.
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Affiliation(s)
- Jessie N Zurita-Cruz
- Clinical Research Department, Hospital Infantil de México Federico Gómez, and Medicine Faculty of Autonomous National University, Calle Doctor Márquez 162 Col. Doctores, C.P. 06720 Mexico City, Mexico; Unit of Nutrition, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, C.P. 06720 México City, Mexico.
| | - Miguel A Villasís-Keever
- Unit of Analysis and Synthesis of the Evidence, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, C.P. 06720 México City, Mexico.
| | - Leticia Manuel-Apolinar
- Department of Endocrinology Research, Hospital of Medical Specialties, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, CP 06720 México City, Mexico.
| | - Leticia Damasio-Santana
- Department of Endocrinology Research, Hospital of Medical Specialties, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, CP 06720 México City, Mexico.
| | - Alejandro Gutierrez-Gonzalez
- Computer Research Center of Instituto Politecnico Nacional, Av. Luis Enrique Erro S/N, Unidad Profesional Adolfo López Mateos, Zacatenco, C.P. 07738 Mexico City, Mexico.
| | - Guillermo Wakida-Kusunoki
- Pediatrics Service, South Central Hospital of High Specialty of Petroleos Mexicanos, Health Services of Petroleos Mexicanos, Anillo Periferico 4091, Col. Fuentes del Pedregal, Tlalpan, C.P. 14140 Mexico City, Mexico.
| | - Michel Padilla-Rojas
- Pediatrics Service, South Central Hospital of High Specialty of Petroleos Mexicanos, Health Services of Petroleos Mexicanos, Anillo Periferico 4091, Col. Fuentes del Pedregal, Tlalpan, C.P. 14140 Mexico City, Mexico.
| | - Cesar Maldonado-Rivera
- Pediatrics Service, South Central Hospital of High Specialty of Petroleos Mexicanos, Health Services of Petroleos Mexicanos, Anillo Periferico 4091, Col. Fuentes del Pedregal, Tlalpan, C.P. 14140 Mexico City, Mexico.
| | - Eulalia Garrido-Magaña
- Department of Pediatric Endocrinology, Children's Hospital, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, C.P. 06720 México City, Mexico.
| | - Aleida de J Rivera-Hernández
- Department of Pediatric Endocrinology, Children's Hospital, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, C.P. 06720 México City, Mexico.
| | - Elisa Nishimura-Meguro
- Department of Pediatric Endocrinology, Children's Hospital, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc 330, Col. Doctores, C.P. 06720 México City, Mexico.
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Robertsson C, Sävendahl L, Cardemil C. Primary chronic osteomyelitis of the jaw: Rapid improvement after hormonal suppression in a girl with precocious puberty. Bone Rep 2021; 14:101089. [PMID: 34026952 PMCID: PMC8131392 DOI: 10.1016/j.bonr.2021.101089] [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: 12/08/2020] [Revised: 04/09/2021] [Accepted: 05/01/2021] [Indexed: 11/11/2022] Open
Abstract
Primary chronic osteomyelitis (PCO) of the jaw is a non-infectious, inflammatory state of the jawbone of unknown etiology. In recurrent periods, these patients often exhibit swelling of the cheek, impaired ability to open their mouth as well as pain. Available treatments today include anti-inflammatory or antiresorptive drugs, hyperbaric oxygen, surgical decortication or resection followed by reconstruction where none of them have been described to lead to restored anatomy and complete relief of symptoms. We here report the unexpected complete regression of all clinical symptoms of PCO within three months after initiating pubertal suppression therapy with a gonadotropin-releasing hormone analogue in a 9-year-old girl with PCO of the jaw and early onset of pubertal development. Radiology of the jawbone confirmed complete PCO remission when performed 18 months after starting the hormone suppression therapy. To our knowledge, total regression of PCO in such a short period of time has not been described earlier suggesting an effect of the anti-hormonal therapy per se. In this case report, we discuss possible underlying mechanisms and hypothesize that anti-hormonal treatment could be a potential effective treatment in patients with PCO of the jaw.
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Affiliation(s)
- Caroline Robertsson
- Unit of Cranio- & Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Sävendahl
- Unit of Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Carina Cardemil
- Unit of Cranio- & Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Kremen J, Williams C, Barrera EP, Harris RM, McGregor K, Millington K, Guss C, Pilcher S, Tishelman AC, Baskaran C, Carswell J, Roberts S. Addressing Legislation That Restricts Access to Care for Transgender Youth. Pediatrics 2021; 147:peds.2021-049940. [PMID: 33883246 DOI: 10.1542/peds.2021-049940] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Carly Guss
- Boston Children's Hospital, Boston, Massachusetts
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Claahsen - van der Grinten H, Verhaak C, Steensma T, Middelberg T, Roeffen J, Klink D. Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up. Eur J Pediatr 2021; 180:1349-1357. [PMID: 33337526 PMCID: PMC8032627 DOI: 10.1007/s00431-020-03906-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 12/03/2022]
Abstract
Gender incongruence (GI) is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Awareness and more social acceptance have paved the way for early medical intervention about two decades ago and are now part of good clinical practice although much robust data is lacking. Medical and mental treatment in adolescents with GI is complex and is recommended to take place within a team of mental health professionals, psychiatrists, endocrinologists, and other healthcare providers. The somatic treatment generally consists of the use of GnRH analogues to prevent the progression of biological puberty and subsequently gender-affirming hormonal treatment to develop sex characteristics of the self-identified gender and surgical procedures. However to optimize treatment regimens, long-term follow-up and additional studies are still needed. What is known • The prevalence of gender dysphoria increased significantly in the past years and can lead to significant complaints and burdens especially during puberty. • Pubertal suppression and gender-affirmed treatment can be effectively used in adolescence with gender dysphoria. What is new • Transgender mental and medical healthcare is a long-lasting process during which not only the child/adolescent with GI but also their parents/family have to be counseled in making choices about their social, medical, and legal transitions. • There are an increasing number of transgender persons defining as nonbinary. Therefore, an individualized approach by an experienced team is necessary.
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Affiliation(s)
| | - Chris Verhaak
- Department of Medical Psychology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thomas Steensma
- Center of Expertise on Gender Dysphoria and Department of Medical Psychology, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - Tim Middelberg
- Department of plastic surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Joep Roeffen
- Genderteam South Netherlands, Mutsaersstichting, Venlo/Eindhoven, Netherlands
| | - Daniel Klink
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children’s Hospital, Antwerp, Belgium and Division of Pediatric Endocrinology, Department of Internal Medicine and Pediatrics, Ghent University Hospital and Ghent University, Ghent, Belgium
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Wijarn P, Poomthavorn P, Khlairit P, Pongratanakul S, Chailurkit L, Mahachoklertwattana P. Short-term effects of gonadotropin-releasing hormone analogue treatment on leptin, ghrelin and peptide YY in girls with central precocious puberty. J Pediatr Endocrinol Metab 2021; 34:479-484. [PMID: 33655737 DOI: 10.1515/jpem-2020-0470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 01/02/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine appetite-regulating hormone levels in girls with central precocious puberty (CPP) before and after 20 weeks of gonadotropin-releasing hormone analogue (GnRH-A) treatment. METHODS Eighteen newly diagnosed CPP girls were enrolled. Body composition measured by bioelectrical impedance analysis and GnRH-A test were performed with fasting serum leptin, ghrelin and peptide YY (PYY) measurements at baseline (before) and after 20 weeks of GnRH-A treatment. RESULTS Following GnRH-A treatment, all patients had prepubertal gonadotropin and estradiol levels. Mean (SD) fat mass index (FMI) was significantly increased from 4.5 (1.7) to 5.0 (1.8) kg/m2 after treatment. Also, median (IQR) serum leptin level was significantly increased from 6.9 (4.2-8.6) to 7.4 (5.3-13.1) ng/mL. FMI had a positive correlation with serum leptin level (r=0.64, p=0.004). In contrast, no significant changes of serum ghrelin and PYY levels were observed. CONCLUSIONS Decreased estrogen following short-term GnRH-A treatment in CPP girls may cause an increase in appetite and consequently an elevation of FMI. Increased serum leptin may be a result of having increased FMI secondary to an increase in appetite.
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Affiliation(s)
- Piyathida Wijarn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Preamrudee Poomthavorn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patcharin Khlairit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sarunyu Pongratanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Laor Chailurkit
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pat Mahachoklertwattana
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Martinerie L, de Mouzon J, Blumberg J, di Nicola L, Maisonobe P, Carel JC. Fertility of Women Treated during Childhood with Triptorelin (Depot Formulation) for Central Precocious Puberty: The PREFER Study. Horm Res Paediatr 2021; 93:529-538. [PMID: 33774631 PMCID: PMC8686727 DOI: 10.1159/000513702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gonadotropin-releasing hormone analogues (GnRHa) administered as depot formulations are the standard of care for children with central precocious puberty (CPP). Puberty resumes after treatment discontinuation, but little is known concerning fertility in women who have been treated with GnRHa for CPP during childhood. METHODS The PREFER (PREcocious puberty, FERtility) study prospectively analysed fertility, via a series of questionnaires, in women treated during childhood with triptorelin (depot formulation) for CPP. Co-primary endpoints were the proportion of women wanting a pregnancy any time before study inclusion and during the follow-up period but not pregnant 6 and 12 months after stopping contraception and the waiting time to pregnancy (WTP). RESULTS A total of 574 women were identified, and 194 women were included in the analysis. Although there were not enough data for primary endpoint assessment, few women (1.7%) reported issues with fertility or were unable to become pregnant despite trying to conceive. Most pregnancies (84.4%, 95% CI [67.2-94.7%]) occurred within 1 year of trying to conceive, in line with the WTP for women without previous CPP. CONCLUSION The results, based on a limited sample of patients, suggest that CPP treated with triptorelin does not negatively impact women's fertility in adulthood. These results need to be consolidated with a subsequent study performed when these women will have reached their mid-thirties.
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Affiliation(s)
- Laetitia Martinerie
- Université de Paris, AP-HP. Nord Université de Paris, Hôpital Universitaire Robert-Debré, Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Paris, France
- NeuroDiderot, INSERM, Université de Paris, Paris, France
| | | | | | | | | | - Jean-Claude Carel
- Université de Paris, AP-HP. Nord Université de Paris, Hôpital Universitaire Robert-Debré, Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Paris, France
- NeuroDiderot, INSERM, Université de Paris, Paris, France
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Abstract
Central precocious puberty (CPP) is due to the premature activation of the hypothalamic–pituitary–gonadal axis, which is responsible for the appearance of secondary sexual characteristics. It occurs before the age of 8 and 9 in girls and boys, respectively. CPP shows higher incidence in females than in males. Causes of CPP are similar in both sexes, but the idiopathic form is more frequent in girls, while organic forms are more frequent in males. Recent studies demonstrated a role of some genetic variants in the pathogenesis of CPP. The diagnostic evaluation based on accurate physical examination, assessment of the pituitary–gonadal axis, pelvic sonography in girls, and determination of bone age. Magnetic resonance of the central nervous system should be done in all boys and selected girls. Since the 1980s, pharmacologic treatment involves the use of gonadotropin-releasing hormone (GnRH) analogs. These drugs are characterized by few side effects and long-term safety. Many data are available on the outcome of GnRH analog treated female patients, while poor data are reported in boys. Adult height is improved in both sexes.
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Zhu S, Long L, Hu Y, Tuo Y, Li Y, Yu Z. GnRHa/Stanozolol Combined Therapy Maintains Normal Bone Growth in Central Precocious Puberty. Front Endocrinol (Lausanne) 2021; 12:678797. [PMID: 34177807 PMCID: PMC8221533 DOI: 10.3389/fendo.2021.678797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/19/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Gonadotropin-releasing hormone agonist (GnRHa) is the gold standard in the treatment of Central Precocious Puberty (CPP) with progressive puberty and accelerative growth. However, GnRHa treatment is reported to result in growth deceleration and prevents growth plate development which leads to a reduction in height velocity. Stanozolol (ST) has been used to stimulate growth in patients with delayed growth and puberty, nevertheless, the effects and mechanisms of ST on CPP with GnRHa treatment are currently unclear. METHODS AND RESULTS In the current study, we recorded the following vital observations that provided insights into ST induced chondrogenic differentiation and the maintenance of normal growth plate development: (1) ST efficiently prevented growth deceleration and maintained normal growth plate development in rats undergoing GnRHa treatment; (2) ST suppressed the inhibitory effect of GnRHa to promote chondrogenic differentiation; (3) ST induced chondrogenic differentiation through the activation of the JNK/c-Jun/Sox9 signaling pathway; (4) ST promoted chondrogenic differentiation and growth plate development through the JNK/Sox9 signaling pathway in vivo. CONCLUSIONS ST mitigated the inhibitory effects of GnRHa and promoted growth plate development in rats. ST induced the differentiation of chondrocytes and maintained normal growth plate development through the activation of JNK/c-Jun/Sox9 signaling. These novel findings indicated that ST could be a potential agent for maintaining normal bone growth in cases of CPP undergoing GnRHa treatment.
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Affiliation(s)
- Shunye Zhu
- Department of Pediatrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Shunye Zhu, ; Zhenhua Yu,
| | - Lingli Long
- Research Center of Translational Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yue Hu
- Research Center of Translational Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Tuo
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yubin Li
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhenhua Yu
- Department of Neurosurgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Shunye Zhu, ; Zhenhua Yu,
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Aka S, Abali S, Taskin A, Bengur F, Semiz S. Comparison of two different GnRH analogs' impact on final height in girls with early puberty: Triptorelin acetate vs. leuprolide acetate. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2020; 16:402-408. [PMID: 34084230 PMCID: PMC8126396 DOI: 10.4183/aeb.2020.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT GnRHa treatment has been a standard of care in progressive early puberty (EP). Choice of the GnRHa formulation is dependent on the preference of the clinician. OBJECTIVE To compare the effects of triptorelin acetate (TA) and leuprolide acetate (LA) on anthropometry in girls with EP. DESIGN A descriptive observational study. SUBJECTS AND METHODS Girls diagnosed with central EP and treated with GnRHa at least for one year were included; treated with TA (n=46) and LA (n=35). First year anthropometric response and final height were evaluated. RESULTS The mean age at the initiation of GnRHa treatment of girls was 8.5±0.5 years. The ratio of obesity and of overweight was 7.4 and 25.9%, respectively. In both TA and LA groups, anthropometric data of the patients at initiation and at the first year of treatment were similar. Although growth velocity was similar in each group, in LA group height SDS at the first year of the treatment showed a significant decrease (p=0.045), but not in TA group (p=0.317). No significant ΔBMI was observed with treatment. The differences between FH - PAH at initiation (height gain) in TA and LA groups were 2.9±4.7 and 4.0±5.8 cm, respectively (p=.316). Height gain per treatment year was 1.7±3.0 cm. CONCLUSIONS There was a significant decrease in height SDS at the first year of leuprolid treatment, but not in triptorelin. Although these two analogs show similar effects on treatment, a not significant but slightly better benefit in leuprolide was observed.
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Affiliation(s)
| | - S. Abali
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul, Turkey
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Mayhew AC, Gomez-Lobo V. Fertility Options for the Transgender and Gender Nonbinary Patient. J Clin Endocrinol Metab 2020; 105:5892794. [PMID: 32797184 PMCID: PMC7455280 DOI: 10.1210/clinem/dgaa529] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Comprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.
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Affiliation(s)
- Allison C Mayhew
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
- Correspondence and Reprint Requests: Veronica Gomez-Lobo, MD, National Institute of Child Health and Human Development, Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology, 10 Central Dr, Bldg 10, Rm 8N248, Bethesda, MD 20892, USA. E-mail:
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Fertility preservation options for transgender and gender-nonconforming individuals. Curr Opin Obstet Gynecol 2020; 31:170-176. [PMID: 30870185 DOI: 10.1097/gco.0000000000000537] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of the current state of knowledge of fertility risks of gender-affirming therapy, review fertility preservation options for transgender individuals and ways to minimize gender dysphoria during fertility treatment, and identify gaps in knowledge. RECENT FINDINGS Recent studies have corroborated older data that gender-affirming hormone therapy creates histopathological changes in the gonads; however, the newer data suggests that some function of the gametes may be preserved. One study in transgender men reported successful in-vitro maturation of testosterone-exposed oocytes with normal spindle structures, and recent studies in transgender women reveal early spermatogenesis in estradiol-exposed testes and some recovery of semen parameters following cessation of hormones. Particular attention has recently been given to fertility preservation in transgender adolescents, revealing unmet informational needs in this population and very few are actually pursuing fertility preservation, even with counseling. SUMMARY There is currently a paucity of data on the fertility effects of gender-affirming hormones, necessitating fertility preservation counseling prior to initiation of therapy. Several modifications can be made to fertility preservation protocols and procedures to decrease gender dysphoria or distress in transgender individuals, but outcome data is still lacking. Achieving high-quality data collection will likely require cooperation across multiple institutions.
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Lim KI, Lee HS, Hwang JS. Changes in body mass index in boys with central precocious puberty over 2 years of gonadotropin-releasing hormone agonist therapy. Ann Pediatr Endocrinol Metab 2020; 25:169-173. [PMID: 33017886 PMCID: PMC7538302 DOI: 10.6065/apem.1938176.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/04/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Gonadotropin-releasing hormone agonist (GnRHa) is a safe and effective therapy used to treat central precocious puberty (CPP). Although most studies have reported no significant difference in body mass index (BMI) in girls during and after GnRHa therapy, few studies have investigated changes in BMI in boys with CPP. This study evaluated the effects of GnRHa therapy on BMI in boys with CPP. METHODS This study included 75 boys with CPP at Ajou University Hospital between January 1, 2007 and December 31, 2016, who treated with leuprorelin acetate or triptorelin acetate every 4 weeks for at least 2 years. The subjects were divided into 3 groups according to BMI: normal weight, overweight, and obese. We analyzed the BMI standard deviation score (SDS) in each group before therapy and after 1 year and 2 years of therapy. RESULTS Of the 75 boys, 37 were in the normal weight group, 21 were in the overweight group, and 17 were in the obese group. Magnetic resonance imaging that was performed before treatment showed abnormal findings in 9 boys. The mean BMI SDS for all participants at initiation was 1.0±0.8, and that in the normal weight, overweight, and obese groups was 0.3±0.4, 1.3±0.1, and 1.9±0.3, respectively. There were no significant differences in BMI SDS in any group after 1 or 2 years of treatment. CONCLUSION The BMI SDS in boys with CPP did not significantly change over 2 years of GnRHa therapy.
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Affiliation(s)
- Kyung In Lim
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Hae Sang Lee
- Depar tment of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Jin Soon Hwang
- Depar tment of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea,Address for correspondence: Jin Soon Hwang, MD, PhD Division of Pediatric Endocrinology, Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5166 Fax: +82-31-249-5169 E-mail:
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Ethical issues involving fertility preservation for transgender youth. J Assist Reprod Genet 2020; 37:2453-2462. [PMID: 32780317 DOI: 10.1007/s10815-020-01873-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To investigate ethical issues associated with fertility preservation (FP) in transgender youth based on reports of patients and their parents. METHODS Our qualitative study involved in-person interviews with 54 subjects (35 patients and 19 parents). Interviews were audio recorded, transcribed, and verified. Each subject completed a demographic questionnaire, and each patient's medical chart was reviewed for additional information. We analyzed the data using inductive thematic content analysis. RESULTS Themes that emerged included a range of desires and ambivalence about having genetically related children, variability in understanding the potentially irreversible impact of gender affirming hormones (GAHs) on fertility, use of adoption, and the impact of age on decision-making. Subjects (patients and parents) noted barriers to FP, such as cost and insurance coverage. Several parents expressed concern that their transgender children may have future regret about not attempting FP. Both transgender youth and their parents felt FP was an important precaution. CONCLUSIONS Our study took advantage of the richness of personal narratives to identify ongoing ethical issues associated with fertility preservation in transgender youth. Transgender youth and their parents did not fully understand the process of FP, especially regarding the effects of GAHs, had fears that FP could reactivate gender dysphoria, and noted barriers to FP, such as cost, highlighting economic disparity and lack of justice. These findings highlight ethical issues involving the adequacy of informed consent and economic injustice in access to FP despite expressed interest in the topic.
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Park HK, Choo MS, Shim YS. Adult height after gonadotropin-releasing hormone agonist treatment in girls with early puberty: A meta-analysis. Clin Endocrinol (Oxf) 2020; 93:135-145. [PMID: 32392622 DOI: 10.1111/cen.14214] [Citation(s) in RCA: 2] [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: 12/01/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This analysis of previously published reports was performed to examine the effects of gonadotropin-releasing hormone (GnRH) agonist treatment on adult height and the factors associated with adult height outcomes. CONTEXT GnRH agonists are first-line agents in the treatment of precocious puberty. However, studies regarding the treatment effect on subjects with early puberty have reported inconsistent results. DESIGN A total of 14 studies identified from a search of electronic databases (AMED, EMBASE, MEDLINE and RISS) were included. Controlled studies with girls who developed puberty before 10 years of age and measurements of the adult heights of the subjects were selected. Studies using only long-acting GnRH agonists to suppress puberty were included. Adult height, duration of the treatment, age at the start of treatment and bone age advancement were analysed. RESULTS The mean age of the subjects ranged from 6.3 to 9.0 years. The meta-analysis showed a pooled mean difference in adult height of 3.2 cm and a 95% confidence interval of 1.3-5.1 cm. The height difference between the treated subjects and controls was significantly associated with the duration of treatment (P = .005) rather than the age at the start of treatment (P = .084) or the difference between bone age and chronological age (P = .427). CONCLUSIONS Administration of GnRH agonists in girls who develop early puberty and demonstrate advanced bone age may be effective for increasing adult height, especially if a sufficiently long treatment duration can be achieved.
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Affiliation(s)
- Hong Kyu Park
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Min Soo Choo
- Department of Urology, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Young Suk Shim
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
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Satitpatanapan P, Jaruratanasirikul S, Sriplung H. Menstrual cycle, reproductive function, body mass index, and metabolic profiles of women with former central precocious puberty: 10-20-year longitudinal cohort study in southern Thailand. J Pediatr Endocrinol Metab 2020; 33:933-940. [PMID: 32623380 DOI: 10.1515/jpem-2020-0019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/24/2020] [Indexed: 12/28/2022]
Abstract
Background In 2011, we described 64 girls diagnosed with central precocious puberty (CPP) during 1995-2009. In 2019, the former CPP patients were 16-30 years of age and had been followed-up for 6-20 years after cessation of gonadotropin-releasing hormone analog (GnRHa) treatment. Objectives To determine the menstrual cycle, reproductive function, and long-term sequelae of the former GnRHa-treated and untreated CPP patients. Methods Sixty-seven former CPP women diagnosed during January 1995 to December 2010 were evaluated in 2019 for current menstrual cycle and pregnancy rate and for general health status, weight, height, blood pressure, and metabolic profiles of glucose, lipids, insulin, and testosterone. Results In 2019, the former CPP women averaged 20.7 ± 2.7 years of age (range: 16.5-30). Eighty-three percent had a regular menstrual cycle. Of the 14 married women, six (43%) were fertile with 1-2 children. The untreated women had a significantly higher rate of obesity (BMI >25 kg/m2) than the GnRHa-treated women (72.1% vs. 36.6%, p < 0.01). Two women (3%) had polycystic ovary syndrome (PCOS). Fasting plasma glucose, serum high-density lipoprotein cholesterol (HDL-C), and testosterone levels were normal and similar between the GnRHa-treated and untreated participants. The serum insulin, cholesterol, triglyceride, low-density lipoprotein cholesterol (LDL-C), and homeostasis model assessment-insulin resistance (HOMA-IR) levels were higher in the untreated group than the GnRHa-treated group, but without significant differences. Conclusions At a 10-20-year follow-up, our former CPP patients had regular menstruation, normal reproductive function, and normal metabolic outcomes. The low prevalence of PCOS of 3% suggests that CPP is not a risk factor for PCOS, at least during early adulthood.
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Affiliation(s)
- Pitchaya Satitpatanapan
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Somchit Jaruratanasirikul
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Hutcha Sriplung
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Lasorella S, Porto R, Iezzi ML, Pistone C, Marseglia GL, Verrotti A, Brambilla I. Comparison of triptorelin acetate vs triptorelin pamoate in the treatment of Central precocious puberty (CPP): a retrospective study. Gynecol Endocrinol 2020; 36:338-340. [PMID: 31441342 DOI: 10.1080/09513590.2019.1655726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The aim of this study is to compare the clinical and biochemical outcomes of triptorelin acetate (TPA) versus triptorelin pamoate (TPP) treatment in girls with central precocious puberty. A total of 60 patients with idiopathic CPP were retrospectively recruited. Thirty girls were treated with triptorelin acetate 3.75 mg/month (TPA group) and thirty girls in a second group received triptorelin pamoate 3.75 mg/4 weeks (TPP group). Patient follow-up at 12 and 24 months included GnRH Test at 12 months and baseline LH at 24 months. Patients were monitored with pelvic ultrasound, X-Ray of the hand and wrist and anthropometric evaluations. A total of 60/60 girls showed a good response to both formulations. Significant reductions in basal and LH peaks, estradiol values, breast pubertal stage, progression of bone age and growth velocity rate after 12 months treatment were obtained in both groups, demonstrating the equivalence of the two formulations in regulating the hypothalamic-pituitary-gonadal (HPG) axis. Triptorelin pamoate provided a more effective and significant reduction in LH peak after 12 months in comparison with triptorelin acetate more effective in reducing ovarian volume and endometrial thickness. Both formulations were equivalent, even though the LH peak was significantly lower in girls treated with triptorelin pamoate.
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Affiliation(s)
- Stefania Lasorella
- Department of Pediatrics, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Rossella Porto
- Department of Pediatrics, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
| | - Maria Laura Iezzi
- Department of Pediatrics, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Carmelo Pistone
- Department of Pediatrics, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Ilaria Brambilla
- Department of Pediatrics, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
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Bangalore Krishna K, Fuqua JS, Rogol AD, Klein KO, Popovic J, Houk CP, Charmandari E, Lee PA, Freire AV, Ropelato MG, Yazid Jalaludin M, Mbogo J, Kanaka-Gantenbein C, Luo X, Eugster EA, Klein KO, Vogiatzi MG, Reifschneider K, Bamba V, Garcia Rudaz C, Kaplowitz P, Backeljauw P, Allen DB, Palmert MR, Harrington J, Guerra-Junior G, Stanley T, Torres Tamayo M, Miranda Lora AL, Bajpai A, Silverman LA, Miller BS, Dayal A, Horikawa R, Oberfield S, Rogol AD, Tajima T, Popovic J, Witchel SF, Rosenthal SM, Finlayson C, Hannema SE, Castilla-Peon MF, Mericq V, Medina Bravo PG. Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium. Horm Res Paediatr 2020; 91:357-372. [PMID: 31319416 DOI: 10.1159/000501336] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022] Open
Abstract
This update, written by authors designated by multiple pediatric endocrinology societies (see List of Participating Societies) from around the globe, concisely addresses topics related to changes in GnRHa usage in children and adolescents over the last decade. Topics related to the use of GnRHa in precocious puberty include diagnostic criteria, globally available formulations, considerations of benefit of treatment, monitoring of therapy, adverse events, and long-term outcome data. Additional sections review use in transgender individuals and other pediatric endocrine related conditions. Although there have been many significant changes in GnRHa usage, there is a definite paucity of evidence-based publications to support them. Therefore, this paper is explicitly not intended to evaluate what is recommended in terms of the best use of GnRHa, based on evidence and expert opinion, but rather to describe how these drugs are used, irrespective of any qualitative evaluation. Thus, this paper should be considered a narrative review on GnRHa utilization in precocious puberty and other clinical situations. These changes are reviewed not only to point out deficiencies in the literature but also to stimulate future studies and publications in this area.
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Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA,
| | - John S Fuqua
- Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Alan D Rogol
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Karen O Klein
- University of California, San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Jadranka Popovic
- Division of Pediatric Endocrinology, Pediatric Alliance, Pittsburgh, Pennsylvania, USA
| | - Christopher P Houk
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Peter A Lee
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
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Abstract
Gender affirming medical and surgical treatments affect the reproductive potential of transgender individuals. Prior to the development of assisted reproductive technologies (ART), genital gender-affirming surgery frequently eliminated a patient’s reproductive potential. Today, all patients should be counseled on their fertility preservation (FP) options before medical and surgical transition, yet this appears to seldom occur in practice. The following review is the result of a systematic literature search of PubMed, Medline and Google Scholar to identify current and future FP options, barriers to treatment patients face, practice patterns of transgender health care providers, and if there were any standardized counseling protocols. Options for transwomen at any point in their transition range from simply providing a semen sample to be used with assistive reproductive techniques to experimental techniques involving testicular cryopreservation followed by in vitro initiation of spermatogenesis. Transmen before and after starting hormone therapy can pursue any assistive reproductive techniques available for ciswomen. Future options currently under investigation include ovarian tissue cryopreservation (OTC) with in vitro oocyte maturation. In addition to counseling about their FP options, patients should be advised prospectively about the requirements, process details, the total costs associated with achieving pregnancy, and the inherent risks associated with using preserved genetic material including risk of failure, and maternal and fetal health risks. Transgender patients report using assistive reproductive services difficult, due to a lack of dialogue about fertility and the lack of information offered to them- presumably because their circumstances do not fit into a traditional narrative familiar to providers. Physicians and health care providers would benefit from better educational tools to help transgender patients make informed decisions and better training about transgender patients in general, and FP options available to them.
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Affiliation(s)
- Joshua Sterling
- Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Maurice M Garcia
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, Los Angeles, CA, USA.,Department of Urology, University of California San Francisco, San Francisco, CA, USA.,Department of Anatomy, University of California San Francisco, San Francisco, CA, USA
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Fu J, Zhang J, Chen R, Ma X, Wang C, Chen L, Liang Y, Luo X, Yang Y, Xiong F, Su Z, Wu J, Yao H, Xu J, Wu D, Ni Y. Long-Term Outcomes of Treatments for Central Precocious Puberty or Early and Fast Puberty in Chinese Girls. J Clin Endocrinol Metab 2020; 105:dgz027. [PMID: 31702013 DOI: 10.1210/clinem/dgz027] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 10/04/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Gonadotropin-releasing hormone analogues (GnRHa) and recombinant human growth hormone (rhGH) have been widely used to treat idiopathic central precocious puberty (CPP) or early and fast puberty (EFP). However, large-scale studies to evaluate the treatment effects on final adult height (FAH) are still lacking. OBJECTIVE To assess the effects of long-term treatment for CPP/EFP on FAH and its main influencing factors. DESIGN AND SETTING Retrospective, multicenter observational study from 1998 to 2017. PARTICIPANTS Four hundred forty-eight Chinese girls with CPP/EFP received GnRHa and rhGH treatment (n = 118), GnRHa alone (n = 276), or no treatment (n = 54). MAIN OUTCOME MEASURES FAH, target height (Tht), and predictive adult height (PAH). RESULTS The height gain (FAH-PAH) was significantly different among the GnRHa and rhGH treatment, GnRHa alone, and no treatment groups (P < 0.05; 9.51 ± 0.53, 8.07 ± 0.37, and 6.44 ± 0.91 cm, respectively). The genetic height gain (FAH-Tht) was 4.0 ± 0.5 cm for the GnRHa + rhGH group and 2.0 ± 0.27 cm for the GnRHa group, while the control group reached their Tht. In addition, 5 critical parameters derived from PAH, bone age, and Tht, showed excellent performance in predicting which patients could gain ≥5 cm (FAH-PAH), and this was further validated using an independent study. CONCLUSIONS The overall beneficial effect of GnRHa + rhGH or GnRHa on FAH was significant. The control group also reached their genetic target height. Clinicians are recommended to consider both the potential gains in height and the cost of medication.
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Affiliation(s)
- Junfen Fu
- Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jianwei Zhang
- Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Shaoxing Women and Children's Hospital, Shaoxing, China
| | - Ruimin Chen
- Fuzhou Children's Hospital of Fujian, Fujian Medical University Teaching Hospital, Fuzhou, China
| | - Xiaoyu Ma
- Ruijin Hospital of Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chunlin Wang
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Linqi Chen
- Children's Hospital of Soochow University, Suzhou, China
| | - Yan Liang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoping Luo
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Yang
- Children's Hospital of Jiangxi Province, Nanchang, China
| | - Feng Xiong
- Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhe Su
- Shenzhen Children's Hospital, Shenzhen, China
| | - Jing Wu
- Lishui City People's Hospital, Lishui, China
| | - Hui Yao
- Wuhan Children's Hospital, Wuhan, China
| | - Jinliang Xu
- Shaoxing Women and Children's Hospital, Shaoxing, China
| | - Di Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yan Ni
- Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Naderi F, Soheilirad Z, Haghshenas Z. The Influence of Gonadotropin-Releasing Hormone Agonist Treatment on Thyroid Function Tests in Children with Central Idiopathic Precocious Puberty. Med Arch 2020; 73:101-103. [PMID: 31391696 PMCID: PMC6643324 DOI: 10.5455/medarh.2019.73.101-103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: In recent years, the treatment of idiopathic central precocious puberty using gonadotropin-releasing hormone agonist (GnRH) agonist has been considered as a common treatment. To date, there is not much information about the effect of GnRH agonist treatment on pediatric thyroid function. Aim: The aim of this study was to evaluate the influence of GnRH treatment on thyroid function tests in children with central idiopathic precocious puberty. Material and Methods: This cross-sectional study investigated 50 children with idiopathic precocious puberty treated with GnRH agonist, who were referred to Bahrami pediatric hospital, Tehran, Iran. Patients` height, weight, and symptoms of hypothyroidism were evaluated every two months. Thyroid function tests, T4 and thyroid-stimulating hormone (TSH), were reviewed every 6 months. Data were analyzed using SPSS Statistics, Version 18. Results: The majority of the children who participate in this study were female. 72% of children with central idiopathic precocious puberty had a significant increase in TSH level (P=0.002). In this group of patients, 66% and 6% had subclinical and clinical increases in thyroid function tests, respectively. The estimated time to thyroid dysfunction was 12.37 months. It is found that only 2% of patients showed thyroid dysfunction during the first 6 months of the treatment. Conclusion: The results of this study showed that more than 70% of children who were undergoing GnRH agonist treatment for central precocious puberty had impaired thyroid function (especially subclinical hypothyroidism). Therefore, evaluating thyroid function in children with precocious puberty who are under treating with GnRH agonist, would be reasonable; especially one year after initiating the treatment.
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Affiliation(s)
- Fariba Naderi
- Department of Endocrinology, Bahrami Pediatrics Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Soheilirad
- Department of Pediatrics, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Zahra Haghshenas
- Department of Endocrinology, Bahrami Pediatrics Hospital, Tehran University of Medical Sciences, Tehran, Iran
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50
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Vuralli D, Ozon ZA, Gonc EN, Alikasifoglu A, Kandemir N. Long-term effects of GnRH agonist treatment on body mass index in girls with idiopathic central precocious puberty. J Pediatr Endocrinol Metab 2020; 33:99-105. [PMID: 31804960 DOI: 10.1515/jpem-2019-0214] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/27/2019] [Indexed: 11/15/2022]
Abstract
Introduction Studies evaluating effects of gonadotropin-releasing hormone agonist (GnRHa) on weight and body-mass-index (BMI) in girls with idiopathic central precocious puberty (iCPP) include short-term effects. The aim of this study is to investigate changes in BMI during and 2 years after completion of GnRHa to determine the factors that may impact BMI in girls with iCPP. Methods Medical files of 138 girls who completed GnRHa were evaluated. All patients had weight and height measurements at the beginning and end of treatment, and 111 patients had anthropometric measurements 2 years after the completion of treatment. Results In the beginning, 82 (59.4%) had normal weight (NW), 42 (30.4%) were overweight (OW), and 14 (10.2%) were obese (OB). Analysis of BMI-standard deviation score (SDS) in the whole group showed an overall increase during GnRHa treatment (0.92 ± 0.74 vs. 1.20 ± 0.51, p < 0.001). Changes in BMI-SDS (ΔBMI-SDS) during GnRHa differed between NW and OW/OB (0.45 ± 0.31 vs. 0.03 ± 0.20, p < 0.001). BMI-SDSs of both groups returned to baseline scores (or initial levels) 2 years after the completion of treatment. Two factors affecting ΔBMI-SDS in multiple linear regression analyses were baseline BMI and Δheight-SDS, both correlated negatively with ΔBMI-SDS. Conclusions The present study is one of the studies evaluating BMI change over a long period of time in girls with CPP. Although BMI-SDS increased during GnRHa in NW girls, it was reversible in follow-up after treatment. However, BMI-SDS did not change during and in follow-up in OW/OB girls. Conserving BMI-SDS in OW/OB girls may be related to the fact that weight management programs were recommended for these patients. Dietary recommendations should be provided for children with NW who undergo GnRHa, as is the case for OW patients.
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Affiliation(s)
- Dogus Vuralli
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Zeynep Alev Ozon
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Elmas Nazli Gonc
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Ayfer Alikasifoglu
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Nurgun Kandemir
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
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