1
|
Jayasena CN, Devine K, Barber K, Comninos AN, Conway GS, Crown A, Davies MC, Ewart A, Seal LJ, Smyth A, Turner HE, Webber L, Anderson RA, Quinton R. Society for endocrinology guideline for understanding, diagnosing and treating female hypogonadism. Clin Endocrinol (Oxf) 2024. [PMID: 39031660 DOI: 10.1111/cen.15097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/18/2024] [Accepted: 05/27/2024] [Indexed: 07/22/2024]
Abstract
Female hypogonadism (FH) is a relatively common endocrine disorder in women of premenopausal age, but there are significant uncertainties and wide variation in its management. Most current guidelines are monospecialty and only address premature ovarian insufficiency (POI); some allude to management in very brief and general terms, and most rely upon the extrapolation of evidence from the studies relating to physiological estrogen deficiency in postmenopausal women. The Society for Endocrinology commissioned new guidance to provide all care providers with a multidisciplinary perspective on managing patients with all forms of FH. It has been compiled using expertise from Endocrinology, Primary Care, Gynaecology and Reproductive Health practices, with contributions from expert patients and a patient support group, to help clinicians best manage FH resulting from both POI and hypothalamo-pituitary disorders, whether organic or functional.
Collapse
Affiliation(s)
- Channa N Jayasena
- Section of Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Kerri Devine
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Katie Barber
- Community Gynaecology (NHS), Principal Medical Limited, Bicester, Oxfordshire, UK
- Oxford Menopause Ltd, Ardington, Wantage, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology & Metabolism, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Gerard S Conway
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Anna Crown
- Department of Endocrinology, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Melanie C Davies
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Ann Ewart
- Kallman Syndrome and Congenital Hypogonadotropic Hypogonadism Support Group, Dallas, Texas, United States
| | - Leighton J Seal
- Department of Endocrinology, St George's Hospital Medical School, London, UK
| | - Arlene Smyth
- UK Turner Syndrome Support Society, Clydebank, UK
| | - Helen E Turner
- Department of Endocrinology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lisa Webber
- Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore
| | - Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Richard Quinton
- Section of Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| |
Collapse
|
2
|
Choi E, Lee YJ, Kim HI, Kim H, Seo SK, Choi YS, Yun BH. Oral hormone replacement therapy and uterine volume in Korean adolescents with Turner syndrome: A retrospective case-control study. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00237-7. [PMID: 38906216 DOI: 10.1016/j.jpag.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 06/14/2024] [Accepted: 06/16/2024] [Indexed: 06/23/2024]
Abstract
STUDY OBJECTIVE We aimed to identify critical factors for uterine development by comparing uterine volume (UV) among patients with Turner syndrome (TS) who underwent pubertal induction (PI), patients with TS who had natural menarche (NM), and patients in a non-TS control group. METHODS This retrospective case-control study included patients with TS who had undergone PI with oral estrogen in a PI group(n=31) and a NM group(n=7). The control group included patients without TS with spontaneous puberty who underwent pelvic ultrasound at 16 years of age. For TS patients, both the UV from the first ultrasound performed at age 16 or older (1st-UV) and the UV from the most recent final ultrasound (final-UV) were obtained. RESULTS The 1st-UV was larger for patients in the NM group than those in the PI group (p<0.001), but did not differ significantly between the NM and control groups (p=0.375). The final-UV of the PI group was larger than their 1st-UV (p<0.001), but still smaller than the NM group (p=0.021). HRT duration and 1st-UV of PI group were positively correlated (p=0.048). There were no variables that were significantly correlated with final-UV of PI group. CONCLUSION Patients with TS who experienced NM showed normal uterine development, but TS patients who underwent PI showed significantly smaller, undeveloped UV. While HRT duration and UV are positively correlated at the beginning of HRT, it is unclear what determines the final UV; however, late PI initiation and use of oral estrogen probably contributed to the lack of UV development.
Collapse
Affiliation(s)
- Euna Choi
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yeon Ju Lee
- Bundang Cheil Women's Hospital, Seongnam, Korea
| | - Hye In Kim
- Department of Obstetrics and Gynecology, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Heeyon Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Kyo Seo
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sik Choi
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Bo Hyon Yun
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
3
|
Gravholt CH, Andersen NH, Christin-Maitre S, Davis SM, Duijnhouwer A, Gawlik A, Maciel-Guerra AT, Gutmark-Little I, Fleischer K, Hong D, Klein KO, Prakash SK, Shankar RK, Sandberg DE, Sas TCJ, Skakkebæk A, Stochholm K, van der Velden JA, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome. Eur J Endocrinol 2024; 190:G53-G151. [PMID: 38748847 DOI: 10.1093/ejendo/lvae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/19/2024] [Indexed: 06/16/2024]
Abstract
Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.
Collapse
Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sophie Christin-Maitre
- Endocrine and Reproductive Medicine Unit, Center of Rare Endocrine Diseases of Growth and Development (CMERCD), FIRENDO, Endo ERN Hôpital Saint-Antoine, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, United States
- eXtraOrdinarY Kids Clinic, Children's Hospital Colorado, Aurora, CO 80045, United States
| | - Anthonie Duijnhouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
| | - Aneta Gawlik
- Departments of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Andrea T Maciel-Guerra
- Area of Medical Genetics, Department of Translational Medicine, School of Medical Sciences, State University of Campinas, 13083-888 São Paulo, Brazil
| | - Iris Gutmark-Little
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
| | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, Ripseweg 9, 5424 SM Elsendorp, The Netherlands
| | - David Hong
- Division of Interdisciplinary Brain Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, CA 92123, United States
| | - Siddharth K Prakash
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | - Roopa Kanakatti Shankar
- Division of Endocrinology, Children's National Hospital, The George Washington University School of Medicine, Washington, DC 20010, United States
| | - David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
| | - Theo C J Sas
- Department the Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam 3015 CN, The Netherlands
- Department of Pediatrics, Centre for Pediatric and Adult Diabetes Care and Research, Rotterdam 3015 CN, The Netherlands
| | - Anne Skakkebæk
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Janielle A van der Velden
- Department of Pediatric Endocrinology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen 6500 HB, The Netherlands
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
| |
Collapse
|
4
|
Greene DN, Goldstein Z, Krasowski MD. Uncertainty in Hormone Monitoring of Transgender and Non-Binary People. J Appl Lab Med 2024; 9:426-429. [PMID: 38452237 DOI: 10.1093/jalm/jfae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Dina N Greene
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Zil Goldstein
- Callen-Lorde Community Health Center, New York, NY, United States
- City University of New York, Graduate School of Public Health & Health Policy, New York, NY, United States
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| |
Collapse
|
5
|
Dowlut-McElroy T, Kanakatti Shankar R. Hormone Replacement Therapy after Pubertal Induction in Adolescents and Young Adults with Turner Syndrome: A Survey Study. Horm Res Paediatr 2023; 97:62-69. [PMID: 37094554 DOI: 10.1159/000530724] [Citation(s) in RCA: 2] [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: 12/30/2022] [Accepted: 04/03/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Turner syndrome (TS) is associated with primary ovarian insufficiency (POI) and most adolescents and young adults (AYA) with TS require treatment with hormone replacement therapy (HRT). International consensus guidelines are unclear on the optimal formulation and dosing for HRT after pubertal induction. This study assessed current HRT practice patterns of endocrinologists and gynecologists in North America. METHODS Email listserv members of the North American Society for Pediatric and Adolescent Gynecology (NASPAG) and the Pediatric Endocrine Society (PES) were invited to complete a 19-question survey to assess HRT treatment preferences for the management of POI after completion of pubertal induction in AYA with TS. Descriptive analysis and multinomial logistic regression to predict factors associated with preferred HRT are presented. RESULTS 155 providers (79% pediatric endocrinology, 17% pediatric gynecology) completed the survey. Although 87% (135) reported confidence in prescribing HRT, only half (51%, 79) were aware of published guidelines. Factors significantly associated with preferred HRT included specialty (p = 0.032) and number of patients with TS seen every 3 months (p = 0.024). Gynecologists were 4 times less likely than endocrinologists to prefer hormonal contraceptives and 4 times more likely to favor transdermal estradiol dose of 100 μg/day as compared to lower doses. CONCLUSION Although most endocrinologists and gynecologists report confidence in prescribing HRT to AYA with TS after pubertal induction, there are clear differences in provider preferences based on specialty and higher volume of patients with TS in their practice. Additional studies on comparative effectiveness of the HRT regimens and evidence-based guidelines are necessary for AYA with TS.
Collapse
Affiliation(s)
- Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Roopa Kanakatti Shankar
- Division of Endocrinology, Children's National Hospital, Washington D.C., USA
- George Washington University School of Medicine, Washington D.C., USA
| |
Collapse
|
6
|
Eklund EA, Miller BS, Boucher AA. Thrombosis risk with estrogen use for puberty induction in congenital disorders of glycosylation. Mol Genet Metab 2023; 138:107562. [PMID: 37023501 DOI: 10.1016/j.ymgme.2023.107562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023]
Abstract
Congenital disorders of glycosylation are a group of rare related disorders causing multisystem dysfunction, including ovarian failure in females that requires early estrogen replacement. Glycosylation defects also disrupt normal synthesis of several coagulation factors, increasing thrombotic risks and complicating hormone replacement. This series describes four females with different types of CDG who developed venous thromboses while on transdermal estrogen replacement. The authors highlight the knowledge gaps around anticoagulation for this population and propose further investigations.
Collapse
Affiliation(s)
- Erik A Eklund
- Department of Pediatrics, Clinical Sciences, Lund University, Lund, Sweden
| | - Bradley S Miller
- Division of Pediatric Endocrinology, University of Minnesota, Minneapolis, MN, USA
| | - Alexander A Boucher
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA; Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA.
| |
Collapse
|
7
|
Hasegawa Y, Hasegawa T, Satoh M, Ikegawa K, Itonaga T, Mitani-Konno M, Kawai M. Pubertal induction in Turner syndrome without gonadal function: A possibility of earlier, lower-dose estrogen therapy. Front Endocrinol (Lausanne) 2023; 14:1051695. [PMID: 37056677 PMCID: PMC10088859 DOI: 10.3389/fendo.2023.1051695] [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: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 03/30/2023] Open
Abstract
Delayed and absent puberty and infertility in Turner syndrome (TS) are caused by primary hypogonadism. A majority of patients with TS who are followed at hospitals during childhood will not experience regular menstruation. In fact, almost all patients with TS need estrogen replacement therapy (ERT) before they are young adults. ERT in TS is administered empirically. However, some practical issues concerning puberty induction in TS require clarification, such as how early to start ERT. The present monograph aims to review current pubertal induction therapies for TS without endogenous estrogen production and suggests a new therapeutic approach using a transdermal estradiol patch that mimics incremental increases in circulating, physiological estradiol. Although evidence supporting this approach is still scarce, pubertal induction with earlier, lower-dose estrogen therapy more closely approximates endogenous estradiol secretion.
Collapse
Affiliation(s)
- Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Mari Satoh
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Kento Ikegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Clinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Tomoyo Itonaga
- Department of Pediatrics, Oita University Faculty of Medicine, Oita, Japan
| | - Marie Mitani-Konno
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Masanobu Kawai
- Department of Bone and Mineral Research, Research Institute, Osaka Women’s and Children’s Hospital, Osaka, Japan
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women’s and Children’s Hospital, Osaka, Japan
| |
Collapse
|
8
|
Jones L, Blair J, Hawcutt DB, Lip GYH, Shantsila A. Hypertension in Turner syndrome: a review of proposed mechanisms, management and new directions. J Hypertens 2023; 41:203-211. [PMID: 36583347 DOI: 10.1097/hjh.0000000000003321] [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: 12/31/2022]
Abstract
Acquired cardiovascular diseases account for much of the increased risk of premature death in patients with Turner syndrome (TS). Hypertension is a major modifiable cardiovascular risk factor. It has a high prevalence in TS developing at an early age and thus leading to prolonged exposure to high blood pressure. The aetiology for hypertension in TS is largely unknown. It is likely multifactorial, and recent hypotheses include altered sympathetic tone, vasculopathy and endocrine factors. In this review article we aim to provide a comprehensive review of data on mechanisms of hypertension in TS and their implication for diagnostics and optimal choice of antihypertensive treatments. Ultimately this knowledge should help prevent hypertension-related complications, and improve quality of life and life expectancy for patients with TS.
Collapse
Affiliation(s)
- Lily Jones
- Department of Women's and Children's Health, University of Liverpool
| | - Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| |
Collapse
|
9
|
Gravholt CH, Viuff M, Just J, Sandahl K, Brun S, van der Velden J, Andersen NH, Skakkebaek A. The Changing Face of Turner Syndrome. Endocr Rev 2023; 44:33-69. [PMID: 35695701 DOI: 10.1210/endrev/bnac016] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Indexed: 01/20/2023]
Abstract
Turner syndrome (TS) is a condition in females missing the second sex chromosome (45,X) or parts thereof. It is considered a rare genetic condition and is associated with a wide range of clinical stigmata, such as short stature, ovarian dysgenesis, delayed puberty and infertility, congenital malformations, endocrine disorders, including a range of autoimmune conditions and type 2 diabetes, and neurocognitive deficits. Morbidity and mortality are clearly increased compared with the general population and the average age at diagnosis is quite delayed. During recent years it has become clear that a multidisciplinary approach is necessary toward the patient with TS. A number of clinical advances has been implemented, and these are reviewed. Our understanding of the genomic architecture of TS is advancing rapidly, and these latest developments are reviewed and discussed. Several candidate genes, genomic pathways and mechanisms, including an altered transcriptome and epigenome, are also presented.
Collapse
Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark
| | - Mette Viuff
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark
| | - Jesper Just
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark
| | - Kristian Sandahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark
| | - Sara Brun
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark
| | - Janielle van der Velden
- Department of Pediatrics, Radboud University Medical Centre, Amalia Children's Hospital, 6525 Nijmegen, the Netherlands
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg 9000, Denmark
| | - Anne Skakkebaek
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200 N, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus 8200 N, Denmark
| |
Collapse
|
10
|
Dural O, Ulusoy HE, Tikiz MA, Gurbanova T, Yasa C, Ugurlucan FG, Akhan SE. Effects of Hormone Replacement Therapy on Low Bone Mineral Density in Adolescents and Young Women with Hypogonadism: Comparison of Oral and Transdermal 17 Beta-Estradiol Administration. J Pediatr Adolesc Gynecol 2022; 35:634-637. [PMID: 35644512 DOI: 10.1016/j.jpag.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To evaluate the effects of physiological dose 17 beta-estradiol (E2) replacement on low bone mineral density (BMD) and compare the results of oral and transdermal (TD) E2 administration in adolescents and young women with hypogonadism DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed the medical records of patients aged 15 to 24 years who were diagnosed with hypogonadism, who had begun receiving oral or TD E2 replacement, and whose initial dual-energy X-ray absorptiometry scan detected a lumbar spine BMD Z-score of -1 or lower between 2014 and 2018. The patients were divided into 2 groups according to the E2 route of administration as those who received 2 mg orally (Group 1) and 0.1 mg TD (Group 2). INTERVENTIONS None MAIN OUTCOME MEASURE: BMD scans of the patients at baseline and repeated within 2 years after E2 replacement RESULTS: In total, 43 patients who met the inclusion criteria were included in the study. Two groups did not differ for BMD scores at baseline. A significant improvement in BMD was observed with physiological dose E2 replacement in both groups. Mean BMD Z-score increased by +0.7 (95% CI, 0.47-0.93) in response to TD E2 administration, compared with +0.41 (95% CI, 0.25-0.58) during oral E2 replacement (P = .037). CONCLUSION We conclude that physiological dose E2 replacement, even within a short period of 2 years, has a significant beneficial effect on bone mass acquisition on the lumbar spine. Our study also demonstrates the possible superiority of TD E2 replacement over the oral route in increasing lumbar spine BMD.
Collapse
Affiliation(s)
- Ozlem Dural
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey.
| | - Hevra Ekin Ulusoy
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Muge Ates Tikiz
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Turkane Gurbanova
- Medical Park Gebze Hospital, Section of Obstetrics and Gynecology, Gebze, Kocaeli, Turkey
| | - Cenk Yasa
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Funda Gungor Ugurlucan
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| | - Suleyman Engin Akhan
- Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, Fatih, Istanbul, Turkey
| |
Collapse
|
11
|
Craciunas L, Zdoukopoulos N, Vinayagam S, Mohiyiddeen L. Hormone therapy for uterine and endometrial development in women with premature ovarian insufficiency. Cochrane Database Syst Rev 2022; 10:CD008209. [PMID: 36200708 PMCID: PMC9536017 DOI: 10.1002/14651858.cd008209.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Premature ovarian insufficiency (POI) is a clinical syndrome resulting from loss of ovarian function before the age of 40. It is a state of hypergonadotropic hypogonadism, characterised by amenorrhoea or oligomenorrhoea, with low ovarian sex hormones (oestrogen deficiency) and elevated pituitary gonadotrophins. POI with primary amenorrhoea may occur as a result of chromosomal and genetic abnormalities, such as Turner syndrome, Fragile X, or autosomal gene defects; secondary amenorrhoea may be iatrogenic after the surgical removal of the ovaries, radiotherapy, or chemotherapy. Other causes include autoimmune diseases, viral infections, and environmental factors; in most cases, POI is idiopathic. Appropriate replacement of sex hormones in women with POI may facilitate the achievement of near normal uterine development. However, the optimal effective hormone therapy (HT) regimen to maximise the reproductive potential for women with POI remains unclear. OBJECTIVES To investigate the effectiveness and safety of different hormonal regimens on uterine and endometrial development in women with POI. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in September 2021. We also checked references of included studies, and contacted study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) investigating the effect of various hormonal preparations on the uterine development of women diagnosed with POI. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary review outcome was uterine volume; secondary outcomes were endometrial thickness, endometrial histology, uterine perfusion, reproductive outcomes, and any reported adverse events. MAIN RESULTS We included three studies (52 participants analysed in total) investigating the role of various hormonal preparations in three different contexts, which deemed meta-analysis unfeasible. We found very low-certainty evidence; the main limitation was very serious imprecision due to small sample size. Conjugated oral oestrogens versus transdermal 17ß-oestradiol We are uncertain of the effect of conjugated oral oestrogens compared to transdermal 17ß-oestradiol (mean difference (MD) -18.2 (mL), 95% confidence interval (CI) -23.18 to -13.22; 1 RCT, N = 12; very low-certainty evidence) on uterine volume, measured after 12 months of treatment. The study reported no other relevant outcomes (including adverse events). Low versus high 17ß-oestradiol dose We are uncertain of the effect of a lower dose of 17ß-oestradiol compared to a higher dose of 17ß-oestradiol on uterine volume after three or five years of treatment, or adverse events (1 RCT, N = 20; very low-certainty evidence). The study reported no other relevant outcomes. Oral versus vaginal administration of oestradiol and dydrogesterone We are uncertain of the effect of an oral or vaginal administration route on uterine volume and endometrial thickness after 14 or 21 days of administration (1 RCT, N = 20; very low-certainty evidence). The study reported no other relevant outcomes (including adverse events). AUTHORS' CONCLUSIONS No clear conclusions can be drawn in this systematic review, due to the very low-certainty of the evidence. There is a need for pragmatic, well designed, randomised controlled trials, with adequate power to detect differences between various HT regimens on uterine growth, endometrial development, and pregnancy outcomes following the transfer of donated gametes or embryos in women diagnosed with POI.
Collapse
Affiliation(s)
| | | | - Suganthi Vinayagam
- Obstetrics and Gynaecology, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | | |
Collapse
|
12
|
Federici S, Goggi G, Quinton R, Giovanelli L, Persani L, Cangiano B, Bonomi M. New and Consolidated Therapeutic Options for Pubertal Induction in Hypogonadism: In-depth Review of the Literature. Endocr Rev 2022; 43:824-851. [PMID: 34864951 DOI: 10.1210/endrev/bnab043] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Indexed: 01/15/2023]
Abstract
Delayed puberty (DP) defines a retardation of onset/progression of sexual maturation beyond the expected age from either a lack/delay of the hypothalamo-pituitary-gonadal axis activation or a gonadal failure. DP usually gives rise to concern and uncertainty in patients and their families, potentially affecting their immediate psychosocial well-being and also creating longer term psychosexual sequelae. The most frequent form of DP in younger teenagers is self-limiting and may not need any intervention. Conversely, DP from hypogonadism requires prompt and specific treatment that we summarize in this review. Hormone therapy primarily targets genital maturation, development of secondary sexual characteristics, and the achievement of target height in line with genetic potential, but other key standards of care include body composition and bone mass. Finally, pubertal induction should promote psychosexual development and mitigate both short- and long-term impairments comprising low self-esteem, social withdrawal, depression, and psychosexual difficulties. Different therapeutic options for pubertal induction have been described for both males and females, but we lack the necessary larger randomized trials to define the best approaches for both sexes. We provide an in-depth and updated literature review regarding therapeutic options for inducing puberty in males and females, particularly focusing on recent therapeutic refinements that better encompass the heterogeneity of this population, and underlining key differences in therapeutic timing and goals. We also highlight persistent shortcomings in clinical practice, wherein strategies directed at "the child with delayed puberty of uncertain etiology" risk being misapplied to older adolescents likely to have permanent hypogonadism.
Collapse
Affiliation(s)
- Silvia Federici
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Giovanni Goggi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Richard Quinton
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals, Newcastle-upon-Tyne NE1 4LP, UK.,Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne NE1 4EP, UK
| | - Luca Giovanelli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Biagio Cangiano
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Marco Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| |
Collapse
|
13
|
Karppinen JE, Juppi HK, Hintikka J, Wiklund P, Haapala EA, Hyvärinen M, Tammelin TH, Aukee P, Kujala UM, Laukkanen J, Laakkonen EK. Associations of resting and peak fat oxidation with sex hormone profile and blood glucose control in middle-aged women. Nutr Metab Cardiovasc Dis 2022; 32:2157-2167. [PMID: 35752543 DOI: 10.1016/j.numecd.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Menopause may reduce fat oxidation. We investigated whether sex hormone profile explains resting fat oxidation (RFO) or peak fat oxidation (PFO) during incremental cycling in middle-aged women. Secondarily, we studied associations of RFO and PFO with glucose regulation. METHOD AND RESULTS We measured RFO and PFO of 42 women (age 52-58 years) with indirect calorimetry. Seven participants were pre- or perimenopausal, 26 were postmenopausal, and nine were postmenopausal hormone therapy users. Serum estradiol (E2), follicle-stimulating hormone, progesterone, and testosterone levels were quantified with immunoassays. Insulin sensitivity (Matsuda index) and glucose tolerance (area under the curve) were determined by glucose tolerance testing. Body composition was assessed with dual-energy X-ray absorptiometry; physical activity with self-report and accelerometry; and diet, with food diaries. Menopausal status or sex hormone levels were not associated with the fat oxidation outcomes. RFO determinants were fat mass (β = 0.44, P = 0.006) and preceding energy intake (β = -0.40, P = 0.019). Cardiorespiratory fitness (β = 0.59, P = 0.002), lean mass (β = 0.49, P = 0.002) and physical activity (self-reported β = 0.37, P = 0.020; accelerometer-measured β = 0.35, P = 0.024) explained PFO. RFO and PFO were not related to insulin sensitivity. Higher RFO was associated with poorer glucose tolerance (β = 0.52, P = 0.002). CONCLUSION Among studied middle-aged women, sex hormone profile did not explain RFO or PFO, and higher fat oxidation capacity did not indicate better glucose control.
Collapse
Affiliation(s)
- Jari E Karppinen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
| | - Hanna-Kaarina Juppi
- Gerontology Research Center and Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Jukka Hintikka
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Petri Wiklund
- Exercise Translational Medicine Center, Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China; Huawei Helsinki R&D Center, Huawei Technologies Ltd, Helsinki, Finland
| | - Eero A Haapala
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland; Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - Matti Hyvärinen
- Gerontology Research Center and Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | | | - Pauliina Aukee
- Department of Obstetrics and Gynecology, Central Finland Health Care District, Jyväskylä, Finland
| | - Urho M Kujala
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Jari Laukkanen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland; Department of Internal Medicine, Central Finland Healthcare District, Jyväskylä, Finland; Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Eija K Laakkonen
- Gerontology Research Center and Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| |
Collapse
|
14
|
Boogers LS, Wiepjes CM, Klink DT, Hellinga I, van Trotsenburg ASP, den Heijer M, Hannema SE. Transgender Girls Grow Tall: Adult Height Is Unaffected by GnRH Analogue and Estradiol Treatment. J Clin Endocrinol Metab 2022; 107:e3805-e3815. [PMID: 35666195 PMCID: PMC9387709 DOI: 10.1210/clinem/dgac349] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Transgender adolescents can receive gonadotropin-releasing hormone analogues (GnRH) and gender-affirming hormone therapy (GAHT), but little is known about effects on growth and adult height. This is of interest since height differs between sexes and some transgender girls wish to limit their growth. OBJECTIVE This work aims to investigate the effects of GnRHa and GAHT on growth, and the efficacy of growth-reductive treatment. METHODS This retrospective cohort study took place at a specialized tertiary gender clinic. A total of 161 transgender girls were treated with GnRHa and estradiol at a regular dose (2 mg) or high growth-reductive doses of estradiol (6 mg) or ethinyl estradiol (EE, 100-200 µg). Main outcome measures included growth, adult height, and the difference from predicted adult height (PAH) and target height. RESULTS Growth velocity and bone maturation decreased during GnRHa, but increased during GAHT. Adult height after regular-dose treatment was 180.4 ± 5.6 cm, which was 1.5 cm below PAH at the start GnRHa (95% CI, 0.2 cm to 2.7 cm), and close to target height (-1.1 cm; 95% CI, -2.5 cm to 0.3 cm). Compared to regular-dose treatment, high-dose estradiol and EE reduced adult height by 0.9 cm (95% CI, -0.9 cm to 2.8 cm) and 3.0 cm (95% CI, 0.2 cm to 5.8 cm), respectively. CONCLUSION Growth decelerated during GnRHa and accelerated during GAHT. After regular-dose treatment, adult height was slightly lower than predicted at start of GnRHa, likely due to systematic overestimation of PAH as described in boys from the general population, but not significantly different from target height. High-dose EE resulted in greater reduction of adult height than high-dose estradiol, but this needs to be weighed against possible adverse effects.
Collapse
Affiliation(s)
- Lidewij Sophia Boogers
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Department Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Chantal Maria Wiepjes
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Department Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Daniel Tatting Klink
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent, Oost-Vlaanderen 9000, Belgium
| | - Ilse Hellinga
- Department of Pediatrics, Zaans Medical Center, 1502DV Zaandam, Noord-Holland, the Netherlands
| | - Adrianus Sarinus Paulus van Trotsenburg
- Department of Pediatric Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Department Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Department Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Sabine Elisabeth Hannema
- Correspondence: S. E. Hannema, MD, PhD, Department of Pediatrics, Section Endocrinology, Amsterdam University Medical Centers, Amsterdam, the Netherlands, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
| |
Collapse
|
15
|
The Care of Adolescents and Young Adults with Turner Syndrome: A Pediatric and Adolescent Gynecology Perspective. J Pediatr Adolesc Gynecol 2022; 35:429-434. [PMID: 35272055 PMCID: PMC9288983 DOI: 10.1016/j.jpag.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 01/03/2022] [Accepted: 02/27/2022] [Indexed: 01/03/2023]
Abstract
Turner syndrome (TS) is caused by the absence of a part or whole X chromosome in a phenotypic female and has an estimated prevalence of 25-50/100,000 live-born females. The primary gynecologic manifestation of TS is primary ovarian insufficiency (POI), and the resulting hypoestrogenism and infertility are experienced by most individuals with TS. In this review, we summarize the recommendations for the care of adolescents and young adults with TS, with a focus on primary ovarian insufficiency in TS, hormone replacement therapy, fertility preservation, and pregnancy in TS.
Collapse
|
16
|
Auxological and Endocrinological Features in Children and Adolescents with Cystic Fibrosis. J Clin Med 2022; 11:jcm11144041. [PMID: 35887806 PMCID: PMC9323690 DOI: 10.3390/jcm11144041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 02/01/2023] Open
Abstract
Cystic fibrosis (CF) is a multisystem autosomal recessive disease caused by mutations that lead to deficient or dysfunctional CF transmembrane conductance regulator (CFTR) proteins. Patients typically present malnutrition resulting from the malabsorption of fundamental nutrients and recurring lung infections, with a progressive worsening of the respiratory function. For these reasons, the clinical management of CF requires a multidisciplinary team. From an endocrinological point of view, patients often present major complications, such as diabetes, bone disease, thyroid disorders, delayed growth and puberty, hypogonadism and infertility, which negatively affect their quality of life and, in some cases, significantly reduce life expectancy. These complications can arise as a direct result of CFTR dysfunction and/or as a consequence of a deterioration in the function of the organs affected. The objective of this review is to analyze all the possible endocrinological complications that can occur in patients with CF by evaluating the most recent papers in the literature.
Collapse
|
17
|
Fiot E, Alauze B, Donadille B, Samara-Boustani D, Houang M, De Filippo G, Bachelot A, Delcour C, Beyler C, Bois E, Bourrat E, Bui Quoc E, Bourcigaux N, Chaussain C, Cohen A, Cohen-Solal M, Da Costa S, Dossier C, Ederhy S, Elmaleh M, Iserin L, Lengliné H, Poujol-Robert A, Roulot D, Viala J, Albarel F, Bismuth E, Bernard V, Bouvattier C, Brac A, Bretones P, Chabbert-Buffet N, Chanson P, Coutant R, de Warren M, Demaret B, Duranteau L, Eustache F, Gautheret L, Gelwane G, Gourbesville C, Grynberg M, Gueniche K, Jorgensen C, Kerlan V, Lebrun C, Lefevre C, Lorenzini F, Manouvrier S, Pienkowski C, Reynaud R, Reznik Y, Siffroi JP, Tabet AC, Tauber M, Vautier V, Tauveron I, Wambre S, Zenaty D, Netchine I, Polak M, Touraine P, Carel JC, Christin-Maitre S, Léger J. Turner syndrome: French National Diagnosis and Care Protocol (NDCP; National Diagnosis and Care Protocol). Orphanet J Rare Dis 2022; 17:261. [PMID: 35821070 PMCID: PMC9277788 DOI: 10.1186/s13023-022-02423-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Turner syndrome (TS; ORPHA 881) is a rare condition in which all or part of one X chromosome is absent from some or all cells. It affects approximately one in every 1/2500 liveborn girls. The most frequently observed karyotypes are 45,X (40–50%) and the 45,X/46,XX mosaic karyotype (15–25%). Karyotypes with an X isochromosome (45,X/46,isoXq or 45,X/46,isoXp), a Y chromosome, X ring chromosome or deletions of the X chromosome are less frequent. The objective of the French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins) is to provide health professionals with information about the optimal management and care for patients, based on a critical literature review and multidisciplinary expert consensus. The PNDS, written by members of the French National Reference Center for Rare Growth and Developmental Endocrine disorders, is available from the French Health Authority website. Turner Syndrome is associated with several phenotypic conditions and a higher risk of comorbidity. The most frequently reported features are growth retardation with short adult stature and gonadal dysgenesis. TS may be associated with various congenital (heart and kidney) or acquired diseases (autoimmune thyroid disease, celiac disease, hearing loss, overweight/obesity, glucose intolerance/type 2 diabetes, dyslipidemia, cardiovascular complications and liver dysfunction). Most of the clinical traits of TS are due to the haploinsufficiency of various genes on the X chromosome, particularly those in the pseudoautosomal regions (PAR 1 and PAR 2), which normally escape the physiological process of X inactivation, although other regions may also be implicated. The management of patients with TS requires collaboration between several healthcare providers. The attending physician, in collaboration with the national care network, will ensure that the patient receives optimal care through regular follow-up and screening. The various elements of this PNDS are designed to provide such support.
Collapse
Affiliation(s)
- Elodie Fiot
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Bertille Alauze
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Bruno Donadille
- Department of Reproductive Endocrinology, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Dinane Samara-Boustani
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Université de Paris, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Muriel Houang
- Explorations Fonctionnelles Endocriniennes, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Armand-Trousseau Hospital, 75012, Paris, France
| | - Gianpaolo De Filippo
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Anne Bachelot
- Endocrinology and Reproductive Medicine Department, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pitié Salpétrière University Hospital, 75013, Paris, France
| | - Clemence Delcour
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Constance Beyler
- Cardiopaediatric Unit, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Emilie Bois
- Pediatric Otorhinolaryngology Department, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Emmanuelle Bourrat
- Dermatology Unit, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Emmanuel Bui Quoc
- Ophthalmology Department, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Nathalie Bourcigaux
- Department of Reproductive Endocrinology, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Catherine Chaussain
- Odontology Department, Assistance Publique-Hôpitaux de Paris, University Hospitals Charles Foix, PNVS, and Henri Mondor, 94000, Créteil, France
| | - Ariel Cohen
- Department of Cardiology, GRC n°27, GRECO, AP-HP, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Martine Cohen-Solal
- Department of Rheumatology, Assistance Publique-Hôpitaux de Paris, Université de Paris, Lariboisière Hospital, 75010, Paris, France
| | - Sabrina Da Costa
- Reference Center for Rare Gynecological Pathologies, Pediatric Endocrinology Department, Assistance Publique-Hôpitaux de Paris, Université de Paris, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Claire Dossier
- Department of Paediatric Nephrology, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Stephane Ederhy
- Department of Cardiology, GRC n°27, GRECO, AP-HP, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Monique Elmaleh
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Laurence Iserin
- Adult Congenital Heart Disease Unit, Cardiology Department, Assistance Publique-Hôpitaux de Paris, Université de Paris, Georges Pompidou University Hospital, 75015, Paris, France
| | - Hélène Lengliné
- Department of Pediatric Gastroenterology and Nutrition, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Armelle Poujol-Robert
- Hepatology Department, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Dominique Roulot
- Hepatology Department, Assistance Publique-Hopitaux de Paris, Université Sorbonne Paris Nord, Avicenne Hospital, 93009, Bobigny, France
| | - Jerome Viala
- Department of Pediatric Gastroenterology and Nutrition, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Frederique Albarel
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille. Hospital La Conception, 13005, Marseille, France
| | - Elise Bismuth
- Department of Pediatric Endocrinology and Diabetology, Competence Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Valérie Bernard
- CHU Pellegrin, Department of Gynecological Surgery, Medical Gynecology and Reproductive Medicine, Centre Aliénor d'aquitaine, Bordeaux University Hospitals, 33000, Bordeaux, France
| | - Claire Bouvattier
- Paediatric Endocrinology Department, Reference Center for Rare Genital Development Disorders, Assistance Publique-Hôpitaux de Paris, Kremlin-Bicêtre University Hospital, Paris-Sud University, 94270, Le Kremlin-Bicêtre, France
| | - Aude Brac
- Department of Endocrinology Pediatric and Adult, Reference Center for Rare Genital Development Disorders, Lyon Hospices Civils, Est Hospital Group, 69677, Bron, France
| | - Patricia Bretones
- Department of Endocrinology Pediatric and Adult, Reference Center for Rare Genital Development Disorders, Lyon Hospices Civils, Est Hospital Group, 69677, Bron, France
| | - Nathalie Chabbert-Buffet
- Gynecology-Obstetrics and Reproductive Medicine Department, Assistance Publique-Hôpitaux de Paris, Tenon University Hospital, 75020, Paris, France
| | - Philippe Chanson
- Department of Endocrinology and Reproductive Diseases, Assistance Publique-Hôpitaux de Paris, Kremlin-Bicêtre University Hospital, Paris-Sud University, 94270, Le Kremlin-Bicêtre, France
| | - Regis Coutant
- Department of Pediatric Endocrinology and Diabetology and Reference Center for Rare Diseases of Thyroid and Hormone Receptivity, Angers University Hospital, 49100, Angers, France
| | - Marguerite de Warren
- AGAT, French Turner Syndrome Association (AGAT; Association Des Groupes Amitié Turner), 75011, Paris, France
| | - Béatrice Demaret
- Grandir Association (French Growth Disorders Association), 92600, Asnières-sur-Seine, France
| | - Lise Duranteau
- Adolescent and Young Adult Gynecology Unit, Reference Center for Rare Genital Development Disorders, Assistance Publique-Hôpitaux de Paris, Kremlin-Bicêtre University Hospital, Paris-Sud University, 94270, Le Kremlin-Bicêtre, France
| | - Florence Eustache
- Reproductive Biology Department, Assistance Publique-Hôpitaux de Paris, Jean Verdier University Hospital, 93140, Bondy, France
| | - Lydie Gautheret
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Georges Gelwane
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Claire Gourbesville
- Department of Endocrinology and Metabolic Diseases, Caen University Hospital, 14000, Caen, France
| | - Mickaël Grynberg
- Department of Reproductive Medicine and Fertility Preservation, Assistance Publique-Hôpitaux de Paris, Antoine Béclère University Hospital, 92140, Clamart, France
| | - Karinne Gueniche
- Reference Center for Rare Gynecological Pathologies, Pediatric Endocrinology Department, Assistance Publique-Hôpitaux de Paris, Université de Paris, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Carina Jorgensen
- Endocrinology and Metabolism Department, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Veronique Kerlan
- Endocrinology and Metabolism Department, Brest University Hospital Centre, 29200, Brest, France
| | - Charlotte Lebrun
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Christine Lefevre
- Pediatric Endocrinology, Lille University Jeanne de Flandre Hospital, 59000, Lille, France
| | - Françoise Lorenzini
- Department of Endocrinology, Toulouse University Paule Viguier Hospital, 31300, Toulouse, France
| | - Sylvie Manouvrier
- Clinical Genetics Department, DEV GEN Genital Development Reference Center, Lille University Jeanne de Flandre Hospital, 59000, Lille, France
| | - Catherine Pienkowski
- Genetics and Medical Gynecology Department, Reference Center for Rare Gynecological Pathologies, Toulouse University Hospitals - Hôpital Des Enfants, Pediatrics - Endocrinology, 31059, Toulouse, France
| | - Rachel Reynaud
- Department of Multidisciplinary Pediatrics, Reference Center for Pituitary Rare Diseases Aix Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital de La Timone Enfants, 13005, Marseille, France
| | - Yves Reznik
- Department of Endocrinology and Metabolic Diseases, Caen University Hospital, 14000, Caen, France
| | - Jean-Pierre Siffroi
- Genetics and Embryology Department, Sorbonne Université; INSERM UMRS-933, Assistance Publique-Hôpitaux de Paris, Hôpital d'Enfants Armand-Trousseau, Paris, France
| | - Anne-Claude Tabet
- Genetics Department, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 75019, Paris, France
| | - Maithé Tauber
- Genetics and Medical Gynecology Department, Toulouse University Hospital - Hôpital Des Enfants, Pediatrics - Endocrinology, 31059, Toulouse, France
| | - Vanessa Vautier
- Pediatric Diabetology Department, Bordeaux University Hospitals, 33000, Bordeaux, France
| | - Igor Tauveron
- Clermont-Ferrand University Hospital, Endocrinology Department, Clermont Auvergne University, 63000, Clermont-Ferrand, France
| | - Sebastien Wambre
- French Turner Syndrome Association (Turner Et Vous Association), 59155, Faches-Thumesnil, France
| | - Delphine Zenaty
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Irène Netchine
- Explorations Fonctionnelles Endocriniennes, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Armand-Trousseau Hospital, 75012, Paris, France
| | - Michel Polak
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Université de Paris, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Philippe Touraine
- Endocrinology and Reproductive Medicine Department, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pitié Salpétrière University Hospital, 75013, Paris, France
| | - Jean-Claude Carel
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France
| | - Sophie Christin-Maitre
- Department of Reproductive Endocrinology, Reference Center for Rare Growth and Development Endocrine Diseases, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Saint Antoine Hospital, 75012, Paris, France
| | - Juliane Léger
- Pediatric Endocrinology-Diabetology Department, Reference Center for Rare Growth and Development Endocrine Diseases, INSERM NeuroDiderot, Assistance Publique-Hôpitaux de Paris, Université de Paris, Robert Debré University Hospital, 48 Bd Sérurier, 75019, Paris, France.
| |
Collapse
|
18
|
Abstract
Pediatric endocrinologists often evaluate and treat youth with delayed puberty. Stereotypically, these patients are 14-year-old young men who present due to lack of pubertal development. Concerns about stature are often present, arising from gradual shifts to lower height percentiles on the population-based, cross-sectional curves. Fathers and/or mothers may have also experienced later than average pubertal onset. In this review, we will discuss a practical clinical approach to the evaluation and management of youth with delayed puberty, including the differential diagnosis and key aspects of evaluation and management informed by recent review of the existing literature. We will also discuss scenarios that pose additional clinical challenges, including: (1) the young woman whose case poses questions regarding how presentation and approach differs for females vs males; (2) the 14-year-old female or 16-year-old young man who highlight the need to reconsider the most likely diagnoses, including whether idiopathic delayed puberty can still be considered constitutional delay of growth and puberty at such late ages; and finally (3) the 12- to 13-year-old whose presentation raises questions about whether age cutoffs for the diagnosis and treatment of delayed puberty should be adjusted downward to coincide with the earlier onset of puberty in the general population.
Collapse
Affiliation(s)
- Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, 5006, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, 5000, Australia
| | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
- Departments of Pediatrics and Physiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| |
Collapse
|
19
|
Turner Syndrome. ENDOCRINES 2022. [DOI: 10.3390/endocrines3020022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Turner syndrome (TS) affects approximately 1 out of every 1500–2500 live female births, with clinical features including short stature, premature ovarian failure, dysmorphic features and other endocrine, skeletal, cardiovascular, renal, gastrointestinal and neurodevelopmental organ system involvement. TS, a common genetic syndrome, is caused by sex chromosome aneuploidy, mosaicism or abnormalities with complete or partial loss of function of the second X chromosome. Advances in genetic and genomic testing have further elucidated other possible mechanisms that contribute to pathogenic variability in phenotypic expression that are not necessarily explained by monosomy or haploinsufficiency of the X chromosome alone. The role of epigenetics in variations of gene expression and how this knowledge can contribute to more individualized therapy is currently being explored. TS is established as a multisystemic condition, with several endocrine manifestations of TS affecting growth, puberty and fertility having significant impact on quality of life. Treatment guidelines are in place for the management of these conditions; however, further data on optimal management is needed.
Collapse
|
20
|
Voutsadaki K, Matalliotakis M, Ladomenou F. Hypogonadism in adolescent girls: treatment and long-term effects. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022317. [PMID: 36300209 PMCID: PMC9686158 DOI: 10.23750/abm.v93i5.13719] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIM Hypogonadism in adolescent females presents as delayed puberty or primary amenorrhea. Constitutional delay of growth and puberty, hypogonadotropic hypogonadism and hypergonadotropic hypogonadism represent the principal differential diagnosis of delayed puberty. Girls with hypogonadism require hormone replacement therapy to initiate and sustain puberty. We aimed to provide a brief review concerning treatment for female adolescents with hypogonadism and further to focus on current data regarding long-term effects of therapy. METHODS The published studies and articles of the international literature were used regarding the approach to adolescent girls with hypogonadism. RESULTS The aim of therapy is the development of secondary sexual characteristics and achievement of target height, body composition and bone mass, to promote psychosexual health and, finally, to maximize the potential for fertility. Hypogonadal females need long-term HRT, so it is of great importance to fully define risks and benefits of therapy. CONCLUSIONS The optimal pubertal induction in women contains both estrogens and progesterone regimens. Different therapeutic options have been described over the years in the literature, but larger randomized trials are required in order to define the ideal approach. The latest acquisitions in the field seem to propose that transdermal 17β-estradiol and micronized progesterone present the most physiological formulations available for this purpose. Further studies and follow up are needed concerning the long-term effects of HRT in adolescents.
Collapse
Affiliation(s)
- Kleanthi Voutsadaki
- Department of Pediatrics, Venizeleion General Hospital Heraklion, Crete, Greece
| | - Michail Matalliotakis
- Obstetrics and Gynecology Department of Venizeleion General Hospital Heraklion, Crete, Greece
| | - Fani Ladomenou
- Department of Pediatrics, Venizeleion General Hospital Heraklion, Crete, Greece
| |
Collapse
|
21
|
Butler MG, Miller BS, Romano A, Ross J, Abuzzahab MJ, Backeljauw P, Bamba V, Bhangoo A, Mauras N, Geffner M. Genetic conditions of short stature: A review of three classic examples. Front Endocrinol (Lausanne) 2022; 13:1011960. [PMID: 36339399 PMCID: PMC9634554 DOI: 10.3389/fendo.2022.1011960] [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: 08/04/2022] [Accepted: 09/20/2022] [Indexed: 11/30/2022] Open
Abstract
Noonan, Turner, and Prader-Willi syndromes are classical genetic disorders that are marked by short stature. Each disorder has been recognized for several decades and is backed by extensive published literature describing its features, genetic origins, and optimal treatment strategies. These disorders are accompanied by a multitude of comorbidities, including cardiovascular issues, endocrinopathies, and infertility. Diagnostic delays, syndrome-associated comorbidities, and inefficient communication among the members of a patient's health care team can affect a patient's well-being from birth through adulthood. Insufficient information is available to help patients and their multidisciplinary team of providers transition from pediatric to adult health care systems. The aim of this review is to summarize the clinical features and genetics associated with each syndrome, describe best practices for diagnosis and treatment, and emphasize the importance of multidisciplinary teams and appropriate care plans for the pediatric to adult health care transition.
Collapse
Affiliation(s)
- Merlin G. Butler
- Department of Psychiatry & Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS, United States
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, United States
- *Correspondence: Merlin G. Butler,
| | - Bradley S. Miller
- Pediatric Endocrinology, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Alicia Romano
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States
| | - Judith Ross
- Department of Pediatrics, Nemours Children’s Health, Wilmington, DE, United States
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - Philippe Backeljauw
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Vaneeta Bamba
- Division of Endocrinology, Children’s Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Amrit Bhangoo
- Pediatric Endocrinology, Children's Health of Orange County (CHOC) Children’s Hospital, Orange, CA, United States
| | - Nelly Mauras
- Division of Endocrinology, Nemours Children’s Health, Jacksonville, FL, United States
| | - Mitchell Geffner
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, CA, United States
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
22
|
Stefil M, Kotalczyk A, Blair J, Lip GYH. Cardiovascular considerations in management of patients with Turner syndrome. Trends Cardiovasc Med 2021; 33:150-158. [PMID: 34906657 DOI: 10.1016/j.tcm.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/30/2021] [Accepted: 12/08/2021] [Indexed: 01/15/2023]
Abstract
Turner syndrome (TS) is a chromosomal disorder that affects 25-50 per 100,000 live born females. Patients with TS face a heavy burden of cardiovascular disease (congenital and acquired) with an increased risk of mortality and morbidity compared to the general population. Cardiovascular diseases are a major cause of death in females with TS. Approximately 50% of TS patients have a congenital heart abnormality, with a high incidence of bicuspid aortic valve (BAV), coarctation of the aorta (CoA) and generalised arteriopathy. Frequently, females with TS have systemic hypertension, which is also a risk factor for progressive cardiac dysfunction and aortopathy. This paper aims to provide an overview of the cardiovascular assessment, management and follow up strategies in this high-risk population of TS patients.
Collapse
Affiliation(s)
- Maria Stefil
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom.
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Joanne Blair
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool United Kingdom; Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
23
|
Aversa T, Corica D, Pepe G, Pajno GB, Valenzise M, Messina MF, Wasniewska M. Pubertal induction in girls with Turner Syndrome. Minerva Endocrinol (Torino) 2021; 46:469-480. [PMID: 33435643 DOI: 10.23736/s2724-6507.20.03285-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Turner Syndrome (TS) is the most common female sex chromosome aneuploidy in females, and patients may present with hypergonadotropic hypogonadism due to gonadal dysgenesis. Timing and modalities of pubertal induction in these patients is still a matter of debate. Aim of this review was to focus on the latest update on pubertal induction in TS. Based on literature data, the following practical approach to this issue is recommended. Pubertal induction should begin between 11 and 12 years of age, starting with low doses of estradiol to preserve height potential. Transdermal 17β-Estradiol (17β-E2) could represent the first-choice induction regimen as it is more physiologic compared to an oral regimen and avoids the first-pass mechanism in the liver. In the case of poor compliance, administration of oral 17β-E2 or ethinyl estradiol could be offered. Incremental dose increases, approximately every 6 months, can contribute to mimic normal pubertal progression until adult dosing is reached over a 2- to 3-year period. Progestin should be added once breakthrough bleeding occurs or after 2 to 3 years of estrogen therapy or if ultrasound shows a mature uterus with thick endometrium. Treatment needs to be individualized and monitored by clinical assessment in relation to patient compliance and satisfaction. Well-designed prospective randomized clinical trials aimed to identify the best estrogen regimen for pubertal induction in TS girls are needed.
Collapse
Affiliation(s)
- Tommaso Aversa
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy -
| | - Domenico Corica
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giorgia Pepe
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giovanni B Pajno
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Mariella Valenzise
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Maria F Messina
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Malgorzata Wasniewska
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| |
Collapse
|
24
|
Cirrincione LR, Winston McPherson G, Rongitsch J, Sadilkova K, Drees JC, Krasowski MD, Dickerson JA, Greene DN. Sublingual Estradiol Is Associated with Higher Estrone Concentrations than Transdermal or Injectable Preparations in Transgender Women and Gender Nonbinary Adults. LGBT Health 2021; 8:125-132. [PMID: 33439749 DOI: 10.1089/lgbt.2020.0249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: Serum hormone profiles among different feminizing gender-affirming hormone therapies (GAHT) are poorly characterized. To address this gap, we described the serum estrogen profiles of three 17β-estradiol preparations, taken with or without an antiandrogen, using a novel liquid chromatography-mass spectrometry (LC-MS/MS) assay in adults taking feminizing GAHT. Methods: This was a secondary analysis of 93 healthy transgender women and gender nonbinary adults taking feminizing GAHT in a prospective cross-sectional study. Eligible participants took 17β-estradiol (sublingual tablet, transdermal patch, or intramuscular/subcutaneous injection) with or without oral spironolactone for ≥12 months before study entry. We determined serum estrone and estradiol concentrations for each hormone preparation and described the association between estrone and (1) clinically relevant estradiol concentration ranges (≤200 and >200 pg/mL) and (2) antiandrogen use. To achieve our objectives, we described our protocol for developing an LC-MS/MS assay to measure estrone and estradiol concentrations. Results: Estrone concentrations were higher among participants taking sublingual 17β-estradiol tablets compared with transdermal or injectable preparations (p < 0.0001). Estradiol concentrations were higher for injectable versus transdermal preparations (p = 0.0201), but both were similar to sublingual tablet concentrations (p > 0.05). Estradiol >200 pg/mL (vs. ≤200 pg/mL) was associated with higher estrone concentrations among participants taking sublingual 17β-estradiol, but not transdermal or injectable 17β-estradiol. We observed no association between spironolactone and estrone concentrations (p > 0.5). Conclusion: Estrone concentrations were higher among transgender women and gender nonbinary adults taking sublingual 17β-estradiol compared with transdermal or injectable preparations. The role of estrone in clinical monitoring and the influence of other antiandrogens (e.g., cyproterone acetate) on the estrogen profile remain to be determined.
Collapse
Affiliation(s)
| | | | | | - Katerina Sadilkova
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington, USA
| | - Julia C Drees
- The Permanente Medical Group Regional Laboratories, Berkeley, California, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jane A Dickerson
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,Department of Laboratories, Seattle Children's Hospital, Seattle, Washington, USA
| | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
25
|
Abstract
Puberty, which in humans is considered to include both gonadarche and adrenarche, is the period of becoming capable of reproducing sexually and is recognized by maturation of the gonads and development of secondary sex characteristics. Gonadarche referring to growth and maturation of the gonads is fundamental to puberty since it encompasses increased gonadal steroid secretion and initiation of gametogenesis resulting from enhanced pituitary gonadotropin secretion, triggered in turn by robust pulsatile GnRH release from the hypothalamus. This chapter reviews the development of GnRH pulsatility from before birth until the onset of puberty. In humans, GnRH pulse generation is restrained during childhood and juvenile development. This prepubertal hiatus in hypothalamic activity is considered to result from a neurobiological brake imposed upon the GnRH pulse generator resident in the infundibular nucleus. Reactivation of the GnRH pulse generator initiates pubertal development. Current understanding of the genetics and physiology of the brake will be discussed, as will hypotheses proposed to account for timing the resurgence in pulsatile GnRH and initiation of puberty. The chapter ends with a discussion of disorders associated with precocious or delayed puberty with a focus on those with etiologies attributed to aberrant GnRH neuron anatomy or function. A pediatric approach to patients with pubertal disorders is provided and contemporary treatments for both precocious and delayed puberty outlined.
Collapse
Affiliation(s)
- Selma Feldman Witchel
- Pediatric Endocrinology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Tony M Plant
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
26
|
Gea M, Toso A, Schilirò T. Estrogenic activity of biological samples as a biomarker. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 740:140050. [PMID: 32927569 DOI: 10.1016/j.scitotenv.2020.140050] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 06/11/2023]
Abstract
Biological assays can evaluate the cumulative effect of a mixture, considering synergistic/antagonistic interactions and effects of unknown/unconsidered compounds. Therefore, their application could increase in the next years also to analyse biological samples. The aim of this review is to discuss the methodological approach and the application of estrogenic activity assays in human biological samples. 75 research articles were analysed and divided according to whether they used these assays: i) to quantify the level of estrogens and/or as a biomarker of estrogenic status ii) as a biomarker of exposure to endocrine disrupting chemicals (EDCs). For the first purpose, some authors extracted biological samples while others tested them directly without any treatment. The study of these methodologies outlined that the methodology applied influenced the specificity of analysis. The estrogenic activity biomarker was used to analyse physiological variations of estrogens, pediatric diseases, hormone-dependent diseases and estrogen suppression/enhancement after pharmaceutical treatments. For the second purpose, some authors extracted samples while others tested them directly, some authors divided endogenous estrogens from xenoestrogens while others tested samples without separation. The analysis of these methodologies outlined some limitations related to the efficiency of extraction and the incorrect separation of some compounds. The studies which applied this EDC biomarker showed that it was correlated with some EDCs, it varied according to the exposure of the population and it allowed the identification of some relationships between EDC exposure and breast cancer, type 1 diabetes and adverse health effects on children. In conclusion, the estrogenic activity of biological samples can be a useful tool: to quantify low levels of 17β-estradiol, to assess the combined effect of endogenous estrogens and xenoestrogens, to estimate the estrogenic status providing considerable insight into physiological or pathological conditions, to evaluate EDC presence implementing the existing knowledge about EDC exposure and adverse health effects.
Collapse
Affiliation(s)
- Marta Gea
- Department of Public Health and Pediatrics, University of Torino, Piazza Polonia 94, 10126 Torino, Italy.
| | - Anna Toso
- Department of Public Health and Pediatrics, University of Torino, Piazza Polonia 94, 10126 Torino, Italy
| | - Tiziana Schilirò
- Department of Public Health and Pediatrics, University of Torino, Piazza Polonia 94, 10126 Torino, Italy
| |
Collapse
|
27
|
Tanaka T. Perspectives on growth promoting treatment for patients with Turner syndrome in Japan. Clin Pediatr Endocrinol 2020; 29:91-97. [PMID: 32694884 PMCID: PMC7348636 DOI: 10.1297/cpe.29.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/18/2020] [Indexed: 11/04/2022] Open
Abstract
In Japan, anabolic steroid hormone (ASH) treatment for Turner syndrome (TS) to promote growth had been provided before GH therapy for TS was approved. ASH effectively improved the adult height (AH) of TS patients without spontaneous puberty but decreased the AH of TS patients with spontaneous puberty. Although GH therapy for TS was approved in 1991, the approved dosage remained 0.5 IU/kg/wk for GH-deficient TS patients and improved AH by approximately 7 cm. However, AH did not reach -2 standard deviations in healthy girls. In 1999, the requirement of GH deficiency was removed and a dose of 1.0 IU/kg/wk was approved. Although an increase in AH was expected, no reports showed significant improvements in AH at a high dose of GH. GH + ASH combination therapy was reevaluated and recommended for TS patients with gonadal failure and an extremely short stature or those who respond poorly to GH therapy. Although early estrogen replacement therapy is recommended to improve psychological quality of life and prevent osteoporosis, it lowered AH even at a low dose of ethinyl estradiol (25 ng/kg/d). The initiation of ethynyl estradiol at an extremely low dose (1-5 ng/kg/d) at a relatively young age successfully improved AH.
Collapse
|
28
|
Kostopoulou E, Bosdou JK, Anagnostis P, Stevenson JC, Goulis DG. Cardiovascular Complications in Patients with Turner's Syndrome. Curr Pharm Des 2020; 26:5650-5659. [PMID: 32473616 DOI: 10.2174/1381612826666200531152459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 01/15/2023]
Abstract
Turner's or Turner syndrome (TS) is the most prevalent chromosomal abnormality in live female births. Patients with TS are predisposed to an increased risk of cardiovascular diseases (CVD), mainly due to the frequently observed congenital structural cardiovascular defects, such as valvular and aortic abnormalities (coarctation, dilatation, and dissection). The increased prevalence of cardiometabolic risk factors, such as arterial hypertension, insulin resistance, diabetes mellitus, dyslipidaemia, central obesity, and increased carotid intima-media thickness, also contribute to increased morbidity and mortality in TS patients. Menopausal hormone therapy (MHT) is the treatment of choice, combined with growth hormone (GH). Although MHT may, in general, ameliorate CVD risk factors, its effect on CVD mortality in TS has not yet been established. The exact effect of GH on these parameters has not been clarified. Specific considerations should be provided in TS cases during pregnancy, due to the higher risk of CVD complications, such as aortic dissection. Optimal cardiovascular monitoring, including physical examination, electrocardiogram, CVD risk factor assessment, and transthoracic echocardiography, is recommended. Moreover, the cardiac magnetic resonance from the age of 12 years is recommended due to the high risk of aortic aneurysm and other anatomical vascular complications.
Collapse
Affiliation(s)
- Eirini Kostopoulou
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University of Patras School of Medicine, Patras, 26500, Greece
| | - Julia K Bosdou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John C Stevenson
- National Heart and Lung Institute, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, United Kingdom
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
29
|
Mathez ALG, Monteagudo PT, do Nascimento Verreschi IT, Dias-da-Silva MR. Levonorgestrel correlates with less weight gain than other progestins during hormonal replacement therapy in Turner Syndrome patients. Sci Rep 2020; 10:8298. [PMID: 32427839 PMCID: PMC7237408 DOI: 10.1038/s41598-020-64992-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/22/2020] [Indexed: 01/15/2023] Open
Abstract
Turner Syndrome (TS) is associated with an increased risk of cardiovascular and metabolic complications. Furthermore, TS women need hormone replacement therapy (HRT), of which progestins can influence body weight. We aimed to analyze the metabolic and weight profile in a cohort of 111 TS women. They started receiving estrogen at 15.8 (±3.6) years old, with no change in hypertension, dysglycemia, and dyslipidemia incidence but with a tendency to increase overweight (p = 0.054). As the first used type of progestin, most had received cycles of 10 days per month of medroxyprogesterone (MPA) or levonorgestrel (LNG), then shifted to micronized progesterone (MP), which has currently become the most used one. By multiple linear regression analysis, we found that the prolonged use of MPA, LNG, or MP showed no metabolic change except for weight gain. The percentage of annual BMI increment was positive for all progestins used in TS women (MPA 2.2 ± 2.2; LNG 0.2 ± 1.2; and MP 2.2 ± 2.6 kg/m2), but LNG seemed to best prevent on weight gain over time (p < 0.05). In conclusion, metabolic comorbidities are prevalent in TS even before the HRT regimen, and LNG performed better on less weight gain than MPA and MP in our cohort of the TS population.
Collapse
Affiliation(s)
- Andréia Latanza Gomes Mathez
- Endocrinology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Patrícia Teófilo Monteagudo
- Endocrinology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil.
| | | | - Magnus Régios Dias-da-Silva
- Endocrinology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Molecular and Translational Endocrinology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
30
|
|
31
|
Cleemann L, Holm K, Fallentin E, Møller N, Kristensen B, Skouby SO, Leth-Esbensen P, Jeppesen EM, Jensen AK, Gravholt CH. Effect of Dosage of 17ß-Estradiol on Uterine Growth in Turner Syndrome-A Randomized Controlled Clinical Pilot Trial. J Clin Endocrinol Metab 2020; 105:5587948. [PMID: 31613320 DOI: 10.1210/clinem/dgz061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 10/08/2019] [Indexed: 01/15/2023]
Abstract
CONTEXT Most Turner syndrome (TS) girls need exogenous estrogen treatment to induce puberty and normal uterine growth. After puberty, the optimal estrogen treatment protocol has not been determined. OBJECTIVE To compare 2 doses of oral 17ß-estradiol on uterine size. DESIGN A double-blind, 5-year randomized controlled clinical trial. SETTING Ambulatory care. PARTICIPANTS Twenty young TS women (19.2 ± 2.5 years, range 16.0-24.9) participated. Sixteen patients completed the study. No patients withdrew due to adverse effects. INTERVENTION The lower dose (LD) group took 2 mg 17ß-estradiol/d orally and placebo. The higher dose (HD) group took 4 mg 17ß-estradiol/d orally. MAIN OUTCOME MEASURE(S) Uterine volume evaluated by transabdominal ultrasound yearly. RESULTS Uterine size increased significantly more in the HD group compared with the LD group (P = 0.038), with a gain in uterine volume within the first 3 years of treatment of 19.6 mL (95% confidence interval [CI] = 4.0-19.0) in the HD group compared with 11.5 mL (95% CI = 11.2-27.9) in the LD group. The difference in 3-year gain was 8.1 mL (95% CI = 0.7-15.9). At the last visit, there were no significant differences in uterine volume between the groups. CONCLUSION HD oral 17ß-estradiol induces a steeper increase in uterine volume within the first years of treatment compared with the LD. However, the uterine growth potential seems to be the same in most young TS women making the duration of treatment equally significant as estrogen dose, although a few TS women did not experience sufficient uterine growth on 2 mg of estradiol. CLINICALTRIALS.GOV NCT00134745Abbreviations: BMI, body mass index; BSA, body surface area; DHEAS, dihydroepiandrosteronesulfate; HD, higher dose; HRT, hormone replacement therapy; LD, lower dose; TS, Turner syndrome; US, ultrasound.
Collapse
Affiliation(s)
- Line Cleemann
- Department of Pediatrics, Nordsjællands Hospital, Hillerød, Denmark
| | - Kirsten Holm
- Department of Pediatrics, Nordsjællands Hospital, Hillerød, Denmark
| | - Eva Fallentin
- Department of Radiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nini Møller
- Department of Gynecology and Obstetrics, Nordsjællands Hospital, Hillerød, Denmark
| | - Bent Kristensen
- Department of Radiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Sven O Skouby
- Department of Gynecology and Obstetrics, Herlev University Hospital, Herlev, Denmark
| | | | - Eva M Jeppesen
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
| | - Andreas K Jensen
- Department of Clinical Research, Nordsjællands Hospital, Hillerød, Denmark
- Department of Public Health, University of Copenhagen
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
| |
Collapse
|
32
|
Abstract
During puberty, with activation of the hypothalamic pituitary axis that has been quiescent since the neonatal period, linear growth accelerates, secondary sexual characteristics develop, and adult fertility potential and bone mass are achieved, together with psychosocial and emotional maturation.Disordered pubertal onset and progress, either early or late, presents frequently for endocrine care. Where a disorder is found, due either to a central hypothalamic pituitary cause or to primary gonadal failure, pharmacotherapeutic interventions are required to alter the trajectory of disturbed pubertal onset or progress and for maintenance of adolescent and adult sex hormone status. This paper describes pharmacologic interventions used for pubertal disorders but is not intended to address the diagnostic cascade in detail.
Collapse
Affiliation(s)
- Margaret Zacharin
- Department of Endocrinology, Royal Children's Hospital, Parkville, VIC, Australia.
| |
Collapse
|
33
|
Klein KO, Phillips SA. Review of Hormone Replacement Therapy in Girls and Adolescents with Hypogonadism. J Pediatr Adolesc Gynecol 2019; 32:460-468. [PMID: 31059821 DOI: 10.1016/j.jpag.2019.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 12/13/2022]
Abstract
Girls with either hypo- or hypergonadotropic hypogonadism need treatment with estrogens to initiate puberty and maintain a normal hormonal milieu. The focus of this review is hormone replacement treatment in girls with hypogonadism, to initiate and progress through puberty, and to maintain a healthy hormonal milieu in women. It also addresses what is known in the literature regarding estrogen levels in girls and women, instructive cases, practical tables for reference and application, and thoughts on future directions in this area. It represents a thorough literature review with author opinions and recommendations. Girls with normal ovarian function begin puberty on average at 10.5 years old, although there is variation according to ethnicity and degree of excess weight gain. The aim of estrogen therapy to initiate puberty is to mimic normal onset and rate of progression. On the basis of the currently available literature, when a diagnosis of hypogonadism is established, we recommend initiating treatment between age 11 and 12 years of age, with dose increases approximately every 6 months until adult levels are reached. In some situations, treatment may be delayed to allow time for diagnosis or permit more time for linear growth, or address unique risks found in girls treated for various cancers or blood disorders. When adult dosing is reached, progestins are also used to protect uterine health. This can be combined sequentially, allowing regular menstruation, or combined continuously when menstrual bleeding is not preferred. Treatment is continued until the average age of menopause, again with various considerations for longer or shorter duration on the basis of risk-benefit ratios. Transdermal estrogens are considered the most physiologic replacement and theoretically might have fewer associated risks. We review what is known about risks and outcomes and areas for future research.
Collapse
Affiliation(s)
- Karen O Klein
- Division of Endocriology, Department of Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, California.
| | - Susan A Phillips
- Division of Endocriology, Department of Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, California
| |
Collapse
|
34
|
Puberty in cystic fibrosis. J Cyst Fibros 2019; 18 Suppl 2:S88-S94. [DOI: 10.1016/j.jcf.2019.08.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 12/20/2022]
|
35
|
Abstract
Turner syndrome is one of the most common sex chromosomal anomalies, characterized by the complete or partial loss of one X chromosome. Females with Turner syndrome are characterized by skeletal abnormalities, short stature and primary ovarian insufficiency. The aim of this narrative review was to identify the underlying mechanisms of osteoporosis in Turner syndrome, summarize its clinical manifestations and provide suggestions regarding the management of osteoporosis. Girls and women with Turner syndrome have lower bone mineral density and a higher fracture rate than healthy individuals. The most important risk factors for osteoporosis are inadequately treated primary ovarian insufficiency, followed by intrinsic bone abnormalities. Comorbidities that further increase the risk of osteoporosis include vitamin D deficiency, celiac disease and inflammatory bowel disease. In addition, hearing problems can predispose to falls. Early initiation of hormone replacement therapy (HRT) at the age of 11-13 years, prompt titration to the adult dose after 2 years and long-term follow-up to ensure compliance with HRT are the cornerstones of osteoporosis prevention in women with Turner syndrome.
Collapse
|
36
|
Lanes R, Lindberg A, Carlsson M, Chrysis D, Aydin F, Camacho-Hübner C, King D, Davenport M. Near Adult Height in Girls with Turner Syndrome Treated with Growth Hormone Following Either Induced or Spontaneous Puberty. J Pediatr 2019; 212:172-179.e1. [PMID: 31227282 DOI: 10.1016/j.jpeds.2019.04.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/23/2019] [Accepted: 04/28/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To understand whether spontaneous vs induced puberty and the type and route of estrogen influence the height of girls with Turner syndrome on growth hormone (GH). STUDY DESIGN Search of an international database of children treated with GH revealed 772 girls with Turner syndrome followed from GH initiation to near adult height. Data from girls with sustained spontaneous puberty (n = 145) were compared with those requiring estrogens for induction or maintenance of puberty (n = 627). RESULTS At GH start, mean age (7.5 vs 7.9 years), weight (-1.7 vs -1.7 SDS), and body mass index (0.2 SDS vs 0.1 SDS) were similar for girls with spontaneous puberty and with induced puberty. Although those girls with spontaneous puberty were shorter than those with induced puberty, when midparental height was taken into consideration, starting heights in both groups averaged -2.8 SDS. Both groups received approximately 0.3 mg/kg/week of GH. Girls with spontaneous puberty initiated puberty and reached near adult height earlier than girls with induced puberty (12.6 ± 1.8 years vs 13.4 ± 1.4 years and 16.0 ± 1.3 years vs 16.9 ± 1.4 years, respectively). Although girls with spontaneous puberty grew more in the first year of GH therapy and between the onset of puberty and near adult height (11.0 cm vs 9.3 cm), height SDS at near adult height and the length of time in puberty before reaching near adult height were comparable. A 45,X karyotype was detected in 22.1% of girls with spontaneous puberty and in 58.4% of girls with induced puberty. Patients receiving transdermal estrogens did not grow better than those on oral estrogens. Adverse event reporting was comparable between groups. CONCLUSIONS Girls with Turner syndrome with spontaneous puberty tended to grow better in response to GH than girls with induced puberty, but not enough to produce a difference in height SDS at near adult height.
Collapse
Affiliation(s)
- Roberto Lanes
- Pediatric Endocrine Unit, Hospital de Clinica Caracas, Caracas, Venezuela.
| | | | | | - Dionisios Chrysis
- Division of Endocrinology and Diabetes, Department of Pediatrics, Medical School, University of Patras, Patras, Greece
| | - Ferah Aydin
- Pfizer Health AB, Endocrine Care, Sollentuna, Sweden
| | | | - Donna King
- Pfizer Inc., Endocrine Care, New York, NY
| | - Marsha Davenport
- Division of Pediatric Endocrinology, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
37
|
Cameron-Pimblett A, Davies MC, Burt E, Talaulikar VS, La Rosa C, King TFJ, Conway GS. Effects of Estrogen Therapies on Outcomes in Turner Syndrome: Assessment of Induction of Puberty and Adult Estrogen Use. J Clin Endocrinol Metab 2019; 104:2820-2826. [PMID: 30726925 DOI: 10.1210/jc.2018-02137] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/01/2019] [Indexed: 12/27/2022]
Abstract
CONTEXT Turner syndrome (TS) is often associated with delayed puberty. To induce puberty, estrogen is administered in incremental doses at an age determined by age of presentation. After puberty, various types of maintenance estrogen replacement therapy (ERT) are used. OBJECTIVE We sought associations between age of induction of puberty and type of ERT on adult health outcomes. DESIGN Health surveillance data included blood profiles, bone density, and blood pressure. We assessed interactions between these data and age at first estrogen exposure in women with primary amenorrhea. We also assessed these data according to ERT subgroups [combined oral contraceptive pill (OCP), oral estrogen (OE), and transdermal estradiol (TE)] using data from each of 6679 clinic visits, controlling for age, body mass index, and height. SETTING Adult TS clinic at University College London Hospital. PATIENTS Of 799 women with TS, 624 had primary amenorrhea and 599 had accurate maintenance ERT data. MAIN OUTCOME MEASURES Parameters of health surveillance derived from clinical guidelines. RESULTS Estrogen start age was negatively correlated with adult bone density (spine: r = -0.20 and hip: r = -0.022; P ≤ 0.001). OCP users had higher blood pressure and an adverse lipid profile compared with other ERT subgroups. TE was associated with elevated liver enzymes and hemoglobin A1c compared with OE (P ≤ 0.01). CONCLUSIONS An earlier age of induction of puberty may be beneficial for adult bone density. Given the high prevalence of hypertension in TS, the use of OCP for ERT should be limited. OE may be a benefit for steatohepatitis.
Collapse
Affiliation(s)
| | - Melanie C Davies
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | - Elizabeth Burt
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | | | - Clementina La Rosa
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | - Thomas F J King
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | - Gerard S Conway
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| |
Collapse
|
38
|
Backeljauw P, Klein K. Sex hormone replacement therapy for individuals with Turner syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:13-17. [DOI: 10.1002/ajmg.c.31685] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/05/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Philippe Backeljauw
- Division of Pediatric Endocrinology, The Cincinnati Center for Pediatric and Adult Turner Syndrome Care, Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of Medicine Cincinnati Ohio
| | - Karen Klein
- Division of Pediatric EndocrinologyRady Children's Hospital and University of California San Diego California
| |
Collapse
|
39
|
Mauras N, Torres-Santiago L, Santen R, Mericq V, Ross J, Colon-Otero G, Damaso L, Hossain J, Wang Q, Mesaros C, Blair IA. Impact of route of administration on genotoxic oestrogens concentrations using oral vs transdermal oestradiol in girls with Turner syndrome. Clin Endocrinol (Oxf) 2019; 90:155-161. [PMID: 30281805 DOI: 10.1111/cen.13869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/15/2018] [Accepted: 09/27/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The established link between oestrogen and breast cancer occurs via both oestrogen receptor (ER)-mediated and non ER-mediated mechanisms. The term genotoxic estrogens describes mutagenic metabolites, including oestrogen catechols and quinones, which have been linked to breast carcinogenesis in post-menopausal women. We aimed to assess whether the route of administration of 17β oestradiol (E2 ) affects the accumulation of genotoxic oestrogen metabolites in a model of ovarian failure in young girls with Turner syndrome. METHODS Stored plasma samples obtained at 0 and 12 months were used from 40 adolescents with Turner syndrome who participated in a 12 months randomized controlled trial of the metabolic impact of E2 orally (2 mg/d) vs transdermally (100 µg/d); dose escalation allowed matching of unconjugated E2 levels in the parent study. We measured 12 oestrogen metabolites (total concentrations = conjugated and unconjugated) using a highly sensitive LCMSMS assay. Results from 48 normally menstruating adolescents were used for comparison. RESULTS After treatment, least square mean (SE) total E2 concentrations were higher in the oral vs transdermal group (6784 pmol/L vs 1123 [1614], P < 0.0001), as was oestrone (E1 ) (91 060 pmol/L vs 19 278 [16 534], P < 0.0001). Also, higher after oral treatment were catechol-oestrogens 4-hydroxy-E2 (149 vs 28 [±49] pmol/L), 2-hydroxy-E2 (300 vs 76 [±52]), 4-hydroxy-E1 (450 vs 105 [±113]), 2-hydroxy-E1 (3094 vs 740 [±684]) and 16α-hydroxy-E1 (3,007 vs 157 [±534]) (<0.001 between groups). Levels were much closer to controls in the transdermal group. CONCLUSIONS Common feminizing doses of oral oestradiol for 12 months result in substantial accumulation of unphysiologic, genotoxic oestrogens compared to transdermal oestradiol, expanding concerns about oral oestrogens' first hepatic passage. Further studies assessing long-term risks of these metabolites in women taking different forms of oestrogen are needed.
Collapse
Affiliation(s)
- Nelly Mauras
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health System, Jacksonville, Florida
| | - Lournaris Torres-Santiago
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health System, Jacksonville, Florida
| | - Richard Santen
- Division of Endocrinology, University of Virginia, Charlottesville, Virginia
| | - Veronica Mericq
- Division of Endocrinology, Institute of Maternal and Child Research, University of Chile, Santiago, Chile
| | - Judith Ross
- Nemours Children's Health System, Wilmington, Delaware
| | | | - Ligeia Damaso
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health System, Jacksonville, Florida
| | - Jobayer Hossain
- Department of Statistics & Bioinformatics, Nemours Children's Health System, Wilmington, Delaware
| | - Qingqing Wang
- Penn SRP Center and Center for Excellence in Environmental Toxicology, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Clementina Mesaros
- Penn SRP Center and Center for Excellence in Environmental Toxicology, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian A Blair
- Penn SRP Center and Center for Excellence in Environmental Toxicology, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
40
|
Swee DS, Javaid U, Quinton R. Estrogen Replacement in Young Hypogonadal Women-Transferrable Lessons From the Literature Related to the Care of Young Women With Premature Ovarian Failure and Transgender Women. Front Endocrinol (Lausanne) 2019; 10:685. [PMID: 31681164 PMCID: PMC6798086 DOI: 10.3389/fendo.2019.00685] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/20/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Du Soon Swee
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
- *Correspondence: Du Soon Swee
| | - Usman Javaid
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Richard Quinton
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
41
|
Sun L, Wang Y, Zhou T, Zhao X, Wang Y, Wang G, Gang X. Glucose Metabolism in Turner Syndrome. Front Endocrinol (Lausanne) 2019; 10:49. [PMID: 30792694 PMCID: PMC6374553 DOI: 10.3389/fendo.2019.00049] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/21/2019] [Indexed: 12/20/2022] Open
Abstract
Turner syndrome (TS) is one of the most common female chromosomal disorders. The condition is caused by complete or partial loss of a single X chromosome. Adult patients with TS have a high prevalence of diabetes mellitus (DM). Deranged glucose metabolism in this population seems to be genetically triggered. The traditional risk factors for DM in the general population may not play a major role in the pathogenesis of DM in patients with TS. This review focuses on the latest research studies pertaining to abnormalities of glucose metabolism in TS. We extensively review the available evidence pertaining to the influence of insulin secretion and sensitivity, obesity, autoimmunity, lifestyle, growth hormone, and sex hormone replacement therapy on the occurrence of DM in these patients.
Collapse
Affiliation(s)
- Lin Sun
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
| | - Yao Wang
- Department of Orthopedics, The Second Hospital Jilin University, Changchun, China
| | - Tong Zhou
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
| | - Xue Zhao
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
| | - Yingxuan Wang
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
- *Correspondence: Guixia Wang
| | - Xiaokun Gang
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
- Xiaokun Gang
| |
Collapse
|
42
|
Affiliation(s)
- S. Shah
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - H. H. Nguyen
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - A. J. Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
43
|
Klein KO, Rosenfield RL, Santen RJ, Gawlik AM, Backeljauw PF, Gravholt CH, Sas TCJ, Mauras N. Estrogen Replacement in Turner Syndrome: Literature Review and Practical Considerations. J Clin Endocrinol Metab 2018; 103:1790-1803. [PMID: 29438552 DOI: 10.1210/jc.2017-02183] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/02/2018] [Indexed: 01/15/2023]
Abstract
CONTEXT Most girls with Turner syndrome (TS) have hypergonadotropic hypogonadism and need hormonal replacement for induction of puberty and then for maintaining secondary sex characteristics, attaining peak bone mass, and uterine growth. The optimal estrogen replacement regimen is still being studied. EVIDENCE ACQUISITION We conducted a systematic search of PubMed for studies related to TS and puberty. EVIDENCE SYNTHESIS The goals of replacement are to mimic normal timing and progression of physical and social development while minimizing risks. Treatment should begin at age 11 to 12 years, with dose increases over 2 to 3 years. Initiation with low-dose estradiol (E2) is crucial to preserve growth potential. Delaying estrogen replacement may be deleterious to bone and uterine health. For adults who have undergone pubertal development, we suggest transdermal estrogen and oral progestin and discuss other approaches. We discuss linear growth, lipids, liver function, blood pressure, neurocognition, socialization, and bone and uterine health as related to hormonal replacement. CONCLUSION Evidence supports the effectiveness of starting pubertal estrogen replacement with low-dose transdermal E2. When transdermal E2 is unavailable or the patient prefers, evidence supports use of oral micronized E2 or an intramuscular preparation. Only when these are unavailable should ethinyl E2 be prescribed. We recommend against the use of conjugated estrogens. Once progestin is added, many women prefer the ease of use of a pill containing both an estrogen and a progestin. The risks and benefits of different types of preparations, with examples, are discussed.
Collapse
Affiliation(s)
- Karen O Klein
- University of California, San Diego, California
- Rady Children's Hospital, San Diego, California
| | | | | | - Aneta M Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Theo C J Sas
- Erasmus Medical Center and Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Nelly Mauras
- Nemours Children's Health System, Jacksonville, Florida
| |
Collapse
|
44
|
Christin-Maitre S. Use of Hormone Replacement in Females with Endocrine Disorders. Horm Res Paediatr 2018; 87:215-223. [PMID: 28376481 DOI: 10.1159/000457125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 01/18/2017] [Indexed: 12/16/2022] Open
Abstract
Hormone replacement therapy (HRT) is necessary in adolescents with primary ovarian insufficiency (POI) in order to avoid estrogen deficiency. The goal of this minirewiew is to present the different types of estrogens (17β-estradiol, estradiol valerate, ethinyl estradiol, and combined equine estrogens) as well as the different types of progestins available. In order to choose among the different types of HRTs, the features of each regimen are being discussed as well as their risks and their respective benefits. The differences between oral combined contraceptive pills and a dissociated regimen containing estrogen and progestins are emphasized. The different effects of HRTs, mainly on feminization, growth spurt, bone mass as well as cardiovascular risk, and the follow-up of these young patients are presented. HRT in adolescents and young adults with estrogen deficiency is necessary and should be continued until the age of natural menopause. Studies have so far essentially included children or adolescents with Turner syndrome. Therefore, studies on HRT including patients with POI and a normal karyotype are necessary.
Collapse
|
45
|
Shankar RK, Backeljauw PF. Current best practice in the management of Turner syndrome. Ther Adv Endocrinol Metab 2018; 9:33-40. [PMID: 29344338 PMCID: PMC5761955 DOI: 10.1177/2042018817746291] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/24/2017] [Indexed: 01/15/2023] Open
Abstract
Turner syndrome (TS) is characterized by partial or complete loss of the second X-chromosome in phenotypic females resulting in a constellation of clinical findings that may include lymphedema, cardiac anomalies, short stature, primary ovarian failure and neurocognitive difficulties. Optimizing health care delivery is important to enable these individuals achieve their full potential. We review the current best practice management recommendations for individuals with TS focusing on the latest consensus opinion in regard to genetic diagnosis, treatment of short stature, estrogen supplementation, addressing psychosocial issues, as well screening for other comorbidities. A multidisciplinary approach and a well-planned transition to adult follow-up care will improve health care delivery significantly for this population.
Collapse
Affiliation(s)
- Roopa Kanakatti Shankar
- Assistant Professor, Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Philippe F Backeljauw
- Cincinnati Center for Pediatric and Adult Turner Syndrome Care, Professor, Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| |
Collapse
|
46
|
Lebenthal Y, Levy S, Sofrin-Drucker E, Nagelberg N, Weintrob N, Shalitin S, de Vries L, Tenenbaum A, Phillip M, Lazar L. The Natural History of Metabolic Comorbidities in Turner Syndrome from Childhood to Early Adulthood: Comparison between 45,X Monosomy and Other Karyotypes. Front Endocrinol (Lausanne) 2018; 9:27. [PMID: 29479339 PMCID: PMC5811462 DOI: 10.3389/fendo.2018.00027] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/19/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Patients with Turner syndrome (TS) are at increased risk for metabolic disorders. We aimed to delineate the occurrence and evolution of metabolic comorbidities in TS patients and to determine whether these differ in 45,X monosomy and other karyotypes. METHODS A longitudinal and cross-sectional retrospective cohort study was conducted in a tertiary pediatric endocrine unit during 1980-2016. Ninety-eight TS patients, 30 with 45,X monosomy were followed from childhood to early adulthood. Outcome measures included weight status, blood pressure (BP), glucose metabolism, and lipid profile. RESULTS Longitudinal analysis showed a significant change in body mass index (BMI) percentiles over time [F(3,115) = 4.8, P = 0.003]. Age was associated with evolution of elevated BP [systolic BP: odds ratio (OR) = 0.91, P = 0.003; diastolic BP: OR = 0.93, P = 0.023], impaired glucose metabolism (HbA1c: OR = 1.08, P = 0.029; impaired glucose tolerance: OR = 1.12, P = 0.029), and abnormal lipid profile (cholesterol: OR = 1.06, P = 0.01; low-density lipoprotein cholesterol: OR = 1.07, P = 0.041; high-density lipoprotein cholesterol: OR = 1.07, P = 0.033). The occurrence of metabolic comorbidities was similar in 45,X monosomy and other karyotypes. Coexistence of multiple metabolic comorbidities was significantly higher in 45,X monosomy [F(1,72) = 4.81, P = 0.032]. BMI percentiles were positively correlated with metabolic comorbidities (occurrence and number) in each patient (r = 0.35, P = 0.002 and r = 0.383, P = 0.001, respectively). CONCLUSION Our longitudinal study provides unique insights into the evolution of weight gain and metabolic disorders from childhood to early adulthood in TS patients. Since overweight and increasing age aggravate the risk for metabolic comorbidities, careful surveillance is warranted to prevent and control obesity already from childhood. The more prominent clustering of metabolic comorbidities in 45,X monosomy underscores the importance of a more vigorous intervention in this group.
Collapse
Affiliation(s)
- Yael Lebenthal
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Yael Lebenthal,
| | - Sigal Levy
- Statistical Education Unit, The Academic College of Tel Aviv Yaffo, Jaffa, Israel
| | - Efrat Sofrin-Drucker
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Nessia Nagelberg
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Naomi Weintrob
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shlomit Shalitin
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat de Vries
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Tenenbaum
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liora Lazar
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
47
|
Yang S. Diagnostic and therapeutic considerations in Turner syndrome. Ann Pediatr Endocrinol Metab 2017; 22:226-230. [PMID: 29301182 PMCID: PMC5769837 DOI: 10.6065/apem.2017.22.4.226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/21/2017] [Accepted: 12/10/2017] [Indexed: 12/26/2022] Open
Abstract
Newly developed genetic techniques can reveal mosaicism in individuals diagnosed with monosomy X. Noninvasive prenatal diagnosis using maternal blood can detect most fetuses with X chromosome abnormalities. Low-dose and ultralow-dose estrogen replacement therapy can achieve a more physiological endocrine milieu. However, many complicated and controversial issues with such treatment remain. Therefore, lifetime observation, long-term studies of health problems, and optimal therapeutic plans are needed for women with Turner syndrome. In this review, we discuss several diagnostic trials using recently developed genetic techniques and studies of physiological hormone replacement treatment over the last 5 years.
Collapse
Affiliation(s)
- Seung Yang
- Department of Pediatrics, Kangdong Sacred Hear t Hospital, Hallym University College of Medicine, Seoul, Korea
| |
Collapse
|
48
|
Matthews D, Bath L, Högler W, Mason A, Smyth A, Skae M. Hormone supplementation for pubertal induction in girls. Arch Dis Child 2017; 102:975-980. [PMID: 28446424 DOI: 10.1136/archdischild-2016-311372] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/28/2017] [Accepted: 03/31/2017] [Indexed: 11/04/2022]
Abstract
Pubertal induction in girls with ovarian insufficiency aims to mimic normal puberty, a highly complex process. Here we amalgamate the sparse global evidence and propose three options for pubertal induction regimens including oral ethinyloestradiol, and oral and transdermal 17β-oestradiol. The introduction of progestogens is discussed and the transition to hormone supplementation for adult women. The merits and disadvantages of the different options are detailed. The available evidence indicates that transdermal 17β-oestradiol has the most favourable efficacy, safety and cost profile but randomised controlled trials are urgently required to determine which regimen provides the best clinical outcomes.
Collapse
Affiliation(s)
- Debbie Matthews
- Department of Child Health, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Louise Bath
- Department of Endocrinology and Diabetes, Royal Hospital for Sick Children, Edinburgh, Scotland
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Avril Mason
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, UK
| | - Arlene Smyth
- Executive Officer Turner Syndrome Support Society, Clydebank Business Park, Glasgow, UK
| | - Mars Skae
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.,Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| |
Collapse
|
49
|
Morselli E, Santos RS, Criollo A, Nelson MD, Palmer BF, Clegg DJ. The effects of oestrogens and their receptors on cardiometabolic health. Nat Rev Endocrinol 2017; 13:352-364. [PMID: 28304393 DOI: 10.1038/nrendo.2017.12] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiovascular disease (CVD) is one of the leading causes of mortality in developed countries. The incidence of CVD is sexually dimorphic, and research has focused on the contribution of sex steroids to the development and progression of the cardiometabolic syndrome, which is defined as a clustering of interrelated risk factors that promote the development of atherosclerosis (which can lead to CVD) and type 2 diabetes mellitus. Data are inconclusive as to how sex steroids and their respective receptors increase or suppress the risk of developing the cardiometabolic syndrome and thus CVD. In this Review, we discuss the potential role, or roles, of sex hormones in cardiometabolic health by first focusing on the influence of oestrogens and their receptors on the risk of developing cardiometabolic syndrome and CVD. We also highlight what is known about testosterone and its potential role in protecting against the development of the cardiometabolic syndrome and CVD. Given the inconclusive nature of the data regarding the direct effects of each sex hormone, we advocate and highlight the importance of studying the relative levels and the ratio of sex hormones to each other, as well as the use of cross sex hormone therapy and its effect on cardiometabolic health.
Collapse
Affiliation(s)
- Eugenia Morselli
- Department of Physiology, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Roberta S Santos
- Obesity and Comorbidities Research Center, Institute of Biology, State University of Campinas, Campinas 1, 3083-864, Brazil
- Cedars-Sinai Diabetes and Obesity Research Institute, Department of Biomedical Research, Los Angeles, California 90048, USA
| | - Alfredo Criollo
- Advanced Center for Chronic Diseases (ACCDiS) and Center for Molecular Studies of the Cell (CEMC), Santiago 8380000, Chile
- Instituto de Investigación en Ciencias Odontológicas (ICOD), Facultad de Odontología, Universidad de Chile, Santiago 8380492, Chile
| | - Michael D Nelson
- Applied Physiology and Advanced Imaging Laboratory, Department of Kinesiology, University of Texas at Arlington, Texas 76019, USA
| | - Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Deborah J Clegg
- Cedars-Sinai Diabetes and Obesity Research Institute, Department of Biomedical Research, Los Angeles, California 90048, USA
| |
Collapse
|
50
|
Folsom LJ, Slaven JE, Nabhan ZM, Eugster EA. CHARACTERIZATION OF SPONTANEOUS AND INDUCED PUBERTY IN GIRLS WITH TURNER SYNDROME. Endocr Pract 2017; 23:768-774. [PMID: 28332872 DOI: 10.4158/ep161738.or] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To characterize puberty in girls with Turner syndrome (TS) and determine whether specific patient characteristics are associated with the timing of menarche. We also sought to compare spontaneous versus induced puberty in these patients. METHODS Medical records of girls followed in our Pediatric Endocrine clinic for TS from 2007 to 2015 were reviewed. RESULTS Fifty-three girls were included, of whom 10 (19%) achieved menarche spontaneously and 43 (81%) received hormone replacement therapy (HRT). Of girls receiving HRT, a younger age at estrogen initiation correlated with a longer time to menarche (P = .02), and a mosaic karyotype was associated with a shorter time to menarche (P = .02), whereas no relationship was seen for body mass index, estrogen regimen, or maternal age at menarche. Nineteen girls (44%) receiving HRT had bleeding on estrogen alone at a wide dose range and were more likely to be on transdermal than oral preparations (P = .01). Girls with spontaneous puberty achieved menarche at a younger age (P<.01) and were more likely to have mosaic TS (P = .02). CONCLUSION Significant variability in the timing of menarche exists among girls with TS. However, age at pubertal induction and karyotype were significantly correlated with age at menarche in our patients. A wide range of estrogen doses is seen in girls who bleed prior to progesterone, suggesting extreme variability in estrogen sensitivity among patients with TS. Girls achieving spontaneous menarche are younger and more likely to have a mosaic karyotype than those with induced menarche. Large-scale prospective studies are needed to confirm these results. ABBREVIATIONS BMI = body mass index; HRT = hormone replacement therapy; TS = Turner syndrome.
Collapse
|