Events surrounding the initiation of puberty with long term subcutaneous pulsatile gonadotropin-releasing hormone in a female patient with Kallman's syndrome

A review of Kallmann syndrome: genetics, pathophysiology, and clinical management

Kallmann syndrome is a genetic disorder with the hallmarks of anosmia and hypogonadotrophic hypogonadism. It has a male preponderance. With the elucidation of the genetic pathways involved, affected females and inheritance patterns are becoming more clearly identified. It is an eminently treatable disorder, but it must first be recognized by the physician. With treatment, favorable reproductive outcomes can be attained in addition to maturation of secondary sex characteristics.

Pregnancy in women with Kallmann's syndrome

OBJECTIVE

To induce of ovulation and pregnancy in women with Kallmann's syndrome.

DESIGN

Retrospective study.

PATIENTS

Three women with hypogonadotropic hypogonadism and anosmia with a desire for pregnancy.

INTERVENTIONS

Investigation of hypothalamic-pituitary-ovarian function and induction of ovulation by pulsatile GnRH or intramuscular human pituitary gonadotropins (hPG) or hMG with hCG.

MAIN OUTCOME MEASURES

Successful induction of ovulation as measured by serum P levels and successful pregnancy.

RESULTS

Ovulation was induced successfully in all three patients on more than one occasion and nine pregnancies occurred. Gonadotropin-releasing hormone was given IV by an electronically timed syringe driver. A total of 12 pulsatile GnRH cycles resulted in two pregnancies, 6 of these cycles being in one patient who did not ovulate or conceive with this therapy. Ovulation occurred in 10 of 16 hMG or hPG cycles, with conception in 7 of these. Gonadotropin usage was higher in these women compared with women with hypogonadotropic hypogonadism without anosmia (2,850 compared with 2,100 IU per treatment cycle), and the follicular phase was longer.

CONCLUSIONS

All three women conceived and had children after induction of ovulation. The success rate of these therapies in Kallmann's syndrome appears to be high in spite of very few reports in the literature.

Kallmann's syndrome and anorexia nervosa: a diagnostic dilemma

Kallmann's syndrome is a rare cause of primary amenorrhea, with impairment of release of gonadotropin-releasing hormone and anosmia. We present a case in which Kallmann's syndrome had been diagnosed, but who also fulfilled the diagnostic criteria for anorexia nervosa. We discuss the diagnostic dilemma.

Injection sites and pharmacokinetics of luteinizing hormone releasing hormone: comparison of two different subcutaneous administration routes

A normal pituitary-gonadal function is reinduced by iv or sc pulsatile LHRH therapy, administered by a portable pump. In order to evaluate the differences between different sites of injection on the LHRH bioavailability, we compared the LHRH plasma concentration after a single LHRH injection in the lower abdominal wall and in the upper arm, in 5 patients with idiopathic hypogonadotropic hypogonadism, during LHRH treatment. Our data showed no significant differences in using both administration routes. In fact, LHRH absorption (secretory area and peak value) is quite similar. However, patients tolerated LHRH administration in the abdominal wall more so than in the upper arm. Both ways of administration are effective with regards to the pituitary responsiveness but we can not forget that patients compliance is of great importance in order to obtain the best results in a long-term therapy.

Pituitary function in isolated gonadotrophin deficiency

Hypothalamic-pituitary function was assessed in 24 individuals with isolated gonadotrophin deficiency (IGD). Thirteen had normal olfaction (Group I) while 11 (Group II) had anosmia (Kallmann's syndrome). In response to a 10 micrograms intravenous (i.v.) bolus of GnRH, the minimal dose required to evoke a consistent gonadotrophin response in normal subjects, the patients responded with significant LH and FSH increases over baseline (P less than 0.01). In Group II patients, large doses (150 micrograms) of GnRH, which elicit maximal release of gonadotrophin in normal subjects did not increase gonadotrophin release beyond that produced by a 10 micrograms bolus. In response to two 10 micrograms GnRH doses, at times 0 and 120 min, the IGD patients responded with similar LH increases to both boluses (both P less than 0.01 compared to baseline). The maximal PRL responses to arginine infusion and to TRH in the male patients were similar to those of normal males. However, in the IGD females, the PRL response to TRH was less than in normal females. The TSH responses to TRH in IGD males and females were similar to each other and similar to normal. The IGD male GH response to arginine infusion was comparable to that in normal males. We conclude that (1) IGD patients appear to retain minimal endogenous GnRH secretion so that the IGD pituitary responds to a minimal dose of GnRH without priming; (2) IGD is a heterogeneous syndrome in which affected individuals with and without normal olfaction represent parts of the spectrum of the same disease; and (3) except for the PRL response in females, the PRL, TSH and GH responses demonstrate that the IGD pituitaries are largely intact.

Hypersensitivity reaction with intravenous GnRH after pulsatile subcutaneous GnRH treatment in male hypogonadotrophic hypogonadism

Chronic pulsatile subcutaneous administration of low doses of gonadotrophin releasing hormone (GnRH) is an effective therapy for men with hypogonadotrophic hypogonadism. Hypersensitivity reactions to GnRH are rare. We wish to report hypersensitivity reactions with intravenous GnRH after low dose subcutaneous pulsatile GnRH treatment in two men with hypogonadotrophic hypogonadism due to suprasellar disease.