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Hannema SE, Wolffenbuttel KP, van Bever Y, Bruggenwirth HT, Hersmus R, Oosterhuis JW, Looijenga LHJ. Response to letter to the editor: 'Gonadal tumour screening in XY gonadal dysgenesis'. Clin Endocrinol (Oxf) 2024; 100:466-467. [PMID: 38469934 DOI: 10.1111/cen.15039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Sabine E Hannema
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Pediatric Endocrinology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Paediatric Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Katja P Wolffenbuttel
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Yolande van Bever
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Hennie T Bruggenwirth
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Remko Hersmus
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J Wolter Oosterhuis
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Princess Máxima Center for Pediatric Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leendert H J Looijenga
- Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, DSD-Expert Center, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Princess Máxima Center for Pediatric Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Boogers LS, Wiepjes CM, Staphorsius AS, Klink DT, Ciancia S, Romani A, Stolk THR, van den Boogaard E, Steensma TD, de Vries ALC, van Trotsenburg ASP, den Heijer M, Fisher AD, Cools M, Hannema SE. A European Network for the Investigation of Gender Incongruence in adolescents. J Sex Med 2024; 21:350-356. [PMID: 38427555 DOI: 10.1093/jsxmed/qdae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Knowledge regarding the effects and side effects of gender-affirming hormone therapy (GAHT) in adults is rapidly growing, partly through international research networks such as the European Network for the Investigation of Gender Incongruence (ENIGI). However, data on the effects of puberty suppression (PS) and GAHT in transgender and gender diverse (TGD) youth are limited, although these data are of crucial importance, given the controversies surrounding this treatment. AIM We sought to present a detailed overview of the design of the ENIGI Adolescents study protocol, including the first baseline data. METHODS The ENIGI Adolescents study is an ongoing multicenter prospective cohort study. This study protocol was developed by 3 European centers that provide endocrine care for TGD adolescents and were already part of the ENIGI collaboration: Amsterdam, Ghent, and Florence. OUTCOMES Study outcomes include physical effects and side effects, laboratory parameters, bone mineral density, anthropometric characteristics, attitudes toward fertility and fertility preservation, and psychological well-being, which are measured in the study participants during PS and GAHT, up to 3 years after the start of GAHT. RESULTS Between November 2021 and May 2023, 172 TGD adolescents were included in the ENIGI Adolescents protocol, of whom 51 were assigned male at birth (AMAB) and 121 were assigned female at birth (AFAB); 3 AFAB participants reported a nonbinary gender identification. A total of 76 participants were included at the start of PS, at a median (IQR) age of 13.7 (12.9-16.5) years in AMAB and 13.5 (12.4-16.1) years in AFAB individuals. The remaining 96 participants were included at start of GAHT, at a median (IQR) age of 15.9 (15.1-17.4) years in AFAB and 16.0 (15.1-16.8) years in AMAB individuals. At the time of this report the study was open for inclusion and follow-up measurements were ongoing. CLINICAL IMPLICATIONS In response to the rising demand for gender-affirming treatment among TGD youth, this ongoing study is fulfilling the need for prospective data on the effects and safety of PS and GAHT, thus providing a foundation for evidence-based healthcare decisions. STRENGTHS AND LIMITATIONS This study has a strong multicenter, prospective design that allows for systematic data collection. The use of clinical and self-reported data offers a broad range of outcomes to evaluate. Nevertheless, the burden of additional measurements and questionnaires may lead to withdrawal or lower response rates. Few participants with a non-binary gender identity have been included. CONCLUSION With the ENIGI Adolescents study we aim to create a comprehensive dataset that we can use for a wide range of studies to address current controversies and uncertainties and to improve healthcare for TGD adolescents.
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Affiliation(s)
- Lidewij S Boogers
- Department of Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Pediatric Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1081 HZ, Amsterdam, The Netherlands
| | - Chantal M Wiepjes
- Department of Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1081 HZ, Amsterdam, The Netherlands
| | - Annemieke S Staphorsius
- Department of Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Daniel T Klink
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, 9000, Ghent, Belgium
| | - Silvia Ciancia
- Department of Internal Medicine and Pediatrics, Ghent University, 9000, Ghent, Belgium
| | - Alessia Romani
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, 50139, Florence, Italy
| | - Tessa H R Stolk
- Department of Obstetrics & Gynaecology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Emmy van den Boogaard
- Department of Obstetrics & Gynaecology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Thomas D Steensma
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HZ, Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1081 HZ, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, 50139, Florence, Italy
| | - Martine Cools
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, 9000, Ghent, Belgium
| | - Sabine E Hannema
- Department of Pediatric Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1081 HZ, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, 1081 HZ, Amsterdam, The Netherlands
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Cools M, Grijp C, Neirinck J, Tavernier SJ, Schelstraete P, Van De Velde J, Morbée L, De Baere E, Bonroy C, van Bever Y, Bruggenwirth H, Vermont C, Hannema SE, De Rijke Y, Abdulhadi-Atwan M, Zangen D, Verdin H, Haerynck F. Spleen function is reduced in individuals with NR5A1 variants with or without a difference of sex development: a cross-sectional study. Eur J Endocrinol 2024; 190:34-43. [PMID: 38128121 DOI: 10.1093/ejendo/lvad174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE NR5A1 is a key regulator of sex differentiation and has been implicated in spleen development through transcription activation of TLX1. Concerns exist about hypo- or asplenism in individuals who have a difference of sex development (DSD) due to an NR5A1 disease-causing variant. We aimed to assess spleen anatomy and function in a clinical cohort of such individuals and in their asymptomatic family member carriers. DESIGN Cross-sectional assessment in 22 patients with a DSD or primary ovarian insufficiency and 5 asymptomatic carriers from 18 families, harboring 14 different NR5A1 variants. METHODS Spleen anatomy was assessed by ultrasound, spleen function by peripheral blood cell count, white blood cell differentiation, percentage of nonswitched memory B cells, specific pneumococcal antibody response, % pitted red blood cells, and Howell-Jolly bodies. RESULTS Patients and asymptomatic heterozygous individuals had significantly decreased nonswitched memory B cells compared to healthy controls, but higher than asplenic patients. Thrombocytosis and spleen hypoplasia were present in 50% of heterozygous individuals. Four out of 5 individuals homozygous for the previously described p.(Arg103Gln) variant had asplenia. CONCLUSIONS Individuals harboring a heterozygous NR5A1 variant that may cause DSD have a considerable risk for functional hyposplenism, irrespective of their gonadal phenotype. Splenic function should be assessed in these individuals, and if affected or unknown, prophylaxis is recommended to prevent invasive encapsulated bacterial infections. The splenic phenotype associated with NR5A1 variants is more severe in homozygous individuals and is, at least for the p.(Arg103Gln) variant, associated with asplenism.
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Affiliation(s)
- Martine Cools
- Department of Internal Medicine and Pediatrics, Pediatric Endocrinology Service, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
| | - Celien Grijp
- Department of Internal Medicine and Pediatrics, Pediatric Endocrinology Service, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
| | - Jana Neirinck
- Department of Diagnostic Science, Ghent University, Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | - Simon J Tavernier
- Department of Internal Medicine and Pediatrics, PID Research Lab, Ghent University, 9000 Ghent, Belgium
- Laboratory of Molecular Signal Transduction in Inflammation, Center for Inflammation Research, VIB, 9000 Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Petra Schelstraete
- Department of Internal Medicine and Pediatrics, Pediatric Pulmonology and Infectious Diseases, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
| | - Julie Van De Velde
- Department of Internal Medicine and Pediatrics, Pediatric Endocrinology Service, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
- Center for Medical Genetics, Ghent University Hospital, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Lieve Morbée
- Department of Radiology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics, Ghent University Hospital, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Carolien Bonroy
- Department of Diagnostic Science, Ghent University, Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | - Yolande van Bever
- Department of Clinical Genetics, Erasmus MC, University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Hennie Bruggenwirth
- Department of Clinical Genetics, Erasmus MC, University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Clementien Vermont
- Department of Pediatric Infectious Diseases and Immunology, Erasmus Medical Center-Sophia Children's Hospital, 3015 GD Rotterdam, The Netherlands
| | - Sabine E Hannema
- Department of Pediatric Endocrinology, Erasmus Medical Center-Sophia Children's Hospital, 3015 GD Rotterdam, The Netherlands
- Department of Paediatric Endocrinology, Gastroenterology Endocrinology Metabolism, Reproduction and Development, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Yolanda De Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Center 3015 GD Rotterdam, The Netherlands
| | - Maha Abdulhadi-Atwan
- Department of Pediatrics, Pediatric Endocrinology Service, Palestine Red Crescent Society Hospital, PO Box 421, Hebron, Palestine
| | - David Zangen
- Division of Pediatric Endocrinology, Faculty of Medicine, Hadassah University Hospital, Hebrew University of Jerusalem, 91120 Jerusalem, Israel
| | - Hannah Verdin
- Center for Medical Genetics, Ghent University Hospital, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Filomeen Haerynck
- Department of Internal Medicine and Pediatrics, PID Research Lab, Ghent University, 9000 Ghent, Belgium
- Department of Pediatric Pulmonology and Immunology, Centre for Primary Immune Deficiency, Jeffrey Modell Diagnostic and Research Centre for PID, Ghent University Hospital, 9000 Ghent, Belgium
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Heijboer AC, Hannema SE. Androgen Excess and Deficiency: Analytical and Diagnostic Approaches. Clin Chem 2023; 69:1361-1373. [PMID: 37794651 DOI: 10.1093/clinchem/hvad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/18/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Androgens are synthesized from cholesterol through sequential conversions by enzymes in the adrenal glands and gonads. Serum levels of androgens change during the different phases of life and regulate important developmental and maturational processes. Androgen excess or deficiency can therefore present at various ages in various ways. CONTENT The diagnostic approach for atypical genitalia, premature pubarche, delayed pubertal onset or progression, and hirsutism or virilization, including measurement of androgens (testosterone, androstenedione, 17-OHprogesterone, dehydroepiandrosterone, and dihydrotestosterone) is discussed in the current review. Androgens can be measured in serum, saliva, urine, or dried blood spots. Techniques to measure androgens, including immunoassays and LC-MS, have their own advantages and pitfalls. In addition, pre- and postanalytical issues are important when measuring androgens. SUMMARY During clinical interpretation of androgen measurements, it is important to take preanalytical circumstances, such as time of blood withdrawal, into account. As immunoassays have major drawbacks, especially in samples from women and neonates, concentrations measured using these assays should be interpreted with care. Reference intervals can only be used in relation to the measurement technique and the standardization of the assay. In the near future, new androgens will probably be added to the current repertoire to further improve the diagnosis and follow-up of androgen excess or deficiency.
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Affiliation(s)
- Annemieke C Heijboer
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatric Endocrinology, Amsterdam UMC location Vrije Universiteit, Emma Children's Hospital, Amsterdam, the Netherlands
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Vrouenraets LJJJ, de Vries ALC, Arnoldussen M, Hannema SE, Lindauer RJL, de Vries MC, Hein IM. Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians. Eur Child Adolesc Psychiatry 2023; 32:2343-2361. [PMID: 36115898 PMCID: PMC10576681 DOI: 10.1007/s00787-022-02076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
According to international transgender care guidelines, transgender adolescents should have medical decision-making competence (MDC) to start puberty suppression (PS) and halt endogenous pubertal development. However, MDC is a debated concept in adolescent transgender care and little is known about the transgender adolescents', their parents', and clinicians' perspectives on this. Increasing our understanding of these perspectives can improve transgender adolescent care. A qualitative interview study with adolescents attending two Dutch gender identity clinics (eight transgender adolescents who proceeded to gender-affirming hormones after PS, and six adolescents who discontinued PS) and 12 of their parents, and focus groups with ten clinicians was conducted. From thematic analysis, three themes emerged regarding transgender adolescents' MDC to start PS: (1) challenges when assessing MDC, (2) aspects that are considered when assessing MDC, and (3) MDC's relevance. The four criteria one needs to fulfill to have MDC-understanding, appreciating, reasoning, communicating a choice-were all, to a greater or lesser extent, mentioned by most participants, just as MDC being relative to a specific decision and context. Interestingly, most adolescents, parents and clinicians find understanding and appreciating PS and its consequences important for MDC. Nevertheless, most state that the adolescents did not fully understand and appreciate PS and its consequences, but were nonetheless able to decide about PS. Parents' support of their child was considered essential in the decision-making process. Clinicians find MDC difficult to assess and put into practice in a uniform way. Dissemination of knowledge about MDC to start PS would help to adequately support adolescents, parents and clinicians in the decision-making process.
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Affiliation(s)
- Lieke Josephina Jeanne Johanna Vrouenraets
- Department of Medical Psychology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Emma Children's Hospital, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ramón J L Lindauer
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
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Hannema SE, Wolffenbuttel KP, van Bever Y, Brüggenwirth HT, van den Berg SAA, Hersmus R, Oosterhuis JW, Looijenga LHJ. Undetectable anti-Mullerian hormone and inhibin B do not preclude the presence of germ cell tumours in 45,X/46,XY or 46,XY gonadal dysgenesis. Clin Endocrinol (Oxf) 2023; 99:58-63. [PMID: 36905105 DOI: 10.1111/cen.14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Individuals with 45,X/46,XY or 46,XY gonadal dysgenesis are at increased risk of germ cell malignancies. Therefore, prophylactic bilateral gonadectomy is advised in girls and considered in boys with atypical genitalia for undescended, macroscopically abnormal gonads. However, severely dysgenetic gonads may not contain germ cells rendering gonadectomy unnecessary. Therefore, we investigate if undetectable preoperative serum anti-Müllerian hormone (AMH) and inhibin B can predict the absence of germ cells, (pre)malignant or otherwise. DESIGN, PATIENTS AND MEASUREMENTS Individuals who had undergone bilateral gonadal biopsy and/or gonadectomy because of suspected gonadal dysgenesis in 1999-2019 were included in this retrospective study if preoperative AMH and/or inhibin B were available. Histological material was reviewed by an experienced pathologist. Haematoxylin and eosin and immunohistochemical stainings for SOX9, OCT4, TSPY and SCF (KITL) were used. RESULTS Thirteen males and 16 females were included, 20 with 46,XY and 9 with 45,X/46,XY DSD. Three females had dysgerminoma alongside gonadoblastoma; two gonadoblastoma, one germ cell neoplasia in situ (GCNIS) and three males had pre-GCNIS and/or pre-gonadoblastoma. Gonadoblastoma and/or dysgerminoma were present in 3/11 individuals with undetectable AMH and inhibin B, one of whom also had non-(pre)malignant germ cells. Of the other 18, in whom AMH and/or inhibin B were detectable, only one had no germ cells. CONCLUSIONS Undetectable serum AMH and inhibin B cannot reliably predict the absence of germ cells and germ cell tumours in individuals with 45,X/46,XY or 46,XY gonadal dysgenesis. This information should help in counselling about prophylactic gonadectomy, taking into account both the germ cell cancer risk and potential for gonadal function.
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Affiliation(s)
- Sabine E Hannema
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatric Endocrinology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Katja P Wolffenbuttel
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Yolande van Bever
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hennie T Brüggenwirth
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, the Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Remko Hersmus
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - J Wolter Oosterhuis
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leendert H J Looijenga
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Claahsen-van der Grinten HL, Hannema SE, Klink D, Roeffen J, Spath MA, Verhaak C, de Vries ALC. [Children and adolescents with gender questions: dilemmas in the hormonal treatment by multidisciplinary teams]. Ned Tijdschr Geneeskd 2023; 167:D7548. [PMID: 37493291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
In the Netherlands but also in many other countries, there is an increasing social discussion about gender identity and gender diversity, and an increasing number of children and adolescents are seeking medical help because of questions about their gender identity. The cause of this increase is still unknown. Gender questions are diverse and require an individual approach by a multidisciplinary team. A number of adolescents have additional problems such as mood problems, autistiform symptoms and systemic problems. Diagnosis and treatment takes place in accordance with the quality standard for transgender care somatic and psychological. Hormonal treatment can help to reduce gender dysphoria and improve mental health.
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Affiliation(s)
| | - Sabine E Hannema
- Amsterdam UMC, locatie VUmc, Kennis- en Zorgcentrum voor Genderdysforie, Amsterdam
| | - Daniel Klink
- Amsterdam UMC, locatie VUmc, Kennis- en Zorgcentrum voor Genderdysforie, Amsterdam
| | - Joep Roeffen
- Amsterdam UMC, locatie VUmc, Kennis- en Zorgcentrum voor Genderdysforie, Amsterdam
| | - Marian A Spath
- Radboudumc, Expertisecentrum Geslacht & Gender, Nijmegen
| | - Chris Verhaak
- Radboudumc, Expertisecentrum Geslacht & Gender, Nijmegen
| | - Annelou L C de Vries
- Amsterdam UMC, locatie VUmc, Kennis- en Zorgcentrum voor Genderdysforie, Amsterdam
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van der Stoep MYEC, Bense JE, de Kloet LC, von Asmuth EGJ, de Pagter APJ, Hannema SE, Guchelaar HJ, Zwaveling J, Lankester AC. Effect of busulfan and treosulfan on gonadal function after allogeneic stem cell transplantation in children and adolescents with nonmalignant diseases is not exposure-dependent. Transplant Cell Ther 2023:S2666-6367(23)01287-3. [PMID: 37156421 DOI: 10.1016/j.jtct.2023.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/05/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
With an increasing number of young patients surviving into adulthood after hematopoietic stem cell transplantation (HSCT), gonadal dysfunction becomes an important late effect with significant impact on quality of life. In this retrospective study, we evaluated the exposure of busulfan (BU) and treosulfan (TREO) in relation to gonadal function in pediatric patients transplanted for a nonmalignant disease between 1997 and 2018. In the BU cohort, 56 patients could be evaluated and gonadal dysfunction occurred in 35 (63%) patients. Lower BU exposure (cumulative area under the curve cAUC <70 mg*h/L) was not associated with a reduced risk of gonadal dysfunction (OR 0.92 95% confidence interval (CI) 0.25-3.49, p=0.90). In the TREO cohort, 32 patients were evaluable and gonadal insufficiency occurred in 9 patients (28%). Lower TREO exposure (AUC <1750 mg*h/L on day 1) was not associated with a reduced risk of gonadal dysfunction (OR 1.6 95%CI 0.16-36.6, p=0.71). Our data do not support the premise that reduced intensity BU-based conditioning lowers the risk for gonadal toxicity and it is unlikely that TDM-based reduced treosulfan exposure will further limit the risk for gonadal dysfunction.
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Affiliation(s)
- M Y Eileen C van der Stoep
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands; Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Joëll E Bense
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Liselotte C de Kloet
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik G J von Asmuth
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne P J de Pagter
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Juliette Zwaveling
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C Lankester
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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9
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van der Loos MATC, Klink DT, Hannema SE, Bruinsma S, Steensma TD, Kreukels BPC, Cohen-Kettenis PT, de Vries ALC, den Heijer M, Wiepjes CM. Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol. J Sex Med 2023; 20:398-409. [PMID: 36763938 DOI: 10.1093/jsxmed/qdac029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/10/2022] [Accepted: 11/10/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Twenty years ago, the Dutch Protocol-consisting of a gonadotropin-releasing hormone agonist (GnRHa) to halt puberty and subsequent gender-affirming hormones (GAHs)-was implemented to treat adolescents with gender dysphoria. AIM To study trends in trajectories in children and adolescents who were referred for evaluation of gender dysphoria and/or treated following the Dutch Protocol. METHODS The current study is based on a retrospective cohort of 1766 children and adolescents in the Amsterdam Cohort of Gender Dysphoria. OUTCOMES Outcomes included trends in number of intakes, ratio of assigned sex at birth, age at intake, age at start of GnRHa and GAH, puberty stage at start of GnRHa, proportions of adolescents starting and stopping GnRHa, reasons for refraining from GnRHa, and proportions of people undergoing gender-affirming surgery. RESULTS A steep increase in referrals was observed over the years. A change in the AMAB:AFAB ratio (assigned male at birth to assigned female at birth) was seen over time, tipping the balance toward AFAB. Age at intake and at start of GnRHa has increased over time. Of possibly eligible adolescents who had their first visit before age 10 years, nearly half started GnRHa vs around two-thirds who had their first visit at or after age 10 years. The proportion starting GnRHa rose only for those first visiting before age 10. Puberty stage at start of GnRHa fluctuated over time. Absence of gender dysphoria diagnosis was the main reason for not starting GnRHa. Very few stopped GnRHa (1.4%), mostly because of remission of gender dysphoria. Age at start of GAH has increased mainly in the most recent years. When a change in law was made in July 2014 no longer requiring gonadectomy to change legal sex, percentages of people undergoing gonadectomy decreased in AMAB and AFAB. CLINICAL IMPLICATIONS A substantial number of adolescents did not start medical treatment. In the ones who did, risk for retransitioning was very low, providing ongoing support for medical interventions in comprehensively assessed gender diverse adolescents. STRENGTHS AND LIMITATIONS Important topics on transgender health care for children and adolescents were studied in a large cohort over an unprecedented time span, limited by the retrospective design. CONCLUSION Trajectories in diagnostic evaluation and medical treatment in children and adolescents referred for gender dysphoria are diverse. Initiating medical treatment and need for surgical procedures depends on not only personal characteristics but societal and legal factors as well.
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Affiliation(s)
- Maria A T C van der Loos
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Endocrinology and Metabolism, 1081HV, Amsterdam, The Netherlands
| | - Daniel T Klink
- Ghent University Hospital, Division of Pediatric Endocrinology, 9000, Ghent, Belgium
| | - Sabine E Hannema
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Pediatrics, 1081HV, Amsterdam, The Netherlands
| | - Sjoerdje Bruinsma
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Medical Psychology, 1081HV, Amsterdam, The Netherlands
| | - Thomas D Steensma
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Medical Psychology, 1081HV, Amsterdam, The Netherlands
| | - Baudewijntje P C Kreukels
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Medical Psychology, 1081HV, Amsterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Medical Psychology, 1081HV, Amsterdam, The Netherlands
| | - Annelou L C de Vries
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Child and Adolescent Psychiatry, 1081HV, Amsterdam, The Netherlands
| | - Martin den Heijer
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Endocrinology and Metabolism, 1081HV, Amsterdam, The Netherlands
| | - Chantal M Wiepjes
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Endocrinology and Metabolism, 1081HV, Amsterdam, The Netherlands
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10
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van Bever Y, Groenenberg IAL, Knapen MFCM, Dessens AB, Hannema SE, Wolffenbuttel KP, Diderich KEM, Hoefsloot LH, Srebniak MI, Bruggenwirth HT. Prenatal ultrasound finding of atypical genitalia: Counseling, genetic testing and outcomes. Prenat Diagn 2023; 43:162-182. [PMID: 35808910 DOI: 10.1002/pd.6205] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To report uptake of genetic counseling (GC) and prenatal genetic testing after the finding of atypical genitalia on prenatal ultrasound (US) and the clinical and genetic findings of these pregnancies. METHODS A retrospective cohort study (2017-2019) of atypical fetal genitalia in a large expert center for disorders/differences of sex development. We describe counseling aspects, invasive prenatal testing, genetic and clinical outcome of fetuses apparently without [group 1, n = 22 (38%)] or with [group 2, n = 36 (62%)] additional anomalies on US. RESULTS In group 1, 86% of parents opted for GC versus 72% in group 2, and respectively 58% and 15% of these parents refrained from invasive testing. Atypical genitalia were postnatally confirmed in 91% (group 1) and 64% (group 2), indicating a high rate of false positive US diagnosis of ambiguous genitalia. Four genetic diagnoses were established in group 1 (18%) and 10 in group 2 (28%). The total genetic diagnostic yield was 24%. No terminations of pregnancy occurred in group 1. CONCLUSIONS For optimal care, referral for an expert fetal US scan, GC and invasive diagnostics including broad testing should be offered after prenatal detection of isolated atypical genitalia.
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Affiliation(s)
- Yolande van Bever
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Irene A L Groenenberg
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maarten F C M Knapen
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Arianne B Dessens
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Sabine E Hannema
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Pediatric Endocrinology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Paediatric Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Katja P Wolffenbuttel
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Karin E M Diderich
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Lies H Hoefsloot
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Malgorzata I Srebniak
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hennie T Bruggenwirth
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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11
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de Vries ALC, Hannema SE. Growing Evidence and Remaining Questions in Adolescent Transgender Care. N Engl J Med 2023; 388:275-277. [PMID: 36652360 DOI: 10.1056/nejme2216191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Annelou L C de Vries
- From the Departments of Child and Adolescent Psychiatry (A.L.C.V.) and Pediatrics (S.E.H.), Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam
| | - Sabine E Hannema
- From the Departments of Child and Adolescent Psychiatry (A.L.C.V.) and Pediatrics (S.E.H.), Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam
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12
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Boogers LS, Chen BSJ, Coerts MJ, Rinkel RNPM, Hannema SE. Mobile Phone Applications Voice Tools and Voice Pitch Analyzer Validated With LingWAVES to Measure Voice Frequency. J Voice 2022:S0892-1997(22)00318-6. [PMID: 36371270 DOI: 10.1016/j.jvoice.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Voice frequency can be measured to assess the voice change in transgender men and women during treatment. There are many applications that can analyze voice frequency. This validation study aimed to compare the ability to measure voice frequency of the mobile phone applications "Voice Tools" and "Voice Pitch Analyzer" with the registration program LingWAVES as the gold standard. STUDY DESIGN Prospective validation study. METHODS A total of 45 participants of whom 20 transgender individuals were included. They were asked to read "The North Wind and the Sun" twice. The first measurement compared voice frequency measured by Voice Tools with LingWAVES while the second measurement compared Voice Pitch Analyzer with LingWAVES. The two applications that were being compared simultaneously measured the voice frequency. Pearson's regression correlations were performed to test for correlation between the mobile phone applications and LingWAVES. RESULTS Significant correlations were demonstrated between the measurements of Voice Tools and LingWAVES (P < 0.001) and between Voice Pitch Analyzer and LingWAVES (P < 0.001). Voice Tools overestimated voice frequency with a median deviation of 2Hz (range -4 to 20). The overestimation was more pronounced in the high ranges. Voice Pitch Analyzer showed underestimation of voice frequency in high ranges. Median deviation was -2Hz (range -16 to 14). CONCLUSIONS This validation study shows that voice frequency can be reliably measured with the mobile phone applications "Voice Tools" and "Voice Pitch Analyzer". Combined with the ease of use, these applications can be used to measure voice frequency in clinical practice and for research purposes.
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Affiliation(s)
- Lidewij S Boogers
- Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands
| | - Britney S J Chen
- Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands
| | - Marieke J Coerts
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands; Department of Otolaryngology, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands
| | - Rico N P M Rinkel
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands; Department of Otolaryngology, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands
| | - Sabine E Hannema
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands; Department of Pediatric Endocrinology, Amsterdam University Medical Center, Amsterdam, North Holland, The Netherlands.
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13
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Hoekx CA, Bresters D, le Cessie S, Oostdijk W, Hannema SE. Improved growth with growth hormone treatment in children after hematopoietic stem cell transplantation. Clin Endocrinol (Oxf) 2022; 97:596-603. [PMID: 35606687 PMCID: PMC9796667 DOI: 10.1111/cen.14782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Hematopoietic stem cell transplantation (HSCT) can be a curative treatment for malignant and nonmalignant diseases in children but is associated with significant late effects including growth failure. Growth hormone treatment (GHRx) is offered to improve growth, but limited data are available on its effect on adult height (AH). We aim to evaluate the effectiveness of GHRx. DESIGN Single-center retrospective study. PATIENTS Thirty-four patients who had received GHRx for ≥1 year were matched with two controls each, without GHRx, based on sex, indication for HSCT (malignancy, benign haematological disease or immunodeficiency), age at HSCT and conditioning with/without total body irradiation (TBI). All had reached AH. MEASUREMENTS The primary outcome measure was the difference between AH and predicted AH (PAH) at start of GHRx or the equivalent age in controls (AH-PAH), calculated according to Bailey and Pinneau. RESULTS GHRx was started at age 12.0 ± 2.6 years; median treatment duration was 3.8 years (range 1.7-9.2). AH-PAH standard deviation score (SDS) was significantly higher in growth hormone (GH) treated boys (-0.5 ± 0.7 SDS) than in controls (-1.5 ± 1.0 SDS, p < .001). Girls also had a higher AH-PAH after GHRx (+0.5 ± 0.6 SDS) compared to controls (-0.2 SDS ±0.7, p < .01). AH remained approximately 2 SDS below target height (TH) in treated and untreated individuals. Among GH-treated children, AH-PAH was higher in those who had received busulfan-based compared to TBI-based conditioning. CONCLUSION GHRx had a significant positive effect on AH compared to PAH, although AH remained far below TH. Higher AH-PAH was observed in girls and in those conditioned without TBI.
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Affiliation(s)
- Carlijn A. Hoekx
- Department of PediatricsLeiden University Medical CentreLeidenthe Netherlands
| | - Dorine Bresters
- Department of PediatricsLeiden University Medical CentreLeidenthe Netherlands
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Saskia le Cessie
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Wilma Oostdijk
- Department of PediatricsLeiden University Medical CentreLeidenthe Netherlands
| | - Sabine E. Hannema
- Department of PediatricsLeiden University Medical CentreLeidenthe Netherlands
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14
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Davidse K, van Staa A, Geilvoet W, van Eck JP, Pellikaan K, Baan J, Hokken-Koelega ACS, van den Akker ELT, Sas T, Hannema SE, van der Lely AJ, de Graaff LCG. We mind your step: understanding and preventing drop-out in the transfer from paediatric to adult tertiary endocrine healthcare. Endocr Connect 2022; 11:e220025. [PMID: 35521816 PMCID: PMC9175586 DOI: 10.1530/ec-22-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
Introduction Transition from paediatric to adult endocrinology can be challenging for adolescents, their families and healthcare professionals. Previous studies have shown that up to 25% of young adults with endocrine disorders are lost to follow-up after moving out of paediatric care. This poses a health risk for young adults, which can lead to serious and expensive medical acute and long-term complications. Methods In order to understand and prevent dropout, we studied electronic medical records of patients with endocrine disorders. These patients were over 15 years old when they attended the paediatric endocrine outpatient clinic (OPC) of our hospital in 2013-2014 and should have made the transfer to adult care at the time of the study. Results Of 387 adolescents, 131 had an indication for adult follow-up within our university hospital. Thirty-three (25%) were lost to follow-up. In 24 of them (73%), the invitation for the adult OPC had never been sent. We describe the failures in logistic processes that eventually led to dropout in these patients. Conclusion We found a 25% dropout during transfer from paediatric to adult tertiary endocrine care. Of all dropouts, 73% could be attributed to the failure of logistic steps. In order to prevent these dropouts, we provide practical recommendations for patients and paediatric and adult endocrinologists.
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Affiliation(s)
- Kirsten Davidse
- Department of Internal Medicine-Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Anneloes van Staa
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
| | - Wanda Geilvoet
- Department of Internal Medicine-Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Judith P van Eck
- Department of Paediatric Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Karlijn Pellikaan
- Department of Internal Medicine-Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Janneke Baan
- Department of Internal Medicine-Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Anita C S Hokken-Koelega
- Department of Paediatric Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Academic Centre for Growth, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Dutch Growth Research Foundation, Rotterdam, the Netherlands
| | - Erica L T van den Akker
- Department of Paediatric Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Theo Sas
- Department of Paediatric Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Diabeter, National Diabetes Care and Research Centre, Rotterdam, the Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Aart Jan van der Lely
- Department of Internal Medicine-Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Laura C G de Graaff
- Department of Internal Medicine-Endocrinology, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Academic Centre for Growth, Erasmus University Medical Centre, Rotterdam, the Netherlands
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15
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Neumann U, van der Linde A, Krone RE, Krone NP, Güven A, Güran T, Elsedfy H, Poyrazoglu S, Darendeliler F, Bachega TASS, Balsamo A, Hannema SE, Birkebaek N, Vieites A, Thankamony A, Cools M, Milenkovic T, Bonfig W, Costa EC, Atapattu N, de Vries L, Guaragna-Filho G, Korbonits M, Mohnike K, Bryce J, Ahmed SF, Voet B, Blankenstein O, Claahsen-van der Grinten HL. Treatment of congenital adrenal hyperplasia in children aged 0-3 years: a retrospective multicenter analysis of salt supplementation, glucocorticoid and mineralocorticoid medication, growth and blood pressure. Eur J Endocrinol 2022; 186:587-596. [PMID: 35290211 PMCID: PMC9066592 DOI: 10.1530/eje-21-1085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/15/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVES International guidelines recommend additional salt supplementation during infancy in classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. The influence of corticoid medication and growth has not been assessed. AIM To investigate the current use of salt supplementation, fludrocortisone (FC) and hydrocortisone (HC) dosage as well as weight, height, BMI and blood pressure (BP) in CAH children aged 0-3 years. METHODS Retrospective multicentre analysis using data from the I-CAH registry. Salt-treated (ST) and non-salt-treated (NST) children were compared regarding FC and HC dosage, weight, height and BP at 0, 3, 6, 9, 12, 18, 24, 30, and 36 months. RESULTS We analysed 2483 visits of 331 patients born after year 2000 in 13 countries (male, n = 145) with 203 ST patients (61%). NST children had significantly higher FC dosages at 1.5-4.5 months and higher HC dosages until 1.5 months of age. No differences in weight, length and BP between subgroups were observed. Children of the whole cohort showed increased BMI-SDS during the study period and about half of the reported BP readings were >P95. CONCLUSION In children treated with additional salt supplementation, FC and HC dosages are lower during the first months of life but without differences in weight, length and BP until 3 years of age compared to NST children. All children showed an increase in BMI-SDS and a high rate of BP readings >P95 until 3 years, indicating the start of weight gain and negative effects on blood pressure already in very early life.
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Affiliation(s)
- Uta Neumann
- Institute for Experimental Paediatric Endocrinology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Correspondence should be addressed to U Neumann;
| | - Annelieke van der Linde
- Amalia Children’s Hospital, Radboud University Medical Centre, Nijmegen, Netherlands
- Amphia Hospital, Breda, The Netherlands
| | - Ruth E Krone
- Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Nils P Krone
- University of Sheffield, Sheffield Children’s Hospital, Western Bank, Sheffield, UK
| | - Ayla Güven
- University of Health Science Zeynep Kamil Women and Children Hospital, Pediatric Endocrinology, Istanbul, Turkey
| | - Tülay Güran
- Marmara University Istanbul, Istanbul, Turkey
| | - Heba Elsedfy
- Pediatrics Department, Ain Shams University, Cairo, Egypt
| | - Sukran Poyrazoglu
- Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Feyza Darendeliler
- Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul, Turkey
| | | | | | - Sabine E Hannema
- Leiden University Medical Centre, Leiden, Netherlands
- Erasmus Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Niels Birkebaek
- Department of Pediatrics and Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas Buenos Aires, Buenos Aires, Argentina
| | - Ajay Thankamony
- University of Cambridge and Addenbrooke’s Hospital, Cambridge, UK
| | | | - Tatjana Milenkovic
- Institute for Mother and Child Healthcare of Serbia ‘Dr Vukan Čupić’, Belgrade, Serbia
| | - Walter Bonfig
- Technical University of Munich, Munich, Germany
- Klinikum Wels-Grieskirchen, Wels, Austria
| | | | | | - Liat de Vries
- Institute for Diabetes and Endocrinology, Schneider Children's Medical Center of Israel, Petah-Tikvah, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Klaus Mohnike
- Otto-von-Guericke Universität Magdeburg, Magdeburg, Germany
| | | | | | | | - Oliver Blankenstein
- Institute for Experimental Paediatric Endocrinology, Charité Universitätsmedizin Berlin, Berlin, Germany
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16
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Schröder MAM, van Herwaarden AE, Span PN, van den Akker ELT, Bocca G, Hannema SE, van der Kamp HJ, de Kort SWK, Mooij CF, Schott DA, Straetemans S, van Tellingen V, van der Velden JA, Sweep FCGJ, Claahsen-van der Grinten HL. Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2022; 107:e1661-e1672. [PMID: 34788830 PMCID: PMC8947312 DOI: 10.1210/clinem/dgab826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 11/20/2022]
Abstract
CONTEXT Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice daily, but there is debate about the optimal timing of the highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening). OBJECTIVE We aimed to compare 2 standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure (BP), and sleep and activity scores. METHODS This 6-week crossover study included 39 patients (aged 4-19 years) with 21OHD. Patients were treated for 3 weeks with the highest hydrocortisone dose in the morning, followed by 3 weeks with the highest dose in the evening (n = 21), or vice versa (n = 18). Androstenedione (A4) and 17-hydroxyprogesterone (17OHP) levels were quantified in saliva collected at 5 am; 7 am; 3 pm; and 11 pm during the last 2 days of each treatment period. The main outcome measure was comparison of saliva 17OHP and A4 levels between the 2 treatment strategies. RESULTS Administration of the highest dose in the evening resulted in significantly lower 17OHP levels at 5 am, whereas the highest dose in the morning resulted in significantly lower 17OHP and A4 levels in the afternoon. The 2 treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal BP, and activity and sleep scores. CONCLUSION No clear benefit for either treatment schedule was established. Given the variation in individual responses, we recommend individually optimizing dose distribution and monitoring disease control at multiple time points.
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Affiliation(s)
- Mariska A M Schröder
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Paul N Span
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, DR Rotterdam, the Netherlands
| | - Gianni Bocca
- Beatrix Children’s Hospital, Department of Pediatrics, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, RC Leiden, the Netherlands
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, MB Amsterdam, the Netherlands
| | - Hetty J van der Kamp
- Wilhelmina Children’s Hospital, Utrecht University Medical Center, EA Utrecht, the Netherlands
| | - Sandra W K de Kort
- Department of Pediatrics, Haga Teaching Hospital/Juliana Children’s Hospital, AA The Hague, the Netherlands
| | - Christiaan F Mooij
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, AZ Amsterdam, the Netherlands
| | - Dina A Schott
- Department of Pediatrics Endocrinology, Zuyderland medical center, PC Heerlen, the Netherlands
| | - Saartje Straetemans
- Department of Pediatric Endocrinology, Maastricht university medical center, HX Maastricht, the Netherlands
| | - Vera van Tellingen
- Department of Pediatrics, Catharina Hospital, EJ Eindhoven, the Netherlands
| | - Janiëlle A van der Velden
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Hedi L Claahsen-van der Grinten
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
- Correspondence: Hedi L. Claahsen-van der Grinten, MD, PhD, Amalia Children’s Hospital, Radboud University Medical Center, Department of Pediatrics, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, the Netherlands.
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17
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Tack LJW, van der Straaten S, Riedl S, Springer A, Holterhus PM, Hornig NC, Kolesinska Z, Niedziela M, Baronio F, Balsamo A, Hannema SE, Nordenström A, Poyrazoglu S, Darendeliler FF, Grinspon R, Rey R, Aljuraibah F, Bryce J, Ahmed F, Tadokoro-Cuccaro R, Hughes I, Guaragna-Filho G, Maciel-Guerra AT, Guerra-Junior G, Cools M. Growth, puberty and testicular function in boys born small for gestational age with a nonspecific disorder of sex development. Clin Endocrinol (Oxf) 2022; 96:165-174. [PMID: 34668586 DOI: 10.1111/cen.14614] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/05/2021] [Accepted: 09/26/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Being born small for gestational age (SGA) is frequently associated with unexplained disorders of sex development (nonspecific DSD) in boys. Little is known about their future growth, puberty and testicular function. Our objective is to determine the long-term endocrine outcome of boys born SGA who have a nonspecific DSD. DESIGN Boys with a nonspecific DSD born SGA and appropriate for GA (AGA) were retrieved through the International Disorders of Sex Development registry and retrospective data collected, based on a spreadsheet containing 102 items. PATIENTS AND MEASUREMENTS In total, 179 boys were included, of which 115 were born SGA and 64 were born AGA. Their growth and pubertal development were compared. Serum LH, FSH, testosterone, AMH and inhibin B levels in infancy and puberty were analysed to assess testicular function. RESULTS At 2 years of age, 30% of SGA boys had incomplete or absent catch-up growth. Boys born SGA also had higher LH during minipuberty and lower testosterone in stimulation tests (p = 0.037 and 0.040, respectively), as compared to boys born AGA. No differences were observed in timing or course of puberty or end-pubertal hormone levels. CONCLUSIONS Almost one out of three SGA boys with a nonspecific DSD experiences insufficient catch-up growth. In addition, our data suggest dysfunction of infantile Leydig cells or altered regulation of the hypothalamic-pituitary-gonadal axis in SGA boys during childhood. Sex steroid production during puberty seems unaffected.
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Affiliation(s)
- Lloyd J W Tack
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Pediatric Endocrinology Service, Ghent University, Ghent, Belgium
| | - Saskia van der Straaten
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Pediatric Endocrinology Service, Ghent University, Ghent, Belgium
| | - Stefan Riedl
- Department of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Department of Pediatrics, St Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Alexander Springer
- Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Paul-Martin Holterhus
- Department of Paediatrics, Division of Paediatric Endocrinology and Diabetes, University Hospital of Schleswig-Holstein, UKSH, Kiel, Germany
| | - Nadine C Hornig
- Department of Paediatrics, Division of Paediatric Endocrinology and Diabetes, University Hospital of Schleswig-Holstein, UKSH, Kiel, Germany
| | - Zofia Kolesinska
- Department of Pediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Federico Baronio
- Department of Medical and Surgical Sciences, Pediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Sabine E Hannema
- Department of Pediatric Endocrinology, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska University Hospital, Pediatric Endocrinology, Karolinska Institutet, Stockholm, Sweden
| | - Sukran Poyrazoglu
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatma F Darendeliler
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Romina Grinspon
- Hospital de Niños Ricardo Gutiérrez, Centro de Investigaciones Endocrinológicas 'Dr César Bergadá' (CEDIE), CONICET-FEI-División de Endocrinología, Buenos Aires, Argentina
| | - Rodolfo Rey
- Hospital de Niños Ricardo Gutiérrez, Centro de Investigaciones Endocrinológicas 'Dr César Bergadá' (CEDIE), CONICET-FEI-División de Endocrinología, Buenos Aires, Argentina
| | - Fahad Aljuraibah
- Royal Hospital for Children, Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Jillian Bryce
- Royal Hospital for Children, Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Faisal Ahmed
- Royal Hospital for Children, Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | | | - Ieuan Hughes
- Department of Pediatrics, Cambridge University Hospital, Cambridge, UK
| | - Guilherme Guaragna-Filho
- Department of Pediatrics, School of Medicine, Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Andrea T Maciel-Guerra
- Department of Pediatrics, School of Medicine, Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Gil Guerra-Junior
- Department of Pediatrics, School of Medicine, Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Martine Cools
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Pediatric Endocrinology Service, Ghent University, Ghent, Belgium
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de Nie I, Mulder CL, Meißner A, Schut Y, Holleman EM, van der Sluis WB, Hannema SE, den Heijer M, Huirne J, van Pelt AMM, van Mello NM. Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women. Hum Reprod 2021; 37:297-308. [PMID: 34791270 PMCID: PMC8804334 DOI: 10.1093/humrep/deab240] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/04/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
STUDY QUESTION Can transgender women cryopreserve germ cells obtained from their orchiectomy specimen for fertility preservation, after having used puberty suppression and/or hormonal treatment? SUMMARY ANSWER In the vast majority of transgender women, there were still immature germ cells present in the orchiectomy specimen, and in 4.7% of transgender women—who all initiated medical treatment in Tanner stage 4 or higher—mature spermatozoa were found, which would enable cryopreservation of spermatozoa or testicular tissue after having used puberty suppression and/or hormonal treatment. WHAT IS KNOWN ALREADY Gender affirming treatment (i.e. puberty suppression, hormonal treatment, and subsequent orchiectomy) impairs reproductive function in transgender women. Although semen cryopreservation is generally offered during the transition process, this option is not feasible for all transgender women (e.g. due to incomplete spermatogenesis when initiating treatment in early puberty, in case of inability to masturbate, or when temporary cessation of hormonal treatment is too disruptive). Harvesting mature spermatozoa, or testicular tissue harboring immature germ cells, from orchiectomy specimens obtained during genital gender-affirming surgery (gGAS) might give this group a chance of having biological children later in life. Previous studies on spermatogenesis in orchiectomy specimens showed conflicting results, ranging from complete absence of germ cells to full spermatogenesis, and did not involve transgender women who initiated medical treatment in early- or late puberty. STUDY DESIGN, SIZE, DURATION Histological and immunohistochemical analyses were performed on orchiectomy specimens from 214 transgender women who underwent gGAS between 2006 and 2018. Six subgroups were identified, depending on pubertal stage at initiation of medical treatment (Tanner stage 2-3, Tanner stage 4-5, adult), and whether hormonal treatment was continued or temporarily stopped prior to gGAS in each of these groups. PARTICIPANTS/MATERIALS, SETTING, METHODS All transgender women used a combination of estrogens and testosterone suppressing therapy. Orchiectomy specimen sections were stained with Mayer’s hematoxylin and eosin and histologically analyzed to assess the Johnsen score and the ratio of most advanced germ cell types in at least 50 seminiferous tubular cross-sections. Subsequently, immunohistochemistry was used to validate these findings using spermatogonia, spermatocytes or spermatids markers (MAGE-A3/A4, γH2AX, Acrosin, respectively). Possibilities for fertility preservation were defined as: preservation of spermatozoa, preservation of spermatogonial stem cells or no possibilities (in case no germ cells were found). Outcomes were compared between subgroups and logistic regression analyses were used to assess the association between the duration of hormonal treatment and the possibilities for fertility preservation. MAIN RESULTS AND THE ROLE OF CHANCE Mature spermatozoa were encountered in 4.7% of orchiectomy specimens, all from transgender women who had initiated medical treatment in Tanner stage 4 or higher. In 88.3% of the study sample orchiectomy specimens only contained immature germ cells (round spermatids, spermatocytes or spermatogonia, as most advanced germ cell type). In 7.0%, a complete absence of germ cells was observed, all these samples were from transgender women who had initiated medical treatment in adulthood. Cessation of hormonal treatment prior to gGAS did not affect the presence of germ cells or their maturation stage, nor was there an effect of the duration of hormonal treatment prior to gGAS. LIMITATIONS, REASONS FOR CAUTION Since data on serum hormone levels on the day of gGAS were not available, we were unable to verify if the transgender women who were asked to temporarily stop hormonal treatment 4 weeks prior to surgery actually did so, and if people with full spermatogenesis were compliant to treatment. WIDER IMPLICATIONS OF THE FINDINGS There may still be options for fertility preservation in orchiectomy specimens obtained during gGAS since a small percentage of transgender women had full spermatogenesis, which could enable cryopreservation of mature spermatozoa via a testicular sperm extraction procedure. Furthermore, the vast majority still had immature germ cells, which could enable cryopreservation of testicular tissue harboring spermatogonial stem cells. If maturation techniques like in vitro spermatogenesis become available in the future, harvesting germ cells from orchiectomy specimens might be a promising option for those who are otherwise unable to have biological children. STUDY FUNDING/COMPETING INTEREST None. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- I de Nie
- Department of Endocrinology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - C L Mulder
- Reproductive Biology Laboratory, Center for Reproductive Medicine, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - A Meißner
- Department of Endocrinology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Y Schut
- Reproductive Biology Laboratory, Center for Reproductive Medicine, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Holleman
- Reproductive Biology Laboratory, Center for Reproductive Medicine, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - W B van der Sluis
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - S E Hannema
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Pediatrics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M den Heijer
- Department of Endocrinology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A M M van Pelt
- Reproductive Biology Laboratory, Center for Reproductive Medicine, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - N M van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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19
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Vrouenraets LJ, de Vries MC, Hein IM, Arnoldussen M, Hannema SE, de Vries AL. Perceptions on the function of puberty suppression of transgender adolescents who continued or discontinued treatment, their parents, and clinicians. Int J Transgend Health 2021; 23:428-441. [PMID: 36324881 PMCID: PMC9621271 DOI: 10.1080/26895269.2021.1974324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Purpose: Treatment of transgender adolescents with puberty suppression (PS) was developed to provide time for exploration before pursuing gender affirming medical treatment (GAMT) with irreversible effects. It may also result in a more satisfactory physical outcome for those who continue with GAMT. Despite being the current first choice treatment, little research has examined the function of PS from the perspectives of transgender adolescents, their parents, and clinicians. Insight into the perceived functions of PS will help to adequately support adolescents in their decision-making process and give them the care they need. Methods: Qualitative study using interviews with eight transgender adolescents who proceeded with GAMT after PS ("continuers"), six adolescents who discontinued PS ("discontinuers") and 12 parents, and focus groups with ten clinicians. Results: All informants considered inhibition of development of secondary sex characteristics an important function of PS. Most continuers saw PS as the first step of GAMT. Nevertheless, some were glad that the effects were reversible even if they didn't expect to change their minds. Some discontinuers did experience PS as an expanded diagnostic phase. One continuer used the time on PS to get used to living in the affirmed gender role, and several parents found the time helpful to adapt to their child's new gender role. PS provided clinicians more time for diagnostic assessment. Conclusions: Adolescents, parents and clinicians do not all report the same functions of PS. Although international guidelines emphasize providing time for exploration of gender identity as an important reason for PS, many adolescents nowadays seem to have clear ideas about their gender identity and treatment wishes, and experience PS as the first step of GAMT. For some discontinuers however, PS offered a valued period of exploration. Guidelines could be modified to provide more customized care, taking adolescents' and parents' ideas about the functions of PS into account.
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Affiliation(s)
- Lieke J.J.J. Vrouenraets
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Oegstgeest, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C. de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M. Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, The Netherlands
| | - Sabine E. Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, the Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Annelou L.C. de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, The Netherlands
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20
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Stroek K, Ruiter A, van der Linde A, Ackermans M, Bouva MJ, Engel H, Jakobs B, Kemper EA, van den Akker ELT, van Albada ME, Bocca G, Finken MJJ, Hannema SE, Mieke Houdijk ECA, van der Kamp HJ, van Tellingen V, Paul van Trotsenburg AS, Zwaveling-Soonawala N, Bosch AM, de Jonge R, Heijboer AC, Claahsen-van der Grinten HL, Boelen A. Second-tier Testing for 21-Hydroxylase Deficiency in the Netherlands: A Newborn Screening Pilot Study. J Clin Endocrinol Metab 2021; 106:e4487-e4496. [PMID: 34171085 DOI: 10.1210/clinem/dgab464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Newborn screening (NBS) for classic congenital adrenal hyperplasia (CAH) consists of 17-hydroxyprogesterone (17-OHP) measurement with gestational age-adjusted cutoffs. A second heel puncture (HP) is performed in newborns with inconclusive results to reduce false positives. OBJECTIVE We assessed the accuracy and turnaround time of the current CAH NBS algorithm in comparison with alternative algorithms by performing a second-tier 21-deoxycortisol (21-DF) pilot study. METHODS Dried blood spots (DBS) of newborns with inconclusive and positive 17-OHP (immunoassay) first HP results were sent from regional NBS laboratories to the Amsterdam UMC Endocrine Laboratory. In 2017-2019, 21-DF concentrations were analyzed by LC-MS/MS in parallel with routine NBS. Diagnoses were confirmed by mutation analysis. RESULTS A total of 328 DBS were analyzed; 37 newborns had confirmed classic CAH, 33 were false-positive and 258 were categorized as negative in the second HP following the current algorithm. With second-tier testing, all 37 confirmed CAH had elevated 21-DF, while all 33 false positives and 253/258 second-HP negatives had undetectable 21-DF. The elevated 21-DF of the other 5 newborns may be NBS false negatives or second-tier false positives. Adding the second-tier results to inconclusive first HPs reduced the number of false positives to 11 and prevented all 286 second HPs. Adding the second tier to both positive and inconclusive first HPs eliminated all false positives but delayed referral for 31 CAH patients (1-4 days). CONCLUSION Application of the second-tier 21-DF measurement to inconclusive first HPs improved our CAH NBS by reducing false positives, abolishing the second HP, and thereby shortening referral time.
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Affiliation(s)
- Kevin Stroek
- Endocrine Laboratory, Department of Clinical Chemistry, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - An Ruiter
- Endocrine Laboratory, Department of Clinical Chemistry, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Annelieke van der Linde
- Department of Pediatric Endocrinology, Radboud University Nijmegen Medical Centre, 6525GA Nijmegen, The Netherlands
- Department of Pediatrics, Amphia Hospital, 4818CK Breda, The Netherlands
| | - Mariette Ackermans
- Endocrine Laboratory, Department of Clinical Chemistry, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Marelle J Bouva
- Center for Health protection, National Institute for Public Health and the Environment, 3721MA Bilthoven, The Netherlands
| | - Henk Engel
- Department of Clinical Chemistry, Isala Hospital, 8025AB Zwolle, The Netherlands
| | - Bernadette Jakobs
- Department of Clinical Chemistry, Elisabeth-Tweesteden Hospital, 5022GC Tilburg, The Netherlands
| | - Evelien A Kemper
- Department of Clinical Chemistry, IJsselland Hospital, 2906ZC Capelle aan den IJssel, The Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, 3015CN Rotterdam, The Netherlands
| | - Mirjam E van Albada
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, 9713GZ Groningen, The Netherlands
| | - Gianni Bocca
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, 9713GZ Groningen, The Netherlands
| | - Martijn J J Finken
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, Vrije Universiteit, 1105AZ Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, Vrije Universiteit, 1105AZ Amsterdam, The Netherlands
| | - E C A Mieke Houdijk
- Department of Pediatrics, Juliana Children's Hospital, 2545AA the Hague, The Netherlands
| | - Hetty J van der Kamp
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, 3584EA Utrecht, The Netherlands
| | - Vera van Tellingen
- Department of Pediatrics, Catharina Hospital, 5623EJ Eindhoven, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Annet M Bosch
- Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Vrije Universiteit & University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Endocrine Laboratory, Department of Clinical Chemistry, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, Vrije Universiteit, 1105AZ Amsterdam, The Netherlands
| | | | - Anita Boelen
- Endocrine Laboratory, Department of Clinical Chemistry, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
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Lucas-Herald AK, Bryce J, Kyriakou A, Ljubicic ML, Arlt W, Audi L, Balsamo A, Baronio F, Bertelloni S, Bettendorf M, Brooke A, Claahsen van der Grinten HL, Davies JH, Hermann G, de Vries L, Hughes IA, Tadokoro-Cuccaro R, Darendeliler F, Poyrazoglu S, Ellaithi M, Evliyaoglu O, Fica S, Nedelea L, Gawlik A, Globa E, Zelinska N, Guran T, Güven A, Hannema SE, Hiort O, Holterhus PM, Iotova V, Mladenov V, Jain V, Sharma R, Jennane F, Johnston C, Guerra Junior G, Konrad D, Gaisl O, Krone N, Krone R, Lachlan K, Li D, Lichiardopol C, Lisa L, Markosyan R, Mazen I, Mohnike K, Niedziela M, Nordenstrom A, Rey R, Skaeil M, Tack LJW, Tomlinson J, Weintrob N, Cools M, Ahmed SF. Gonadectomy in conditions affecting sex development: a registry-based cohort study. Eur J Endocrinol 2021; 184:791-801. [PMID: 33780351 DOI: 10.1530/eje-20-1058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/29/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To determine trends in clinical practice for individuals with DSD requiring gonadectomy. DESIGN Retrospective cohort study. METHODS Information regarding age at gonadectomy according to diagnosis; reported sex; time of presentation to specialist centre; and location of centre from cases reported to the International DSD Registry and who were over 16 years old in January 2019. RESULTS Data regarding gonadectomy were available in 668 (88%) individuals from 44 centres. Of these, 248 (37%) (median age (range) 24 (17, 75) years) were male and 420 (63%) (median age (range) 26 (16, 86) years) were female. Gonadectomy was reported from 36 centres in 351/668 cases (53%). Females were more likely to undergo gonadectomy (n = 311, P < 0.0001). The indication for gonadectomy was reported in 268 (76%). The most common indication was mitigation of tumour risk in 172 (64%). Variations in the practice of gonadectomy were observed; of the 351 cases from 36 centres, 17 (5%) at 9 centres had undergone gonadectomy before their first presentation to the specialist centre. Median age at gonadectomy of cases from high-income countries and low-/middle-income countries (LMIC) was 13.0 years (0.1, 68) years and 16.5 years (1, 28), respectively (P < 0.0001) with the likelihood of long-term retention of gonads being higher in LMIC countries. CONCLUSIONS The likelihood of gonadectomy depends on the underlying diagnosis, sex of rearing and the geographical setting. Clinical benchmarks, which can be studied across all forms of DSD will allow a better understanding of the variation in the practice of gonadectomy.
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Affiliation(s)
| | - Jillian Bryce
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Andreas Kyriakou
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Marie Lindhardt Ljubicic
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Laura Audi
- Department of Pediatrics and Pediatric Endocrinology Unit, Vall d'Hebron Research Institute (VHIR), Hospital Vall d'Hebron, Barcelona, Spain
| | - Antonio Balsamo
- Department of Pediatrics, University of Bologna Hospital of Bologna Sant Orsola-Malpighi, Bologna, Italy
| | - Federico Baronio
- Department of Pediatrics, University of Bologna Hospital of Bologna Sant Orsola-Malpighi, Bologna, Italy
| | | | - Markus Bettendorf
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Antonia Brooke
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | | | - Justin H Davies
- Department of Paediatric Endocrinology, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Gloria Hermann
- Department of Pediatrics and Adolescent Medicine, University Medical Centre, Ulm, Germany
| | - Liat de Vries
- Paediatrics, Tel Aviv Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Centre of Israel, Petah Tikvah, Israel
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - Feyza Darendeliler
- Department of Pediatric Endocrinology, Istanbul University, Istanbul Medical School, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Department of Pediatric Endocrinology, Istanbul University, Istanbul Medical School, Istanbul, Turkey
| | - Mona Ellaithi
- Faculty of Medical Laboratory Sciences, Al-Neelain University, Khartoum, Sudan
| | - Olcay Evliyaoglu
- Department of Pediatric Endocrinology, Istanbul University - Cerrahpasa, Cerrahpaşa Medical School, Istanbul, Turkey
| | - Simone Fica
- Endocrinologie, Universitatea de Medicina si Farmacie Carol Davila Facultatea de Medicine, Bucharest, Romania
| | - Lavinia Nedelea
- Endocrinologie, Universitatea de Medicina si Farmacie Carol Davila Facultatea de Medicine, Bucharest, Romania
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Medical University of Silesia, Katowice, Poland
| | - Evgenia Globa
- Ukrainian Research Center of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, MOH of Ukraine, Kyiv, Ukraine
| | - Nataliya Zelinska
- Ukrainian Research Center of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, MOH of Ukraine, Kyiv, Ukraine
| | - Tulay Guran
- Department of Pediatric Endocrinology, Marmara University, Istanbul, Turkey
| | - Ayla Güven
- Pediatric Endocrinology Clinic, Zeynep Kamil Women and Children Hospital, Istanbul, Turkey
| | - Sabine E Hannema
- Pediatric Endocrinology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf Hiort
- Division of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Paul-Martin Holterhus
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University Hospital of Schleswig-Holstein Campus Kiel/Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Violeta Iotova
- UMHAT 'Sveta Marina', Medical University of Varna, Varna, Bulgaria
| | - Vilhelm Mladenov
- UMHAT 'Sveta Marina', Medical University of Varna, Varna, Bulgaria
| | - Vandana Jain
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Rajni Sharma
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Farida Jennane
- Unité d'Endocrinologie/Diabétologie et Gynécologie de l'Enfant et de l'Adolescent, Hôpital d'Enfants, Casablanca, Morocco
| | - Colin Johnston
- Department of Endocrinology, St Albans City Hospital, West Hertfordshire Hospitals Trust, St Albans, UK
| | - Gil Guerra Junior
- Disciplina de Endocrinologia e Metabologia, Faculdade deo Ciencias Medicas da Universidade de Campinas, Departamento de Pediatria e Departamento de Clinica Medica, Sao Paolo, Brazil
| | - Daniel Konrad
- Division of Pediatric Endocrinology and Diabetology and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Odile Gaisl
- Division of Pediatric Endocrinology and Diabetology and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Nils Krone
- Department of Oncology and Metabolism, Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - Ruth Krone
- Endocrinology, Birmingham Children's Hospital, Birmingham, UK
| | - Katherine Lachlan
- Department of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Dejun Li
- Centre for Prenatal Diagnosis, Jilin University First Hospital, Jilin, China
| | - Corina Lichiardopol
- Endocrinology, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Lidka Lisa
- Endocrinology, Institute of Prague, Czech Republic
| | - Renata Markosyan
- Endocrinology, Yerevan State Medical University Endocrinology Clinic, Yerevan, Armenia
| | - Inas Mazen
- Department of Clinical Genetics, National Research Centre, Cairo, Egypt
| | - Klaus Mohnike
- Department of Pediatrics, Otto-von-Guericke University, Magdeburg, Germany
| | - Marek Niedziela
- Department of Pediatric Endocrinology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Anna Nordenstrom
- Dept of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Rodolfo Rey
- CONICET - FEI - División de Endocrinología, Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá' (CEDIE), Buenos Aires, Argentina
| | - Mars Skaeil
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Lloyd J W Tack
- Pediatric Endocrinology Service, University Hospital Ghent, Ghent, Belgium
| | - Jeremy Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism, NIHR Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, UK
| | - Naomi Weintrob
- Paediatrics, Tel Aviv Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology, Dana Dwek Children's Hospital, Tel Aviv Medical Centre, Tel Aviv, Israel
| | - Martine Cools
- Pediatric Endocrinology Service, University Hospital Ghent, Ghent, Belgium
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
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22
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de Kloet LC, Bense JE, van der Stoep-Yap E, Louwerens M, von Asmuth EGJ, Lankester AC, de Pagter APJ, Hannema SE. Late Endocrine Effects After HSCT in Children With Nonmalignant Diseases; A Single Center Cohort Analysis. J Endocr Soc 2021. [PMCID: PMC8089832 DOI: 10.1210/jendso/bvab048.1364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Endocrine complications are amongst the most frequent late effects after pediatric hematopoietic stem cell transplantation (HSCT) for malignant diseases. Little is known about the prevalence and risk factors of endocrine complications in children transplanted for nonmalignant diseases. This retrospective study included 134 males and 63 females transplanted for a non-malignant disease between 1997 and 2018 with at least 2 years of follow up. Endocrine late effects and growth were evaluated. Gonadal dysfunction was defined as transient or permanent elevation of gonadotropins or hypogonadotropic hypogonadism.
Median age at HSCT was 5.7 years (IQR 2.8-11.3) and median follow-up was 6.2 years (IQR 3.0-10.4). Underlying diseases were inborn errors of immunity (n=74), hemoglobinopathies (n=66) and bone marrow failure (n=57). The majority of patients had received busulfan-based conditioning (46%) or treosulfan-based conditioning (34%).
Gonadal dysfunction occurred in 24/44 (post)pubertal female patients (55%) and was permanent in 19/44 (43%). 22/44 received hormonal substitution, which could be discontinued in 7. In females who received busulfan-based conditioning 16/17 (94%) developed gonadal dysfunction compared to 5/15 (33%) patients with treosulfan-based conditioning; the odds ratio for permanent gonadal dysfunction was 18.7 (3.61-135, p=0.001).
Gonadal dysfunction occurred in 28/66 (post)pubertal male patients (42%) and was permanent in 23/66 (35%). 6/66 received hormonal substitution, which could be discontinued in 1. Gonadal dysfunction was more common in males (post)pubertal at HSCT, 14/21 (67%), compared to those prepubertal at HSCT, 14/45 (31%), p=0.014. 3/15 treated with a treosulfan-based regimen (20%) developed gonadal dysfunction, all transient, versus 19/39 with a busulfan-based regimen (49%), with 2 transient.
29/187 patients developed hypothyroidism (16%), 7 patients received thyroxine treatment (4%). All patients with persistent primary hypothyroidism (n=6) had positive TPO-antibodies.
17 patients received growth hormone treatment and were excluded from analysis. In patients without growth hormone treatment near adult height (NAH) was -1.2 SDS (median, IQR -2.0- -0.3) below mean parental height (MPH) in males and -0.4 SDS (median, IQR -1.6-0.3) in females. NAH below -2 SDS was seen in 13/43 males (30%) and 2/36 females (6%). The majority of these patients already had a height below -2 SDS before HSCT (73%).
In conclusion, this study on late endocrine effects after HSCT in children with nonmalignant diseases indicates frequent gonadal dysfunction, present in 55% of females and 42% of males. In this cohort, risk of gonadal dysfunction in females was higher after busulfan-based conditioning than treosulfan-based conditioning. Careful long-term endocrine follow-up is indicated.
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Affiliation(s)
| | - Joëll E Bense
- Willem-Alexander Children Hospital, LUMC, Leiden, Netherlands
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23
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de Vries ALC, Richards C, Tishelman AC, Motmans J, Hannema SE, Green J, Rosenthal SM. Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. Int J Transgend Health 2021; 22:217-224. [PMID: 34240066 PMCID: PMC8118230 DOI: 10.1080/26895269.2021.1904330] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Annelou L. C. de Vries
- Department of Child and Adolescent Psychiatry, Emma Children’s Hospital, Amsterdam University Medical Centers, location Vumc, Amsterdam, the Netherlands
| | - Christina Richards
- Tavistock and Portman NHS Foundation Trust and Regent’s University London, London, United Kingdom
| | - Amy C. Tishelman
- Department of Psychiatry and Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Joz Motmans
- Transgender Infopunt, Ghent University Hospital, Ghent, Belgium
| | - Sabine E. Hannema
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, location Vumc, Amsterdam, The Netherlands
| | - Jamison Green
- Independent legal scholar and consulting expert in transgender health policy and ethics, World Professional Association for Transgender Health (WPATH), USA
| | - Stephen M. Rosenthal
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
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24
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Bacila I, Freeman N, Daniel E, Sandrk M, Bryce J, Ali SR, Yavas Abali Z, Atapattu N, Bachega TA, Balsamo A, Birkebæk N, Blankenstein O, Bonfig W, Cools M, Costa EC, Darendeliler F, Einaudi S, Elsedfy HH, Finken M, Gevers E, Claahsen-van der Grinten HL, Guran T, Güven A, Hannema SE, Higham CE, Iotova V, van der Kamp HJ, Korbonits M, Krone RE, Lichiardopol C, Luczay A, Mendonca BB, Milenkovic T, Miranda MC, Mohnike K, Neumann U, Ortolano R, Poyrazoglu S, Thankamony A, Tomlinson JW, Vieites A, de Vries L, Ahmed SF, Ross RJ, Krone NP. International practice of corticosteroid replacement therapy in congenital adrenal hyperplasia: data from the I-CAH registry. Eur J Endocrinol 2021; 184:553-563. [PMID: 33460392 DOI: 10.1530/eje-20-1249] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Despite published guidelines no unified approach to hormone replacement in congenital adrenal hyperplasia (CAH) exists. We aimed to explore geographical and temporal variations in the treatment with glucocorticoids and mineralocorticoids in CAH. DESIGN This retrospective multi-center study, including 31 centers (16 countries), analyzed data from the International-CAH Registry. METHODS Data were collected from 461 patients aged 0-18 years with classic 21-hydroxylase deficiency (54.9% females) under follow-up between 1982 and 2018. Type, dose and timing of glucocorticoid and mineralocorticoid replacement were analyzed from 4174 patient visits. RESULTS The most frequently used glucocorticoid was hydrocortisone (87.6%). Overall, there were significant differences between age groups with regards to daily hydrocortisone-equivalent dose for body surface, with the lowest dose (median with interquartile range) of 12.0 (10.0-14.5) mg/m2/day at age 1-8 years and the highest dose of 14.0 (11.6-17.4) mg/m2/day at age 12-18 years. Glucocorticoid doses decreased after 2010 in patients 0-8 years (P < 0.001) and remained unchanged in patients aged 8-18 years. Fludrocortisone was used in 92% of patients, with relative doses decreasing with age. A wide variation was observed among countries with regards to all aspects of steroid hormone replacement. CONCLUSIONS Data from the I-CAH Registry suggests international variations in hormone replacement therapy, with a tendency to treatment with high doses in children.
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Affiliation(s)
- Irina Bacila
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Nicole Freeman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Eleni Daniel
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Marija Sandrk
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Jillian Bryce
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Salma Rashid Ali
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Zehra Yavas Abali
- Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Navoda Atapattu
- Pediatric Endocrinology, Lady Ridgeway Hospital, Colombo, Sri Lanka
| | - Tania A Bachega
- Department of Internal Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Unit, Endo-ERN Center for Rare Endocrine Diseases, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Niels Birkebæk
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Oliver Blankenstein
- Institute for Experimental Pediatric Endocrinology and Center for Chronically Sick Children, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - Walter Bonfig
- Department of Pediatrics, Technical University Munich, Munich, Germany
- Department of Pediatrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Martine Cools
- Pediatric Endocrinology, Internal Medicine and Pediatric Research Unit, University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Eduardo Correa Costa
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Feyza Darendeliler
- Paediatric Endocrinology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Silvia Einaudi
- Department of Paediatric Endocrinology, Regina Margherita Children's Hospital, University of Torino, Torino, Italy
| | | | - Martijn Finken
- Department of Paediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Evelien Gevers
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University London, London, UK
- Department of Paediatric Endocrinology, Barts Health NHS Trust - Royal London Hospital, London, UK
| | | | - Tulay Guran
- Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Ayla Güven
- Saglik Bilimleri University, Medical Faculty Zeynep Kamil Maternity and Children Hospital, Pediatric Endocrinology Clinic, Istanbul, Turkey
| | - Sabine E Hannema
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Violeta Iotova
- Department of Paediatrics, Medical University of Varna, Varna, Bulgaria
| | - Hetty J van der Kamp
- Pediatric Endocrinology Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University London, London, UK
| | - Ruth E Krone
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Corina Lichiardopol
- Department of Endocrinology, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | | | | | - Tatjana Milenkovic
- Department of Endocrinology, Institute for Mother and Child Healthcare of Serbia 'Dr Vukan Čupić' Belgrade, Serbia
| | - Mirela C Miranda
- Department of Internal Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Klaus Mohnike
- Department of Pediatrics, Otto-von-Guericke University, Magdeburg, Germany
| | - Uta Neumann
- Institute for Experimental Pediatric Endocrinology and Center for Chronically Sick Children, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Unit, Endo-ERN Center for Rare Endocrine Diseases, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Sukran Poyrazoglu
- Paediatric Endocrinology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Ajay Thankamony
- Department of Pediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism, NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas (CEDIE-CONICET), Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Liat de Vries
- Institute for Diabetes and Endocrinology, Schneider's Children Medical Center of Israel, Petah-Tikvah, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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25
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Ali SR, Bryce J, Haghpanahan H, Lewsey JD, Tan LE, Atapattu N, Birkebaek NH, Blankenstein O, Neumann U, Balsamo A, Ortolano R, Bonfig W, Claahsen-van der Grinten HL, Cools M, Costa EC, Darendeliler F, Poyrazoglu S, Elsedfy H, Finken MJJ, Fluck CE, Gevers E, Korbonits M, Guaragna-Filho G, Guran T, Guven A, Hannema SE, Higham C, Hughes IA, Tadokoro-Cuccaro R, Thankamony A, Iotova V, Krone NP, Krone R, Lichiardopol C, Luczay A, Mendonca BB, Bachega TASS, Miranda MC, Milenkovic T, Mohnike K, Nordenstrom A, Einaudi S, van der Kamp H, Vieites A, de Vries L, Ross RJM, Ahmed SF. Real-World Estimates of Adrenal Insufficiency-Related Adverse Events in Children With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e192-e203. [PMID: 32995889 PMCID: PMC7990061 DOI: 10.1210/clinem/dgaa694] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although congenital adrenal hyperplasia (CAH) is known to be associated with adrenal crises (AC), its association with patient- or clinician-reported sick day episodes (SDE) is less clear. METHODS Data on children with classic 21-hydroxylase deficiency CAH from 34 centers in 18 countries, of which 7 were Low or Middle Income Countries (LMIC) and 11 were High Income (HIC), were collected from the International CAH Registry and analyzed to examine the clinical factors associated with SDE and AC. RESULTS A total of 518 children-with a median of 11 children (range 1, 53) per center-had 5388 visits evaluated over a total of 2300 patient-years. The median number of AC and SDE per patient-year per center was 0 (0, 3) and 0.4 (0.0, 13.3), respectively. Of the 1544 SDE, an AC was reported in 62 (4%), with no fatalities. Infectious illness was the most frequent precipitating event, reported in 1105 (72%) and 29 (47%) of SDE and AC, respectively. On comparing cases from LMIC and HIC, the median SDE per patient-year was 0.75 (0, 13.3) vs 0.11 (0, 12.0) (P < 0.001), respectively, and the median AC per patient-year was 0 (0, 2.2) vs 0 (0, 3.0) (P = 0.43), respectively. CONCLUSIONS The real-world data that are collected within the I-CAH Registry show wide variability in the reported occurrence of adrenal insufficiency-related adverse events. As these data become increasingly used as a clinical benchmark in CAH care, there is a need for further research to improve and standardize the definition of SDE.
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Affiliation(s)
- Salma R Ali
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Jillian Bryce
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Houra Haghpanahan
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James D Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Li En Tan
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | | | - Niels H Birkebaek
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Uta Neumann
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Walter Bonfig
- Department of Paediatrics, Technical University München, Munich, Germany
- Department of Paediatrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | | | - Martine Cools
- University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Eduardo Correa Costa
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
| | - Feyza Darendeliler
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Heba Elsedfy
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Martijn J J Finken
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Endocrinology, Amsterdam, The Netherlands
| | - Christa E Fluck
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics and Department of BioMedical Research, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Evelien Gevers
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Guilherme Guaragna-Filho
- Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Tulay Guran
- Marmara University, Department of Pediatric Endocrinology and Diabetes, Pendik, Istanbul, Turkey
| | - Ayla Guven
- Health Science University, Medical Faculty, Zeynep Kamil Women and Children Hospital, Pediatric Endocrinology Clinic, Istanbul, Turkey
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, University Of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - Ajay Thankamony
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Violeta Iotova
- Department of Paediatrics, Medical University-Varna, UMHAT “Sv. Marina,” Varna, Bulgaria
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Ruth Krone
- Birmingham Women’s & Children’s Hospital, Department for Endocrinology & Diabetes, Birmingham, UK
| | - Corina Lichiardopol
- Department of Endocrinology, University of Medicine and Pharmacy Craiova, University Emergency Hospital, Craiova, Romania
| | - Andrea Luczay
- Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Mirela C Miranda
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Tatjana Milenkovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia “Dr Vukan Čupić,” Belgrade, Serbia
| | | | | | - Silvia Einaudi
- Pediatric Endocrinology Regina Margherita Children’s Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Hetty van der Kamp
- Wilhelmina Kinderziekenhuis, Division of Pediatric Endocrinology, Utrecht, Netherlands
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Liat de Vries
- The Jesse and Sara Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikvah, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Richard J M Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
- Correspondence and Reprint Requests: Professor S. Faisal Ahmed, MD FRCPCH, Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK. E-mail:
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Stancampiano MR, Lucas-Herald AK, Bryce J, Russo G, Barera G, Balsamo A, Baronio F, Bertelloni S, Valiani M, Cools M, Tack LJW, Darendeliler F, Poyrazoglu S, Globa E, Grinspon R, Hannema SE, Hughes IA, Tadokoro-Cuccaro R, Thankamony A, Iotova V, Mladenov V, Konrad D, Mazen I, Niedziela M, Kolesinska Z, Nordenström A, Ahmed SF. Testosterone Therapy and Its Monitoring in Adolescent Boys with Hypogonadism: Results of an International Survey from the I-DSD Registry. Sex Dev 2021; 15:236-243. [PMID: 34350903 DOI: 10.1159/000516784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/15/2021] [Indexed: 11/19/2022] Open
Abstract
It is unclear whether testosterone replacement therapy (TRT) in adolescent boys, affected by a range of endocrine diseases that may be associated with hypogonadism, is particularly common. The aim of this study was to assess the contemporary practice of TRT in boys included in the I-DSD Registry. All participating centres in the I-DSD Registry that had boys between 10 and 18 years of age and with a condition that could be associated with hypogonadism were invited to provide further information in 2019. Information on 162 boys was collected from 15 centres that had a median (range) number of 6 boys per centre (1.35). Of these, 30 (19%) from 9 centres were receiving TRT and the median (range) age at the start was 12.6 years (10.8-16.2), with 6 boys (20%) starting at <12 years. Median (range) age of boys not on TRT was 11.7 years (10.7-17.7), and 69 out of 132 (52%) were <12 years. TRT had been initiated in 20 of 71 (28%) boys with a disorder of gonadal development, 3 of 14 (21%) with a disorder of androgen synthesis, and all 7 (100%) boys with hypogonadotropic hypogonadism. The remainder who did not have TRT included 15 boys with partial androgen insensitivity, 52 with non-specific XY DSD, and 3 with persistent Müllerian duct syndrome. Before starting TRT, liver function and blood count were checked in 19 (68%) and 18 boys (64%), respectively, a bone age assessment was performed in 23 (82%) and bone mineral density assessment in 12 boys (43%). This snapshot of contemporary practice reveals that TRT in boys included in the I-DSD Registry is not very common, whilst the variation in starting and monitoring therapy is quite marked. Standardisation of practice may lead to more effective assessment of treatment outcomes.
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Affiliation(s)
- Marianna R Stancampiano
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy,
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom,
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Jillian Bryce
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Gianni Russo
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Graziano Barera
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Paediatric Unit, Endo-ERN Center IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Baronio
- Department of Medical and Surgical Sciences, Paediatric Unit, Endo-ERN Center IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvano Bertelloni
- Paediatric and Adolescent Endocrinology, Department of Obstetrics, Gynecology and Paediatrics, Azienda Ospedaliero, Universitaria Pisana, Pisa, Italy
| | - Margherita Valiani
- Paediatric and Adolescent Endocrinology, Department of Obstetrics, Gynecology and Paediatrics, Azienda Ospedaliero, Universitaria Pisana, Pisa, Italy
| | - Martine Cools
- Department of Internal Medicine and Paediatrics, Ghent University and Department of Paediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Lloyd J W Tack
- Department of Internal Medicine and Paediatrics, Ghent University and Department of Paediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Feyza Darendeliler
- Paediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Paediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Scientific Center of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, MoH of Ukraine, Kyiv, Ukraine
| | - Romina Grinspon
- Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá' (CEDIE), CONICET - FEI, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Amsterdam, The Netherlands
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | | | - Ajay Thankamony
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Violeta Iotova
- Department of Paediatrics - UMHAT 'Sv.Marina', Medical University of Varna, Varna, Bulgaria
| | - Vilhelm Mladenov
- Department of Paediatrics - UMHAT 'Sv.Marina', Medical University of Varna, Varna, Bulgaria
| | - Daniel Konrad
- Division of Paediatric Endocrinology and Diabetology, University Children's Hospital, Zurich, Switzerland
| | - Inas Mazen
- Department of Clinical Genetics, National Research Center, Cairo, Egypt
| | - Marek Niedziela
- Department of Paediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Zofia Kolesinska
- Department of Paediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Paediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
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Schagen SEE, Wouters FM, Cohen-Kettenis PT, Gooren LJ, Hannema SE. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. J Clin Endocrinol Metab 2020; 105:5903559. [PMID: 32909025 PMCID: PMC7524308 DOI: 10.1210/clinem/dgaa604] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/08/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT Hormonal interventions in adolescents with gender dysphoria may have adverse effects, such as reduced bone mineral accrual. OBJECTIVE To describe bone mass development in adolescents with gender dysphoria treated with gonadotropin-releasing hormone analogues (GnRHa), subsequently combined with gender-affirming hormones. DESIGN Observational prospective study. SUBJECTS 51 transgirls and 70 transboys receiving GnRHa and 36 transgirls and 42 transboys receiving GnRHa and gender-affirming hormones, subdivided into early- and late-pubertal groups. MAIN OUTCOME MEASURES Bone mineral apparent density (BMAD), age- and sex-specific BMAD z-scores, and serum bone markers. RESULTS At the start of GnRHa treatment, mean areal bone mineral density (aBMD) and BMAD values were within the normal range in all groups. In transgirls, the mean z-scores were well below the population mean. During 2 years of GnRHa treatment, BMAD stabilized or showed a small decrease, whereas z-scores decreased in all groups. During 3 years of combined administration of GnRHa and gender-affirming hormones, a significant increase of BMAD was found. Z-scores normalized in transboys but remained below zero in transgirls. In transgirls and early pubertal transboys, all bone markers decreased during GnRHa treatment. CONCLUSIONS BMAD z-scores decreased during GnRHa treatment and increased during gender-affirming hormone treatment. Transboys had normal z-scores at baseline and at the end of the study. However, transgirls had relatively low z-scores, both at baseline and after 3 years of estrogen treatment. It is currently unclear whether this results in adverse outcomes, such as increased fracture risk, in transgirls as they grow older.
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Affiliation(s)
- Sebastian E E Schagen
- Department of Pediatric Endocrinology, VU University Medical Center, 1081 HV Amsterdam, & Leiden University Medical Center, ZA Leiden, the Netherlands
| | - Femke M Wouters
- Department of Pediatric Endocrinology, VU University Medical Center, HV Amsterdam, the Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, Amsterdam UMC, VU University, HV Amsterdam, the Netherlands
| | - Louis J Gooren
- Department of Endocrinology, VU University Medical Center, HV Amsterdam, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Willem-Alexander Children Hospital, Leiden University Medical Center, ZA Leiden, the Netherlands
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, CN Rotterdam, Netherlands
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28
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Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch Sex Behav 2020; 49:2611-2618. [PMID: 32152785 PMCID: PMC7497424 DOI: 10.1007/s10508-020-01660-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 05/12/2023]
Abstract
Gonadotropin-releasing hormone analogues (GnRHa) are recommended as initial treatment for adolescents diagnosed with gender dysphoria, providing time to follow gender identity development and consider further treatment wishes without distress caused by unwanted pubertal changes. This has been described as an extended diagnostic phase. However, there are also concerns about the physical, neurocognitive, and psychosocial effects of this treatment. In this retrospective study, we document trajectories after the initiation of GnRHa and explore reasons for extended use and discontinuation of GnRHa. Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys; median age, 15.0 years [range, 11.1-18.6] and 16.1 years [range, 10.1-17.9]). After a median duration of 0.8 years (0.3-3.8) on GnRHa, 125 (87%) started gender-affirming hormones (GAH). Nine (6%) discontinued GnRHa, five of whom no longer wished gender-affirming treatment. Thirteen had used GnRHa for longer than required by protocol for reasons other than logistics and regularly met with a mental health professional during this time, supporting the use of GnRHa treatment as an extended diagnostic phase. In conclusion, the vast majority who started GnRHa proceeded to GAH, possibly due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment. Due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome. Few individuals discontinued GnRHa, and only 3.5% no longer wished gender-affirming treatment.
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Affiliation(s)
- Tessa Brik
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Lieke J J J Vrouenraets
- Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands.
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29
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Bever YV, Brüggenwirth HT, Wolffenbuttel KP, Dessens AB, Groenenberg IAL, Knapen MFCM, De Baere E, Cools M, van Ravenswaaij-Arts CMA, Sikkema-Raddatz B, Claahsen-van der Grinten H, Kempers M, Rinne T, Hersmus R, Looijenga L, Hannema SE. Under-reported aspects of diagnosis and treatment addressed in the Dutch-Flemish guideline for comprehensive diagnostics in disorders/differences of sex development. J Med Genet 2020; 57:581-589. [PMID: 32303604 PMCID: PMC7476274 DOI: 10.1136/jmedgenet-2019-106354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 01/02/2020] [Accepted: 01/22/2020] [Indexed: 12/14/2022]
Abstract
We present key points from the updated Dutch-Flemish guideline on comprehensive diagnostics in disorders/differences of sex development (DSD) that have not been widely addressed in the current (inter)national literature. These points are of interest to physicians working in DSD (expert) centres and to professionals who come across persons with a DSD but have no (or limited) experience in this area. The Dutch-Flemish guideline is based on internationally accepted principles. Recent initiatives striving for uniform high-quality care across Europe, and beyond, such as the completed COST action 1303 and the European Reference Network for rare endocrine conditions (EndoERN), have generated several excellent papers covering nearly all aspects of DSD. The Dutch-Flemish guideline follows these international consensus papers and covers a number of other topics relevant to daily practice. For instance, although next-generation sequencing (NGS)-based molecular diagnostics are becoming the gold standard for genetic evaluation, it can be difficult to prove variant causality or relate the genotype to the clinical presentation. Network formation and centralisation are essential to promote functional studies that assess the effects of genetic variants and to the correct histological assessment of gonadal material from DSD patients, as well as allowing for maximisation of expertise and possible cost reductions. The Dutch-Flemish guidelines uniquely address three aspects of DSD. First, we propose an algorithm for counselling and diagnostic evaluation when a DSD is suspected prenatally, a clinical situation that is becoming more common. Referral to ultrasound sonographers and obstetricians who are part of a DSD team is increasingly important here. Second, we pay special attention to healthcare professionals not working within a DSD centre as they are often the first to diagnose or suspect a DSD, but are not regularly exposed to DSDs and may have limited experience. Their thoughtful communication to patients, carers and colleagues, and the accessibility of protocols for first-line management and efficient referral are essential. Careful communication in the prenatal to neonatal period and the adolescent to adult transition are equally important and relatively under-reported in the literature. Third, we discuss the timing of (NGS-based) molecular diagnostics in the initial workup of new patients and in people with a diagnosis made solely on clinical grounds or those who had earlier genetic testing that is not compatible with current state-of-the-art diagnostics.
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Affiliation(s)
- Yolande van Bever
- Department of Clinical Genetics and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hennie T Brüggenwirth
- Department of Clinical Genetics and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Pediatric Urology and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arianne B Dessens
- Department of Child and Adolescent Psychiatry and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene A L Groenenberg
- Department of Obstetrics and Prenatal Medicine and DSD Expert Center Erasmus Medical Center, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Maarten F C M Knapen
- Department of Obstetrics and Prenatal Medicine and DSD Expert Center Erasmus Medical Center, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Elfride De Baere
- Center for Medical Genetics, University Hospital Ghent Center Medical Genetics, Ghent, Belgium
| | - Martine Cools
- Department of Internal Medicine and Paediatrics and Department of Pediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | | | - Birgit Sikkema-Raddatz
- Department of Genetics and DSD team, University Medical Center Groningen, Groningen, The Netherlands
| | - Hedi Claahsen-van der Grinten
- Department of Pediatric Endocrinology and DSD Expert Center Radboud UMC, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Marlies Kempers
- Department of Clinical genetics and DSD Expert Center Radboud UMC, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tuula Rinne
- Department of Clinical genetics and DSD Expert Center Radboud UMC, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Remko Hersmus
- Department of Pathology, DSD Expert Center ErasmusMC, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Leendert Looijenga
- Department of Pathology, DSD Expert Center ErasmusMC, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands.,Department of Pathology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Sabine E Hannema
- Department of Pediatric Endocrinology and DSD Expert Center ErasmusMC, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Bangalore Krishna K, Fuqua JS, Rogol AD, Klein KO, Popovic J, Houk CP, Charmandari E, Lee PA, Freire AV, Ropelato MG, Yazid Jalaludin M, Mbogo J, Kanaka-Gantenbein C, Luo X, Eugster EA, Klein KO, Vogiatzi MG, Reifschneider K, Bamba V, Garcia Rudaz C, Kaplowitz P, Backeljauw P, Allen DB, Palmert MR, Harrington J, Guerra-Junior G, Stanley T, Torres Tamayo M, Miranda Lora AL, Bajpai A, Silverman LA, Miller BS, Dayal A, Horikawa R, Oberfield S, Rogol AD, Tajima T, Popovic J, Witchel SF, Rosenthal SM, Finlayson C, Hannema SE, Castilla-Peon MF, Mericq V, Medina Bravo PG. Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium. Horm Res Paediatr 2020; 91:357-372. [PMID: 31319416 DOI: 10.1159/000501336] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022] Open
Abstract
This update, written by authors designated by multiple pediatric endocrinology societies (see List of Participating Societies) from around the globe, concisely addresses topics related to changes in GnRHa usage in children and adolescents over the last decade. Topics related to the use of GnRHa in precocious puberty include diagnostic criteria, globally available formulations, considerations of benefit of treatment, monitoring of therapy, adverse events, and long-term outcome data. Additional sections review use in transgender individuals and other pediatric endocrine related conditions. Although there have been many significant changes in GnRHa usage, there is a definite paucity of evidence-based publications to support them. Therefore, this paper is explicitly not intended to evaluate what is recommended in terms of the best use of GnRHa, based on evidence and expert opinion, but rather to describe how these drugs are used, irrespective of any qualitative evaluation. Thus, this paper should be considered a narrative review on GnRHa utilization in precocious puberty and other clinical situations. These changes are reviewed not only to point out deficiencies in the literature but also to stimulate future studies and publications in this area.
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Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA,
| | - John S Fuqua
- Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Alan D Rogol
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Karen O Klein
- University of California, San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Jadranka Popovic
- Division of Pediatric Endocrinology, Pediatric Alliance, Pittsburgh, Pennsylvania, USA
| | - Christopher P Houk
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Peter A Lee
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
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31
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van der Straaten S, Springer A, Zecic A, Hebenstreit D, Tonnhofer U, Gawlik A, Baumert M, Szeliga K, Debulpaep S, Desloovere A, Tack L, Smets K, Wasniewska M, Corica D, Calafiore M, Ljubicic ML, Busch AS, Juul A, Nordenström A, Sigurdsson J, Flück CE, Haamberg T, Graf S, Hannema SE, Wolffenbuttel KP, Hiort O, Ahmed SF, Cools M. The External Genitalia Score (EGS): A European Multicenter Validation Study. J Clin Endocrinol Metab 2020; 105:5609091. [PMID: 31665438 DOI: 10.1210/clinem/dgz142] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/25/2019] [Indexed: 12/19/2022]
Abstract
CONTEXT Standardized description of external genitalia is needed in the assessment of children with atypical genitalia. OBJECTIVES To validate the External Genitalia Score (EGS), to present reference values for preterm and term babies up to 24 months and correlate obtained scores with anogenital distances (AGDs). DESIGN, SETTING A European multicenter (n = 8) validation study was conducted from July 2016 to July 2018. PATIENTS AND METHODS EGS is based on the external masculinization score but uses a gradual scale from female to male (range, 0-12) and terminology appropriate for both sexes. The reliability of EGS and AGDs was determined by the interclass correlation coefficient (ICC). Cross-sectional data were obtained in 686 term babies (0-24 months) and 181 preterm babies, and 111 babies with atypical genitalia. RESULTS The ICC of EGS in typical and atypical genitalia is excellent and good, respectively. Median EGS (10th to 90th centile) in males < 28 weeks gestation is 10 (8.6-11.5); in males 28-32 weeks 11.5 (9.2-12); in males 33-36 weeks 11.5 (10.5-12) and in full-term males 12 (10.5-12). In all female babies, EGS is 0 (0-0). The mean (SD) lower/upper AGD ratio (AGDl/u) is 0.45 (0.1), with significant difference between AGDl/u in males 0.49 (0.1) and females 0.39 (0.1) and intermediate values in differences of sex development (DSDs) 0.43 (0.1). The AGDl/u correlates with EGS in males with typical genitalia and in atypical genitalia. CONCLUSIONS EGS is a reliable and valid tool to describe external genitalia in premature and term babies up to 24 months. EGS correlates with AGDl/u in males. It facilitates standardized assessment, clinical decision-making and multicenter research.
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Affiliation(s)
- Saskia van der Straaten
- Ghent University Hospital, Department of Pediatrics, Division of Pediatric Endocrinology and Ghent University, Department of Internal Medicine and Pediatrics, Ghent, Belgium
| | - Alexander Springer
- Medical University of Vienna, Department of Pediatric Surgery, Vienna, Austria
| | - Aleksandra Zecic
- Ghent University Hospital, Department of Neonatology, Ghent, Belgium
| | | | - Ursula Tonnhofer
- Medical University of Vienna, Department of Pediatric Surgery, Vienna, Austria
| | - Aneta Gawlik
- Medical University of Silesia, Department of Pediatrics, Pediatric Endocrinology, Katowice, Poland
| | - Malgorzata Baumert
- Medical University of Silesia, Department of Neonatology, Katowice, Poland
| | - Kamila Szeliga
- Medical University of Silesia, Department of Pediatrics, Pediatric Endocrinology, Katowice, Poland
| | - Sara Debulpaep
- Ghent University Hospital, Department of Pediatrics, Ghent, Belgium
| | - An Desloovere
- Ghent University Hospital, Department of Pediatrics, Ghent, Belgium
| | - Lloyd Tack
- Ghent University Hospital, Department of Pediatrics, Division of Pediatric Endocrinology and Ghent University, Department of Internal Medicine and Pediatrics, Ghent, Belgium
| | - Koen Smets
- Ghent University Hospital, Department of Neonatology, Ghent, Belgium
| | - Malgorzata Wasniewska
- University Hospital of Messina, Department of Human Pathology of Adulthood and Childhood, Messina, Italy
| | - Domenico Corica
- University Hospital of Messina, Department of Human Pathology of Adulthood and Childhood, Messina, Italy
| | - Mariarosa Calafiore
- University Hospital of Messina, Department of Human Pathology of Adulthood and Childhood, Messina, Italy
| | - Marie Lindhardt Ljubicic
- Copenhagen University Hospital - Rigshospitalet, Department of Growth and Reproduction, Copenhagen, Denmark
| | - Alexander Siegfried Busch
- Copenhagen University Hospital - Rigshospitalet, Department of Growth and Reproduction, Copenhagen, Denmark
| | - Anders Juul
- Copenhagen University Hospital - Rigshospitalet, Department of Growth and Reproduction, Copenhagen, Denmark
| | - Anna Nordenström
- Karolinska University Hospital Stockholm, Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Jon Sigurdsson
- Karolinska University Hospital Stockholm, Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Christa E Flück
- Bern University Children's Hospital Inselspital, Department of Pediatrics, Division of Pediatric Endocrinology, Diabetology and Metabolism and Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Tanja Haamberg
- Bern University Children's Hospital Inselspital, Department of Pediatrics, Division of Pediatric Endocrinology, Diabetology and Metabolism and Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Stefanie Graf
- Bern University Children's Hospital Inselspital, Department of Pediatrics, Division of Pediatric Endocrinology, Diabetology and Metabolism and Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Sabine E Hannema
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Pediatric Endocrinology, GD Rotterdam, the Netherlands
- Leiden University Medical Centre, Department of Paediatrics, RC Leiden, The Netherlands
| | - Katja P Wolffenbuttel
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Urology and Paediatric Urology, Rotterdam, the Netherlands
| | - Olaf Hiort
- University of Lübeck, Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Lübeck, Germany
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Martine Cools
- Ghent University Hospital, Department of Pediatrics, Division of Pediatric Endocrinology and Ghent University, Department of Internal Medicine and Pediatrics, Ghent, Belgium
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Ljubicic ML, Jørgensen A, Ribeiro de Andrade JG, Balsamo A, Bertelloni S, Cools M, Cuccaro RT, Darendeliler F, Flück CE, Grinspon RP, Maciel-Guerra A, Guran T, Hannema SE, Lucas-Herald AK, Hiort O, Holterhus PM, Lichiardopol C, Looijenga LHJ, Ortolano R, Riedl S, Ahmed SF, Juul A. Response to Letter to the Editor: "Clinical but Not Histological Outcomes in Males With 45,X/46,XY Mosaicism Vary Depending on Reason for Diagnosis". J Clin Endocrinol Metab 2019; 104:5812-5813. [PMID: 31276168 DOI: 10.1210/jc.2019-01413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Marie Lindhardt Ljubicic
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Jørgensen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvano Bertelloni
- Dipartimento Materno-Infantile Azienda Ospedaliero, Universitaria Pisana, Pisa, Italy
| | - Martine Cools
- Department of Paediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Rieko Tadokoro Cuccaro
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | | | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Children's Hospital, University of Bern, Bern, Switzerland
- Department of BioMedical Research, Bern University Children's Hospital, University of Bern, Bern, Switzerland
| | - Romina P Grinspon
- Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá', CONICET - FEI, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Andrea Maciel-Guerra
- Faculty of Medical Sciences, Department of Medical Genetics, State University of Campinas (Unicamp), São Paulo, São Paulo, Brazil
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sabine E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, Netherlands
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University of Luebeck, Luebeck, Germany
| | - Paul Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Corina Lichiardopol
- Department of Endocrinology, University of Medicine and Pharmacy Craiova, University Emergency Hospital Craiova, Craiova, Romania
| | - Leendert H J Looijenga
- Department of Pathology, Laboratory for Experimental Patho-Oncology, Erasmus Medical Center, University Medical Center Rotterdam, Cancer Institute, Rotterdam, Netherlands
- Princess Maxima Center for Paediatric Oncology, CS Utrecht, Netherlands
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Stefan Riedl
- Pediatric Endocrinology, St. Anna Children´s Hospital, Medical University of Vienna, Vienna, Austria
- Department of Pediatric Pulmology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Kos S, Cobbaert CM, Kuijper TM, Oostdijk W, Hannema SE, Wit JM, Biermasz N, Ballieux BEPB. IGF-1 and IGF-1 SDS - fit for purpose? Eur J Endocrinol 2019; 181:L1-L4. [PMID: 31505458 DOI: 10.1530/eje-19-0458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/09/2019] [Indexed: 11/08/2022]
Affiliation(s)
- S Kos
- Department of Clinical Chemistry, Maasstad Hospital, Rotterdam, The Netherlands
| | - C M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - T M Kuijper
- Department of Science, Maasstad Hospital, Rotterdam, The Netherlands
| | - W Oostdijk
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - S E Hannema
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Wit
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Biermasz
- Division of Endocrinology and Center for Endocrine Tumours, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - B E P B Ballieux
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Rosenthal SM, Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Safer JD, Tangpricha V, T'Sjoen GG. Response to Letter to the Editor: "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab 2019; 104:5102-5103. [PMID: 31046093 DOI: 10.1210/jc.2019-00930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 02/13/2023]
Affiliation(s)
- Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | | | - Louis Gooren
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
| | - Joshua D Safer
- Ichan School of Medicine at Mount Sinai, New York, New York
| | - Vin Tangpricha
- Emory University School of Medicine, Atlanta, Georgia
- The Atlanta VA Medical Center, Atlanta, Georgia
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Ljubicic ML, Jørgensen A, Acerini C, Andrade J, Balsamo A, Bertelloni S, Cools M, Cuccaro RT, Darendeliler F, Flück CE, Grinspon RP, Maciel-Guerra A, Guran T, Hannema SE, Lucas-Herald AK, Hiort O, Holterhus PM, Lichiardopol C, Looijenga LHJ, Ortolano R, Riedl S, Ahmed SF, Juul A. Clinical but Not Histological Outcomes in Males With 45,X/46,XY Mosaicism Vary Depending on Reason for Diagnosis. J Clin Endocrinol Metab 2019; 104:4366-4381. [PMID: 31127831 DOI: 10.1210/jc.2018-02752] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/19/2019] [Indexed: 02/13/2023]
Abstract
CONTEXT Larger studies on outcomes in males with 45,X/46,XY mosaicism are rare. OBJECTIVE To compare health outcomes in males with 45,X/46,XY diagnosed as a result of either genital abnormalities at birth or nongenital reasons later in life. DESIGN A retrospective, multicenter study. SETTING Sixteen tertiary centers. PATIENTS OR OTHER PARTICIPANTS Sixty-three males older than 13 years with 45,X/46,XY mosaicism. MAIN OUTCOME MEASURES Health outcomes, such as genital phenotype, gonadal function, growth, comorbidities, fertility, and gonadal histology, including risk of neoplasia. RESULTS Thirty-five patients were in the genital group and 28 in the nongenital. Eighty percent of all patients experienced spontaneous pubertal onset, significantly more in the nongenital group (P = 0.023). Patients were significantly shorter in the genital group with median adult heights of 156.7 cm and 164.5 cm, respectively (P = 0.016). Twenty-seven percent of patients received recombinant human GH. Forty-four patients had gonadal histology evaluated. Germ cells were detected in 42%. Neoplasia in situ was found in five patients. Twenty-five percent had focal spermatogenesis, and another 25.0% had arrested spermatogenesis. Fourteen out of 17 (82%) with semen analyses were azoospermic; three had motile sperm. CONCLUSION Patients diagnosed as a result of genital abnormalities have poorer health outcomes than those diagnosed as a result of nongenital reasons. Most patients, however, have relatively good endocrine gonadal function, but most are also short statured. Patients have a risk of gonadal neoplasia, and most are azoospermic, but almost one-half of patients has germ cells present histologically and up to one-quarter has focal spermatogenesis, providing hope for fertility treatment options.
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Affiliation(s)
- Marie Lindhardt Ljubicic
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Jørgensen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Carlo Acerini
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Juliana Andrade
- Faculty of Medical Sciences, Department of Medical Genetics, State University of Campinas, São Paulo, Brazil
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, Policlinico S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvano Bertelloni
- Dipartimento Materno-Infantile Azienda Ospedaliero, Universitaria Pisana, Pisa, Italy
| | - Martine Cools
- Department of Paediatric Endocrinology, University Hospital Ghent, and Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Rieko Tadokoro Cuccaro
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | | | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, and Department of BioMedical Research, Bern University Children's Hospital, University of Bern, Bern, Switzerland
| | - Romina P Grinspon
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), National Scientific and Technical Research Council (CONICET) - Fundación de Endocrinología Infantil (FEI) - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Andrea Maciel-Guerra
- Faculty of Medical Sciences, Department of Medical Genetics, State University of Campinas, São Paulo, Brazil
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sabine E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, Netherlands
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University of Luebeck, Luebeck, Germany
| | - Paul Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Corina Lichiardopol
- Department of Endocrinology, University of Medicine and Pharmacy Craiova, University Emergency Hospital, Craiova, Romania
| | - Leendert H J Looijenga
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Erasmus Medical Center, University Medical Center Rotterdam, Cancer Institute, Rotterdam, and Princess Maxima Center for Paediatric Oncology, Utrecht, Netherlands
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, Policlinico S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Stefan Riedl
- Pediatric Endocrinology, St. Anna Children´s Hospital, Medical University of Vienna, Vienna, Austria
- Department of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Stoffers IE, de Vries MC, Hannema SE. Physical changes, laboratory parameters, and bone mineral density during testosterone treatment in adolescents with gender dysphoria. J Sex Med 2019; 16:1459-1468. [PMID: 31405768 DOI: 10.1016/j.jsxm.2019.06.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/25/2019] [Accepted: 06/23/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Current treatment guidelines for adolescents with gender dysphoria recommend therapy with gonadotropin-releasing hormone agonists (GnRHa) and testosterone in transgender males. However, most evidence on the safety and efficacy of testosterone is based on studies in adults. AIM This study aimed to investigate the efficacy and safety of testosterone treatment in transgender adolescents. METHODS The study included 62 adolescents diagnosed with gender dysphoria who had started GnRHa treatment and had subsequently received testosterone treatment for more than 6 months. MAIN OUTCOME MEASURE Virilization, anthropometry, laboratory parameters, and bone mineral density (BMD) were analyzed. RESULTS Adolescents were treated with testosterone for a median duration of 12 months. Voice deepening began within 3 months in 85% of adolescents. Increased hair growth was first reported on the extremities, followed by an increase of facial hair. Acne was most prevalent between 6 and 12 months of testosterone therapy. Most adolescents had already completed linear growth; body mass index and systolic blood pressure increased but diastolic blood pressure did not change. High-density lipoprotein (HDL) cholesterol and sex hormone binding globulin significantly decreased, but hematocrit, hemoglobin, prolactin, androstenedione, and dehydroepiandrosterone sulfate significantly increased, although not all changes were clinically significant. Other lipids and HbA1c did not change. Vitamin D deficiency was seen in 32-54% throughout treatment. BMD z-scores after 12 to 24 months of testosterone treatment remained below z-scores before the start of GnRHa treatment. CLINICAL IMPLICATIONS Adolescents need to be counseled about side effects with potential longer term implications such as increased hematocrit and decreased HDL cholesterol and decreased BMD z-scores. They should be advised on diet, including adequate calcium and vitamin D intake; physical exercise; and the use of tobacco and alcohol to avoid additional risk factors for cardiovascular disease and osteoporosis. STRENGTHS & LIMITATIONS Strengths are the standardized treatment regimen and extensive set of safety parameters investigated. Limitations are the limited duration of follow-up and lack of a control group so some of the observed changes may be due to normal maturation rather than to treatment. CONCLUSION Testosterone effectively induced virilization beginning within 3 months in the majority of adolescents. Acne was a common side effect, but no short-term safety issues were observed. The increased hematocrit, decreased HDL cholesterol, and decreased BMD z-scores are in line with previous studies. Further follow-up studies will need to establish if the observed changes result in adverse outcomes in the long term. Stoffers IE, de Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. J Sex Med 2019;16:1459-1468.
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Affiliation(s)
- Iris E Stoffers
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands; Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands.
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Skordis N, Butler G, de Vries MC, Main K, Hannema SE. ESPE and PES International Survey of Centers and Clinicians Delivering Specialist Care for Children and Adolescents with Gender Dysphoria. Horm Res Paediatr 2019; 90:326-331. [PMID: 30695784 DOI: 10.1159/000496115] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/10/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Increasing numbers of children and adolescents seek medical care because they experience incongruence between their physical sex and their gender identity. METHODS The ESPE working group on gender dysphoria (GD) undertook a survey to investigate the structure and the type of medical care in centers that offer specialist care for transgender adolescents. RESULTS The personnel of each center varied from country to country, and a nationally organized network or plan for managing GD did not exist in all centers. The majority of young people were transitioning from female to male, and the number of new referrals increased remarkably during the past 3 years. Almost all centers follow the guidelines issued by the Endocrine Society and World Professional Association for Transgender Health. GnRH analogues were used as the initial treatment in the majority of the centers. The age from which adolescents are treated with gender-affirming hormones varied between centers. Several legal restrictions that concern or influence the treatment of children and adolescents with GD were finally addressed. CONCLUSION This first international survey examining the variations in availability and provisions of services for children and adolescents with GD serves as a starting block for further dialogue and future studies.
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Affiliation(s)
- Nicos Skordis
- Division of Pediatric Endocrinology, Paedi Center for Specialized Pediatrics, Nicosia, Cyprus, .,University of Nicosia Medical School, Nicosia, Cyprus,
| | - Gary Butler
- Department of Paediatric and Adolescent Endocrinology, University College London Hospitals, London, United Kingdom.,UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,UK Gender Identity Development Service, Tavistock and Portman NHS Trust, London, United Kingdom
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Katharina Main
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - Sabine E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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van der Linde AAA, Schönbeck Y, van der Kamp HJ, van den Akker ELT, van Albada ME, Boelen A, Finken MJJ, Hannema SE, Hoorweg-Nijman G, Odink RJ, Schielen PCJI, Straetemans S, van Trotsenburg PS, Claahsen-van der Grinten HL, Verkerk PH. Evaluation of the Dutch neonatal screening for congenital adrenal hyperplasia. Arch Dis Child 2019; 104:653-657. [PMID: 30712004 DOI: 10.1136/archdischild-2018-315972] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 12/17/2018] [Accepted: 12/30/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND In 2002, a nationwide screening for congenital adrenal hyperplasia (CAH) was introduced in the Netherlands. The aim of our study is to evaluate the validity of the neonatal screening for CAH and to assess how many newborns with salt-wasting (SW) CAH have already been clinically diagnosed before the screening result was known. METHODS Retrospective, descriptive study. The following data of patients with positive screening results since implementation of the screening programme were collected (1 January 2002 up until 31 December 2013): gestational age, sex, diagnosis, clinical presentation and contribution of screening to the diagnosis. RESULTS In the evaluated period, 2 235 931 newborns were screened. 479 children had an abnormal screening result, 133 children were diagnosed with CAH (114 SW, 14 simple virilizing (SV)), five non-classic CAH. During this period, no patients with SW CAH were missed by neonatal screening (sensitivity was 100%). After exclusion of 17 cases with missing information on diagnosis, specificity was 99.98% and positive predictive value was 24.7%. Most false positives (30%) were attributable to prematurity. Of patients with SW CAH, 68% (71/104) patients were detected by neonatal screening and 33 (33/104) were clinically diagnosed. Of girls with SW CAH, 38% (14/37) were detected by neonatal screening and 62% (23/37) were clinically diagnosed. CONCLUSION The Dutch neonatal screening has an excellent sensitivity and high specificity. Both boys and girls can benefit from neonatal screening.
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Affiliation(s)
- Annelieke A A van der Linde
- Department of Paediatric Endocrinology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.,Department of Paediatrics, Amphia Hospital, Breda, The Netherlands
| | | | - Hetty J van der Kamp
- Department of Paediatrics, Utrecht University Hospital, Utrecht, The Netherlands
| | | | - Mirjam E van Albada
- Department of Paediatrics, University Medical Centre, Groningen, The Netherlands
| | - Anita Boelen
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn J J Finken
- Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Erasmus MC, Rotterdam, The Netherlands.,Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Gera Hoorweg-Nijman
- Department of Paediatrics, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Roelof J Odink
- Department of Paediatrics, Catharina Hospital, Eindhoven, The Netherlands
| | - Peter C J I Schielen
- Reference Laboratory for Neonatal Screening, Centre for Health Protection Research, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | | | - Paul S van Trotsenburg
- Department of Paediatric Endocrinology, Emma Children's Hospital Academic Medical Center, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Paul H Verkerk
- TNO, Department of Child Health, Leiden, The Netherlands
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Brik T, Vrouenraets LJJJ, Schagen SEE, Meissner A, de Vries MC, Hannema SE. Use of Fertility Preservation Among a Cohort of Transgirls in the Netherlands. J Adolesc Health 2019; 64:589-593. [PMID: 30691936 DOI: 10.1016/j.jadohealth.2018.11.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The primary aims of the study are to examine the rate of attempted fertility preservation (FP) among a Dutch cohort of transgirls who started gonadotropin-releasing hormone analog treatment and the reasons why adolescents did or did not choose to attempt FP. METHODS The study was a single-center retrospective review of medical records of 35 transgirls who started gonadotropin-releasing hormone analog treatment between 2011 and 2017. RESULTS Ninety-one percent of adolescents were counseled on the option of FP. Thirty-eight percent of counseled adolescents attempted FP, and 75% of them were able to cryopreserve sperm suitable for intrauterine insemination or intracytoplasmic sperm injection. Younger and Caucasian transgirls were less likely to attempt FP. No specific reason for declining FP was known in 33% adolescents, 32% of adolescents were not able to produce a semen sample because of early puberty, 17% felt uncomfortable with masturbation, 17% did not want to have children, and 13% wanted to adopt. CONCLUSIONS One third of adolescents attempted FP, which is much more than the percentage reported in previous studies from the United States. One third of the transgirls could not make use of FP because they were unable to produce a semen sample because of early pubertal stage. For these adolescents, alternatives need to be explored.
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Affiliation(s)
- Tessa Brik
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieke J J J Vrouenraets
- Department of Pediatric Psychology, Curium-Leiden University Medical Center, Leiden, The Netherlands
| | | | - Andreas Meissner
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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van der Tuin K, de Kock L, Kamping EJ, Hannema SE, Pouwels MJM, Niedziela M, van Wezel T, Hes FJ, Jongmans MC, Foulkes WD, Morreau H. Clinical and Molecular Characteristics May Alter Treatment Strategies of Thyroid Malignancies in DICER1 Syndrome. J Clin Endocrinol Metab 2019; 104:277-284. [PMID: 30260442 DOI: 10.1210/jc.2018-00774] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/21/2018] [Indexed: 12/31/2022]
Abstract
CONTEXT DICER1 syndrome is a rare autosomal-dominantly inherited disorder that predisposes to a variety of cancerous and noncancerous tumors of mostly pediatric and adolescent onset, including differentiated thyroid carcinoma (DTC). DTC has been hypothesized to arise secondarily to the increased prevalence of thyroid hyperplastic nodules in syndromic patients. OBJECTIVE To determine somatic alterations in DICER1-associated DTC and to study patient outcomes. DESIGN Retrospective series. SETTING Tertiary referral centers. PATIENTS Ten patients with germline pathogenic DICER1 variants and early-onset DTC. METHODS Somatic DICER1 mutation analysis, extensive somatic DNA variant and gene fusion analyses were performed on all tumors. RESULTS Median age at DTC diagnosis was 13.5 years and there was no recurrent or metastatic disease (median follow-up, 8 years). All thyroid specimens showed diffuse nodular hyperplasia with at least one focus suspicious of DTC but without infiltrative growth, extrathyroidal extension, vascular invasion, or lymph node metastasis. Most of the individual nodules (benign and malignant) sampled from the 10 tumors harbored distinct DICER1 RNase IIIb hotspot mutations, indicating a polyclonal composition of each tumor. Furthermore, nine of 10 DICER1-related DTCs lacked well-known oncogenic driver DNA variants and gene rearrangements. CONCLUSION On the basis of our clinical, histological, and molecular data, we consider that most DICER1-related DTCs form a low-risk subgroup. These tumors may arise within one of multiple benign monoclonal nodules; thus, hemi-thyroidectomy or, more likely, total thyroidectomy may often be required. However, radioiodine treatment may be unnecessary given the patients' ages and the tumors' low propensity for metastases.
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Affiliation(s)
- Karin van der Tuin
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, Netherlands
| | - Leanne de Kock
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Eveline J Kamping
- Department of Clinical Genetics, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Marie-Jose M Pouwels
- Department of Internal Medicine, Division of Endocrinology, Medical Spectrum Twente, Enschede, Netherlands
| | - Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Karol Jonscher's Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Tom van Wezel
- Department of Pathology, Leiden University Medical Centre, Leiden, Netherlands
| | - Frederik J Hes
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, Netherlands
| | - Marjolijn C Jongmans
- Department of Clinical Genetics, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Medical Genetics, Utrecht University Medical Center, Utrecht, Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - William D Foulkes
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Centre, Leiden, Netherlands
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Tack LJW, Maris E, Looijenga LHJ, Hannema SE, Audi L, Köhler B, Holterhus PM, Riedl S, Wisniewski A, Flück CE, Davies JH, T'Sjoen G, Lucas-Herald AK, Evliyaoglu O, Krone N, Iotova V, Marginean O, Balsamo A, Verkauskas G, Weintrob N, Ellaithi M, Nordenström A, Verrijn Stuart A, Kluivers KB, Wolffenbuttel KP, Ahmed SF, Cools M. Management of Gonads in Adults with Androgen Insensitivity: An International Survey. Horm Res Paediatr 2018; 90:236-246. [PMID: 30336477 DOI: 10.1159/000493645] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Complete and partial androgen insensitivity syndrome (CAIS, PAIS) are associated with an increased risk of gonadal germ cell cancer (GGCC). Recent guidelines recommend gonadectomy in women with CAIS in late adolescence. Nevertheless, many adult women prefer to retain their gonads. AIMS This study aims to explore attitudes towards gonadectomy in AIS in centres around the world, estimate the proportion of adults with retained gonads and/or who developed GGCC, and explore reasons for declining gonadectomy. METHODS A survey was performed among health care professionals who use the International DSD Registry (I-DSD). RESULTS Data were provided from 22 centres in 16 countries on 166 women (CAIS) and 26 men (PAIS). In CAIS, gonadectomy was recommended in early adulthood in 67% of centres; 19/166 (11.4%) women refused gonadectomy. Among 142 women who had gonadectomy, evidence of germ cell neoplasm in situ (GCNIS), the precursor of GGCC, was reported in 2 (1.4%) out of 8 from whom pathology results were formally provided. Nine out of 26 men with PAIS (34.6%) had retained gonads; 11% of centres recommended routine gonadectomy in PAIS. CONCLUSION Although development of GGCC seems rare, gonadectomy after puberty is broadly recommended in CAIS; in PAIS this is more variable. Overall, our data reflect the need for evidence-based guidelines regarding prophylactic gonadectomy in AIS.
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Affiliation(s)
- Lloyd J W Tack
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent,
| | - Ellen Maris
- Division of Paediatric Endocrinology, Department of Paediatrics, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Leendert H J Looijenga
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Josephine Nefkens Building, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Laura Audi
- Growth and Development Research Unit, Vall d'Hebron Research Institute (VHIR), Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Birgit Köhler
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel, Kiel, Germany
| | - Stefan Riedl
- Department of Pediatric Pulmology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Department of Pediatrics, St. Anna Children´s Hospital, Medical University of Vienna, Vienna, Austria
| | - Amy Wisniewski
- Department of Urology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Christa E Flück
- Paediatric Endocrinology, Diabetology and Metabolism, Department of Paediatrics and Department of BioMedical Research, Bern University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Justin H Davies
- Department of Endocrinology, University Hospital Southampton, Southampton, United Kingdom
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Olcay Evliyaoglu
- Department of Paediatric Endocrinology, Faculty of Medicine, İstanbul University Cerrahpaşa, İstanbul, Turkey
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Violeta Iotova
- Department of Paediatrics, Medical University Varna, Varna, Bulgaria
| | - Otilia Marginean
- First Paediatric Clinic, University of Medicine and Pharmacy Victor Babes, Timisoara, Romania
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Paediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Gilvydas Verkauskas
- Centre of Paediatric Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Naomi Weintrob
- Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Department of Paediatrics, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mona Ellaithi
- Faculty of Medical Laboratory Sciences, Al-Neelain University, Khartoum, Sudan
| | - Anna Nordenström
- Department of Women's and Children's Health, Paediatric Endocrinology Q2: 04, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Annemarie Verrijn Stuart
- Department of Paediatrics, Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Urology and Paediatric Urology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
| | - Martine Cools
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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Martinerie L, Condat A, Bargiacchi A, Bremont-Weill C, de Vries MC, Hannema SE. MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria. Eur J Endocrinol 2018; 179:R219-R237. [PMID: 30049812 DOI: 10.1530/eje-18-0227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 07/07/2018] [Accepted: 07/25/2018] [Indexed: 02/03/2023]
Abstract
Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.
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Affiliation(s)
- L Martinerie
- Department of Pediatric Endocrinology, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Diderot University, Sorbonne Paris Cité, Paris, France
- INSERM Unit 1145, Le Kremlin-Bicêtre, France
| | - A Condat
- Department of Adolescent and Child Psychiatry, Pitié-Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- CESP INSERM 1018, ED3C, Université Paris Descartes, Paris, France
| | - A Bargiacchi
- Department of Adolescent and Child Psychiatry, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Bremont-Weill
- Department of Endocrinology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M C de Vries
- Departments of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
- Departments of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - S E Hannema
- Departments of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Schagen SEE, Lustenhouwer P, Cohen-Kettenis PT, Delemarre-van de Waal HA, Hannema SE. Changes in Adrenal Androgens During Puberty Suppression and Gender-Affirming Hormone Treatment in Adolescents With Gender Dysphoria. J Sex Med 2018; 15:1357-1363. [PMID: 30224022 DOI: 10.1016/j.jsxm.2018.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/15/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Gender-affirming hormone treatment is known to affect adrenal androgen levels in adult individuals with gender dysphoria (GD). This may be clinically relevant because the adrenal gland plays a critical role in many different metabolic processes. AIM This study aims to assess the effects of gonadotropin-releasing hormone analogs (GnRHa) treatment and gender-affirming hormone treatment on adrenal androgen levels in adolescents with GD. METHODS In this prospective study, dehydroepiandrosterone-sulfate (DHEAS) and androstenedione values were measured every 6 months during 2 years of GnRHa treatment only, and 2 years of GnRHa combined with gender-affirming hormone treatment (estradiol or testosterone) in 73 transgirls and 54 transboys. To determine trends in adrenal androgen levels a linear mixed model was used to approximate androgen levels. MAIN OUTCOME MEASURES DHEAS and androstenedione levels were the main outcome measures. RESULTS DHEAS levels rose in transboys during GnRHa treatment, which may represent the normal increase during adolescence. In transgirls no change in DHEAS levels during GnRHa treatment was found. Gender-affirming hormone treatment did not affect DHEAS levels in either sex. In transboys androstenedione levels decreased during the first year of GnRHa treatment, which may reflect reduced ovarian androstenedione synthesis, and rose during the first year of gender-affirming hormone treatment, possibly due to conversion of administered testosterone. In transgirls androstenedione levels did not change during either GnRHa or gender-affirming hormone treatment. CLINICAL IMPLICATIONS No deleterious effects of treatment on adrenal androgen levels were found during approximately 4 years of follow-up. STRENGTHS & LIMITATIONS This is one of the largest cohort of adolescents with GD, treated using a uniform protocol, with standardized follow-up. The lack of a control group is a limitation. CONCLUSION The changes in androstenedione levels during GnRHa and gender-affirming hormone treatment in transboys may not be of adrenal origin. The absence of changes in androstenedione levels in transgirls or DHEAS levels in either sex during gender-affirming hormone treatment suggests that gender-affirming hormone treatment does not significantly affect adrenal androgen production. Schagen SEE, Lustenhouwer P, Cohen-Kettenis PT, et al. Changes in Adrenal Androgens During Puberty Suppression and Gender-Affirming Hormone Treatment in Adolescents With Gender Dysphoria. J Sex Med 2018;15:1357-1363.
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Affiliation(s)
- Sebastian E E Schagen
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands; Department of Pediatric Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul Lustenhouwer
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center, Amsterdam, The Netherlands
| | - Henriette A Delemarre-van de Waal
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands; Department of Pediatric Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. ENDOCRINE TREATMENT OF GENDER-DYSPHORIC/GENDER-INCONGRUENT PERSONS: AN ENDOCRINE SOCIETY CLINICAL PRACTICE GUIDELINE. Endocr Pract 2018; 23:1437. [PMID: 29320642 DOI: 10.4158/1934-2403-23.12.1437] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
The aim of the European Reference Network for Rare Endocrine Disorders (Endo-ERN) is to ensure equal access to high-quality care for all those affected by a rare endocrine condition across Europe, such as a disorder/difference of sex development (DSD), both for children and adults. Although differences in resources, health care systems, and health insurances between the European countries are challenging and require political action, a European laboratory network within Endo-ERN could improve the diagnostic process in individuals with DSD, building on the work done by previous European collaborations such as the COST action DSDnet. In close collaboration, clinicians and laboratory specialists must make every effort to standardize diagnostic protocols, achieve necessary harmonization of various laboratory tests, e.g., the hCG stimulation test, and implement an external quality control system. This should ideally result in comparable quality across the network centers allowing the sharing of reference values. This would not only improve patient care but also greatly facilitate research.
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Affiliation(s)
- Sabine E Hannema
- Department of Pediatric Endocrinology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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46
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017. [PMID: 28945902 DOI: 10.1210/jc.2017-01658.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objective To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. Participants The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. Evidence This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus Process Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. Conclusion Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
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Affiliation(s)
- Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York 10032
| | | | - Louis Gooren
- VU University Medical Center, 1007 MB Amsterdam, Netherlands
| | | | - Walter J Meyer
- University of Texas Medical Branch, Galveston, Texas 77555
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota 55905
| | - Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California 94143
| | - Joshua D Safer
- Boston University School of Medicine, Boston, Massachusetts 02118
| | - Vin Tangpricha
- Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia 30322
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47
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:3869-3903. [PMID: 28945902 DOI: 10.1210/jc.2017-01658] [Citation(s) in RCA: 1107] [Impact Index Per Article: 158.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. PARTICIPANTS The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. CONCLUSION Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
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Affiliation(s)
- Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York 10032
| | | | - Louis Gooren
- VU University Medical Center, 1007 MB Amsterdam, Netherlands
| | | | - Walter J Meyer
- University of Texas Medical Branch, Galveston, Texas 77555
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota 55905
| | - Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California 94143
| | - Joshua D Safer
- Boston University School of Medicine, Boston, Massachusetts 02118
| | - Vin Tangpricha
- Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia 30322
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Chaudhry S, Tadokoro-Cuccaro R, Hannema SE, Acerini CL, Hughes IA. Frequency of gonadal tumours in complete androgen insensitivity syndrome (CAIS): A retrospective case-series analysis. J Pediatr Urol 2017; 13:498.e1-498.e6. [PMID: 28351649 DOI: 10.1016/j.jpurol.2017.02.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive disorder of sex development (DSD) where affected individuals are phenotypically female, but have an XY karyotype and testes. The risk of gonadal tumour development in CAIS may increase with age; incidence rates have been reported to be 0.8-22% in patients who have retained their gonads into adulthood. Consequently, gonadectomy has been recommended either during childhood or after puberty is complete, although there is no consensus on the optimal timing for this procedure. OBJECTIVE AND HYPOTHESES To establish the frequency of histological abnormalities in CAIS in relation to the age at gonadectomy. METHOD Data were collected from the Cambridge DSD database on patients with CAIS (n = 225; age range 3-88 years) who had undergone gonadectomy, and their age of gonadectomy, gonadal histology and immunohistochemistry. RESULTS Evaluable data were obtained from 133 patients. Median age at gonadectomy was 14.0 years (range: 18 days-68 years). Pubertal status was: prepuberty, n = 62; postpuberty, n = 68. Thirteen cases were aged >20 years at gonadectomy. The pattern of histology is summarised in the Summary table. DISCUSSION In this large case series of CAIS patients who had undergone gonadectomy, while the combined malignant and premalignant gonadal histology prevalence was 6.0%, the findings confirm the low occurrence of gonadal malignancy in CAIS, with a frequency of 1.5%. The two cases of malignancy were postpubertal. Germ cell neoplasia in situ (GCNIS) was observed in six cases, of which one occurred prepuberty and five postpuberty. The study highlighted difficulties in diagnosis of GCNIS and the need for histological analysis in expert centres. CONCLUSION The results support the current recommendation that gonads in CAIS can be retained until early adulthood. The small number of individuals with gonadectomy after age 20 years do not allow firm conclusion regarding later adulthood. Therefore, it is recommended that the option of gonadectomy be discussed in adulthood. Some form of regular surveillance of the gonads is then recommended, although none of the available options are ideal.
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Affiliation(s)
- S Chaudhry
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - R Tadokoro-Cuccaro
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - S E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands; Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C L Acerini
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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van Bever Y, Wolffenbuttel KP, Brüggenwirth HT, Blom E, de Klein A, Eussen BHJ, van der Windt F, Hannema SE, Dessens AB, Dorssers LCJ, Biermann K, Hersmus R, de Rijke YB, Looijenga LHJ. Multiparameter Investigation of a 46,XX/46,XY Tetragametic Chimeric Phenotypical Male Patient with Bilateral Scrotal Ovotestes and Ovulatory Activity. Sex Dev 2017; 12:145-154. [PMID: 28926831 DOI: 10.1159/000479946] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We report on an adult male initially presenting with gynecomastia and a painless scrotal mass without additional genital anomalies. Hyperpigmentation of the skin following the Blaschko's lines was identified. He underwent gonadectomy because of suspected cancer. Histological analyses revealed an ovotestis with ovulatory activity confirmed by immunohistochemistry with multiple markers. Karyotyping of cultured peripheral blood lymphocytes and a buccal smear revealed a 46,XX/46,XY chimeric constitution with different percentages. Multiple molecular analyses as well as blood typing implied a tetragametic origin. After the unilateral gonadectomy, the patient developed recurrent painful cystic swellings of the remaining gonad. Because of the wish to preserve hormonal activity as well as future fertility, the patient underwent surgical resection of a cystic gonadal area. The removed tissue showed ovulation-related features in addition to both testicular and ovarian tissue, diagnosed as an ovotestis. Testosterone therapy was initiated to suppress the persistently elevated gonadotropins and thereby suppress ovarian activity. During treatment, the recurrent pain complaints and cystic swellings ceased, although gonadotropin levels were not fully suppressed. Based on these observations, the importance of a detailed genetic and pathological diagnosis and the clinical dilemmas including the pros and cons of personalized treatment with gonadal preservative surgery are discussed.
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Affiliation(s)
- Yolande van Bever
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
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Hannema SE, Schagen SEE, Cohen-Kettenis PT, Delemarre-van de Waal HA. Efficacy and Safety of Pubertal Induction Using 17β-Estradiol in Transgirls. J Clin Endocrinol Metab 2017; 102:2356-2363. [PMID: 28419243 DOI: 10.1210/jc.2017-00373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/30/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Puberty suppression using gonadotropin-releasing hormone agonists, followed by induction of the desired sex characteristics using sex steroids, has been recommended by the current guidelines as the treatment of choice for gender dysphoric adolescents, although little evidence is available. AIM To evaluate the efficacy and safety of estrogen treatment for pubertal induction in transgirls (female-identifying adolescents assigned male at birth). METHODS Twenty-eight adolescents treated with oral estrogen for ≥1 year were included. The Tanner stage, anthropometry, laboratory parameters, bone age, and body composition were evaluated. RESULTS Breast development started within 3 months in 83% of adolescents, and after 3 years, 86% had Tanner breast stage 4 to 5. The hip circumference increased and the waist/hip ratio decreased. The median serum estradiol was 100 pmol/L (range, 24 to 380) at the standard adult dose of 2 mg of 17β-estradiol. The adult height standard deviation score was +1.9 (for females). The body mass index standard deviation score, lean body mass percentage, fat percentage, and blood pressure did not change. No abnormalities of creatinine or liver enzymes were detected, and the hematocrit and hemoglobin A1c did not change. One individual developed hyperprolactinemia during high-dose ethinylestradiol treatment to limit growth. CONCLUSIONS Pubertal induction using estradiol is effective; however, an adult dose of 2 mg does not always result in appropriate serum estradiol levels. Monitoring renal function, liver enzymes, hematocrit, and hemoglobin A1c during pubertal induction with estradiol is not necessary. Further studies are needed to establish effective and safe methods to limit growth.
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Affiliation(s)
- Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Sebastian E E Schagen
- Department of Pediatrics, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
- Department of Pediatric Endocrinology, VU University Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Henriette A Delemarre-van de Waal
- Department of Pediatrics, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
- Department of Pediatric Endocrinology, VU University Medical Centre, 1081 HV Amsterdam, The Netherlands
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