Transition in Pediatric and Adolescent Hypogonadal Girls: Gynecological Aspects, Estrogen Replacement Therapy, and Contraception.

Hypogonadism may be suspected if puberty is delayed. Pubertal delay may be caused by a normal physiological variant, by primary ovarian insufficiency (Turner syndrome), or reflect congenital hypogonadotropic hypogonadism (HH; genetic) or acquired HH (brain lesions). Any underlying chronic disease like inflammatory bowel disease, celiac disease, malnutrition (anorexia or orthorexia), or excessive physical activity may also result in functional HH. Thus, girls with delayed puberty should be evaluated for an underlying pathology before any treatment, including oral contraception, is initiated. Estrogen replacement is important and natural 17ß-estradiol, preferably transdermally, is the preferred choice, whereas the oral route can be used as an alternative depending on patient preference and compliance. Sexual activity is often delayed in the hypogonadal adolescent girl. In the adolescent hypogonadal girl, hormone replacement therapy (HRT) most likely has been initiated at the time she becomes sexually active. If a risk of unwanted pregnancy cannot be ruled out, there is a need to consider contraception. This consideration does not contradict the principles of HRT but can be included as a part of the substitution, e.g. oral contraceptives containing 17ß-estradiol or a progestogen intrauterine device combined with continuous 17ß-estradiol (transdermal or oral).

Dosage of estradiol, bone and body composition in Turner syndrome: a 5-year randomized controlled clinical trial.

OBJECTIVE: Reduced bone mineral density (BMD) is seen in Turner syndrome (TS) with an increased risk of fractures, and body composition is characterized by increased body fat and decreased lean body mass. To evaluate the effect of two different doses of oral 17B-estradiol in young TS women on bone mineral density (BMD), biochemical markers of bone turnover and body composition with the hypothesis of a positive effect of the higher dose. DESIGN: A double-blind 5-year randomized controlled clinical trial. 20 young TS women participated. Inclusion criteria were diagnosis of TS, age 15-25 years and current treatment with 2 mg oral estradiol daily. METHODS: The low-dose (LD) group was administered 2 mg 17B-estradiol/day orally and placebo, the high-dose (HD) group was administered 2 + 2 mg 17B-estradiol/day orally. Main outcome measures were whole body and regional bone mineral density (BMD), lean body mass (LBM), fat mass (FM) measured yearly by DXA scan and resorptive and formative bone markers in serum. RESULTS: BMD, whole body and regional, increased over time with an attenuation toward the end of the study, and bone turnover markers decreased over time, both with no differences between the treatment groups (P = 0.2-0.9). LBM increased significantly more in the HD group (P = 0.02). FM remained stable in both groups. CONCLUSIONS: A steady increase in BMD over time in TS was found similar to healthy young women. The higher estrogen dose did not differentially affect BMD or bone markers. The positive effect on body composition may have long-ranging health benefits in TS.

Aortic dilatation and dissection in Turner syndrome: what we know, what we are unclear about and what we should do in clinical practice?

Aortic dilatation and aortic dissection are increasingly recognised in patients with Turner syndrome (TS). Risk factors for aortic dissection include aortic dilatation, bicuspid aortic valves, coarctation of aorta and pregnancy. The risk of death due to aortic dissection in pregnancy in TS is 2%, which is approximately 100 times higher than the general population, as maternal mortality is extremely low. Ongoing cardiovascular monitoring is recommended, although there remain several unanswered questions in relation to cardiovascular imaging especially the choice of modality for detection of vascular, valvular abnormalities and measurements of aortic dimensions. Due to the relative short stature of patients with TS, aortic dimensions need to be defined by aortic measurements adjusted for body surface area, known as aortic sized index (ASI). The relationship of ASI and other risk factors with aortic dissection is only beginning to be clarified. Clinical management and monitoring of such patients should be delivered by a group of clinicians familiar with the issues unique to TS patients in a multidisciplinary fashion. All clinicians including the non-specialists need to have a low threshold of suspecting aortic dissection in these adolescents and young adults. This up to date review, including a summary of all 122 published cases of TS patients with aortic dissection, aims to provide a summary of recent publications on characteristics of aortic dissection and aortic dilatation in TS to highlight gaps in knowledge and propose possible clinical monitoring pathway of cardiovascular health in children and adults with TS. Cardiovascular assessment and risk counselling is especially crucial during the period of transition of adolescents with TS, although life long monitoring by expert cognizant to the issues specific in TS is essential.

Disorders of ovarian function in childhood and adolescence: evolving needs of the growing child. An endocrine perspective.

Over the past 15 years there have been changes in the care of children and adolescents paralleling increased longevity of those with chronic illnesses and increased survival after childhood cancer and organ transplantation. A broad understanding of holistic management and long-term risks is required. Optimisation of pubertal progress and normalisation of bone and hormonal health by the end of puberty will reduce the impact of later adult bone loss in chronic disease conditions. Psychosocial issues related to both precocious and delayed puberty can have profound effects on family function.

Tone probe event-related potential differences during a face recognition task in prepubertal children and Turner Syndrome girls.

Hormones have been shown to play a role in both cerebral development and neurocognitive function. Turner Syndrome (TS) provides the opportunity to study the effect of the lack of estrogen on neurocognitive development. In this study, event-related potential (ERP) differences were examined among 12 TS girls, 20 prepubertal control girls, and 20 prepubertal control boys during a face recognition memory task. Stage of puberty was determined by Tanner Scale rating and hormonal assay. ERPs to pairs of auditory probe stimuli were recorded from eight scalp sites while participants performed a faced recognition memory (FRM) task. For the N2 component of the ERP (which has previously been associated with evaluation of stimulus information, categorization difficulty, and attention), control boys displayed greater right versus left hemisphere amplitude, control girls displayed greater left versus right hemisphere amplitude, and there was no amplitude asymmetry for TS girls. Further, control girls had greater left hemisphere N2 amplitude than control boys and TS girls, and greater right hemisphere N2 amplitude than TS girls. The results suggest more right hemisphere activation during face recognition in boys, while the opposite pattern was present in control girls. In contrast, TS girls displayed no asymmetry, indicative of more uniform involvement of the left and right hemispheres during face recognition. These findings are consistent with differences in cortical organization related to face recognition memory processing among prepubertal control boys, girls, and TS girls. They also support the notion that sex differences in cognitive function are present prior to pubertal onset, and that lack of endogenous sex hormones (e.g., estrogen) during prenatal/perinatal development (i.e., for TS girls) may influence brain organization and, in turn, neurocognitive processes that relate to face recognition.

Estrogen and testosterone, but not a nonaromatizable androgen, direct network integration of the hypothalamo-somatotrope (growth hormone)-insulin-like growth factor I axis in the human: evidence from pubertal pathophysiology and sex-steroid hormone replacement.

Activation of the gonadotropic and somatotropic axes in puberty is marked by striking amplification of pulsatile neurohormone secretion. In addition, each axis, as a whole, constitutes a regulated network whose feedback relationships are likely to manifest important changes at the time of puberty. Here, we use the regularity statistic, approximate entropy (ApEn), to assess feedback activity within the somatotropic (hypothalamo-pituitary/GH-insulin-like growth factor I) axis indirectly. To this end, we studied pubertal boys and prepubertal girls or boys with sex-steroid hormone deficiency treated short-term with estrogen, testosterone, or a nonaromatizable androgen in a total of 3 paradigms. First, our cross-sectional analysis of 53 boys at various stages of puberty or young adulthood revealed that mean ApEn, taken as a measure of feedback complexity, of 24-h serum GH concentration profiles is maximal in pre- and mid-late puberty, followed by a significant decline in postpubertal adolescence and young adulthood (P = 0.0008 by ANOVA). This indicates that marked disorderliness of the GH release process occurs in mid-late puberty at or near the time of peak growth velocity, with a return to maximal orderliness thereafter at reproductive maturity. Second, oral administration of ethinyl estradiol for 5 weeks to 7 prepubertal girls with Turner's syndrome also augmented ApEn significantly (P = 0.018), thus showing that estrogen per se can induce greater irregularity of GH secretion. Third, in 5 boys with constitutionally delayed puberty, im testosterone administration also significantly increased ApEn of 24-h GH time series (P = 0.0045). In counterpoint, 5 alpha-dihydrotestosterone, a nonaromatizable androgen, failed to produce a significant ApEn increase (P > 0.43). We conclude from these three distinct experimental contexts that aromatization of testosterone to estrogen in boys, or estrogen itself in girls, is likely the proximate sex-steroid stimulus amplifying secretory activity of the GH axis in puberty. In addition, based on inferences derived from mathematical models that mechanistically link increased disorderliness (higher ApEn) to network changes, we suggest that sex-steroid hormones in normal puberty modulate feedback within, and hence network function of, the hypothalamo-pituitary/GH-insulin-like growth factor I axis.

[Somatotropic function of the pituitary gland in persons with growth disorders]. / Somatotropnaia funktsiia gipofiza u bol'nykh s zaderzhkoi rosta

The authors present the results of study of the somatotropic function of the hypophysis in 18 healthy children and in 70 patients suffering from various forms of growth retardation. The blood serum level of the STH of the hypophysis was studied by the authors by standard sets for radioimmunological determination on fasting stomach and in dynamics during the standard glucose-tolerance test. The data of basal, maximal and mean STH levels were taken into consideration. Investigations revealed a reduction of the somatotropic function of the hypophysis in the patients with hypophysial, cerebral and somatotropic nanism. With the first tow forms of growth retardation the disturbances were associated with the organic affections of the hypophysis or of the hypothalamus, and in the somatogenic one- they were functional. Somatotropic function was retained in spondylo-epiphysial dysplasia and in the patients with thyrogenic nanism given displacement therapy. In the patients with the Shereshevsky-Turner syndrome the STH secretion remained unchanged, but the reaction of the hypothalamo-hypophysial system to the functional distrubances was disturbed. An increase of the mean STH level followed complex therapy.

Pituitary gonadotrophin responsiveness to synthetic LRF in subjects with normal and abnormal hypothalamic-pituitary-gonadal axis.

PIP: Pituitary gonadotropin responsiveness to synthetic LRF was studied in normal males, in normal females at different phases of the menstrual cycle, in premenopausal females treated with synthetic estrogen, and in subjects with various abnormalities of the hypothalamic-pituitary-gonadal axis. Iv injection of from 1 to 450 mcg LRF in normal males resulted in an increase of luteinizing hormone (LH) within 2 minutes, with a maximal concentration of LH at a median time of 25 minutes. Maximal follicle stimulating hormone (FSH) levels occurred at a median time of 45 minutes. LH, and to a lesser extent FSH, increased with dose, although a wide variation in quantitative response to the same dose of LRF was seen among patients. In female subjects, the response to LRF varied during different phases of the menstrual cycle. The most sensitive period for pituitary response to LRF for both LH and FSH was just prior to the midcycle surge. Chronic estrogen treatment of premenopausal women enhanced pituitary responsiveness to LRF, with an alteration in both time and magnitude of response. Altered pituitary responsiveness was seen in patients with gonadal dysgenesis, hypogonadotropism, hypogonadotropic hypothalamic amenorrhea, panhypopituitarism, and pituitary tumor.^ieng