C Bergadá

Gonadotropin Secretion in Prepubertal Normal and Agonadal Children Evaluated by Ultrasensitive Time-Resolved Immunof luorometric Assays

To analyze a possible gonadal effect on the control of gonadotropin secretion during the prepubertal period, we have measured the luteinizing hormone (LH) and follicle-stimulating hormone (FSH) serum concentrations in children with primary gonadal failure (PGF). We measured them using an ultrasensitive immunofluorometric assay (IFMA) in a single daytime serum sample and compared the results with those obtained with a radioimmunoassay (RIA) technique. The patients were 22 children with PGF (13 girls and 9 boys) aged 0.56-15.4 years and 58 normal children (28 girls and 30 boys) aged 0.08-16 years. In the normal group there were significant changes in serum LH and FSH concentrations in relation to sex and pubertal development. These changes were more evident especially in LH concentrations when using IFMA. We observed that during the prepubertal period the normal LH levels (mean +/- SD) were detectable with this method at concentrations well below the limit RIA could detect (girls 0.026 +/- 0.012 IU/l, and boys 0.025 +/- 0.01 IU/l), while at the onset of puberty these LH levels rose significantly in both sexes (girls 1.0 +/- 0.79 IU/l, boys 1.7 +/- 0.7 IU/l; p < 0.01 vs. prepubertal group), reaching similar values to those observed in FSH concentrations (prepubertal girls 1.9 +/- 0.89 IU/l, boys 0.73 +/- 0.41 IU/l; early pubertal girls 3.1 +/- 0.9 IU/l, boys 2.6 +/- 1.3 IU/l). At prepubertal age, most PGF patients showed normal gonadotropin serum levels (particularly LH) when measured by RIA. However, these same samples-when measured by IFMA-showed LH and FSH levels clearly higher than normal in almost all-10 of 12-patients (PGF girls, n = 8, LH 1.1 +/- 1.0 IU/l, FSH 34 +/- 30 IU/l; PGF boys, n = 4, LH 0.13 +/- 0.12 IU/l, FSH 6.5 +/- 5.7 IU/l). We conclude that, during the so-called juvenile pause when the gonadotropin concentrations could be reliably measured, supranormal gonadotropin levels could be observed during a single daytime serum sample in patients with PGF. These findings suggest that during this period of life the gonads contribute to the negative feedback regulation of gonadotropin levels.

Clinical Assessment and Serum Hormonal Profile in Prepubertal Hypertrichosis

Twenty-two prepubertal girls with hypertrichosis were studied and compared to 10 prepubertal normal girls. Hypertrichosis was assessed according to a score that considers the amount and the distribution of vellus hair in androgen- and non-androgen-sensitive areas. Serum androgen profile and free androgen index (FAI) were determined in both groups. The hypertrichosis score was higher in patients than in the normal girls. Testosterone levels and FAI were increased in patients when compared to control; 3α-androstanediol glucuronide levels above 2 SD from the control mean were found in 10 girls and all hormonal parameters falling in the normal range were found in 4 girls. The new score designed to assess the degree of hypertrichosis was useful to differentiate between normal and pathological hair growth. Although most of the girls with prepubertal hypertrichosis showed an increased androgen bio-availability, a slight increase in peripheral 5α-reductase activity and a completely normal androgen profile was also associated with a pathological hair growth.

Bone age at discontinuation of medroxyprogesterone acetate therapy in girls with precocious puberty: effect on final height.

To determine the final height of patients with precocious puberty treated with medroxyprogesterone acetate (MPA; 150 mg every week) for a period > 1 year (mean +/- SD = 3.24 +/- 1.85 years), data from a group of 26 girls were analyzed. The attained final height was 155.6 +/- 8.06 cm (-1.1 SD of the normal population). In a group of 8 untreated girls with precocious puberty, adult height was 149.2 +/- 5.07 (-2.16 SD, p < 0.02). In 9 patients in whom treatment was stopped at a bone age < or = 12 years, final height was 159.2 +/- 10.05 cm, while in 16 girls who had a bone age > 12 years at the end of treatment, the final height was 153.03 +/- 6.28 cm. Our data demonstrate the effectiveness of MPA treatment on ultimate height. The better height observed in those patients who stopped treatment with a bone age < 12 years suggests the advantage of discontinuing therapy before reaching a more advanced degree of skeletal maturation.

Ovarian Steroidogenesis in Congenital Adrenal Hyperplasia (CAH) 30

Amenorrhea and menstrual disorders are frequent in women with CAH, and have been attributed to excessive androgen and/or progestin production. With the aim of analyzing the ovarian steroidogenesis in CAH, 8 young women with 21-OHlase deficiency on corticoid treatment (CA 21.8±3.3 y.), 4 amenorrheic(Am) and 4 with spontaneous menstrual cycles(SC) were studied. Serum LH, FSH, Estradiol (E2), Androstenedione (A), Testosterone (T), 17-hydroxyprogesterone (17OHP) and Progesterone (P) were determined in the basal state(b). Then 150 IU/day purified FSH was given and the same hormone levels were daily measured until an E2 level ≥150 pg/ml was reached or up to a 5 days maximum FSH administration. FSH levels increased under treatment from (x ± SD) 3.0 ±1.8 to 9.0±2.3 IU/L(p<0.0002) and the E2 increase (ΔE2) was 278±158 pg/ml. A significant positive correlation was observed betweenΔ E2 and: bE2(p<0.05), bT(p<0.02), and bA(p<0.02). Basal hormonal levels of the 4 Am patients compared to those of the 4 SC patients showed higher P levels, 4.4±3.9 vs 1.2±0.4 ng/ml (p < 0.01), lower LH levels, 4.1±1.7 vs 7.7±2.6 IU/l (p< 0.05) and a tendency to lower FSH, 1.8±1.4 vs 4.1±1.3 IU/l(p = 0.06). Conclusion: 1)The ovarian ability to secrete E2 in response to exogenous FSH seems not to be impaired in CAH 2)The E2 response was better in those patients with higher basal estrogen and androgen levels 3)The higher P concentration found in amenorrheic patients suggests a role of this steroid in the menstrual abnormality, probably through an inhibition of gonadotropin secretion.

Treatment of Central Diabetes Insipidus With Oral Desmopressin in Children

Twenty patients (15 males), 5 to 20 years of age, with central diabetes insipidus (DI) were studied in order to evaluate efficacy, safety and adverse effects of oral desmopressin (DDAVP) treatment. Basal levels of plasma vasopressin were between 1.5 and 6.0 pg/ml. Evaluation was performed in two periods: during hospitalization (I) and ambulatory (A). Period I: Nineteen patients discontinued previous intranasal DDAVP treatment for a period equal or > to 24 hs. One patient had never been treated before. Water intake and diuresis, and plasma and urinary osmolality were measured before and during treatment. On the second day oral DDAVP was given, starting with 0.1 mg. Dose was gradually increased until a normal diuresis was attained. Period A: in 11 patients long-term (3 months) effect of treatment was evaluated. Results: Values are given in median and range. Table

GONADOTROPIN RESPONSE TO GnRH TEST ASSESSED BY IFMA IN THE DIFFERENTIAL DIAGNOSIS OF PRECOCIOUS PUBERTY

GONADOTROPIN RESPONSE TO GnRH TEST ASSESSED BY IFMA IN THE DIFFERENTIAL DIAGNOSIS OF PRECOCIOUS PUBERTY

IMPROVED ASSAY SENSITIVITY FOR SERUM LH AND PSH IN NORMAL CHILDREN AND ADDOLESCENTS

The onset of puberty is associated with an increase in LH and FSH secretion. A 2- to 6- fold increase in gonadotropin levels has been shown using RIA. with monoclonal antibody assays, greater changes in LH secretion have been observed. In order to document changes in gonadotropin secretion during childhood and puberty, serum basal levels or LH and FSH by IFMA (MDD;0.02 IU/L) and by RIA (MDD:1.0 10/L) were measured in normal children and adoloscents (28F, 29M). Serum LH and FSH basal levels (X±SD). In relationship to chronological age (years), sex and pubertal development (P) are shown in the Table.In conclusion: During the first years of life serum LH levels were clearly higher in boys than in girls. However, we observed that serum FSH levels were significantly higher in females than in males after the onset of puberty. These sex differences could be due to the gonadoster, or to sexual differential secretion in the GnRH pulse generator. We found very low serum LH secretion (30- to 70-fold) at the onset of puberty. Serum FSH levels, clearly higher during the prepubertal period, did not change substantially during puberty, suggesting that the intrinsic CNS inhibitory mechanism which acts during childhood may be less effective on FSH than on LH secretion.

EVALUATION OF CORTISOL SECRETION WITH THE INSULIN TOLERANCE TEST IN SHORT NORMAL CHILDREN

The insulin tolerance test (ITT) is a classic method to assess the secretion of growth hormone (GH) and Cortisol. The objective of this study was to determine the dynamics of Cortisol secretion after hypoglycemia in 31 normal children (F=9, M=22) with short stature, normal growth velocity and normal GH response to ITT and/or clonidine. Mean chronological age was 12.4 ± 2.7 years. Glucose, Cortisol and GH during ITT (0.1 lU/kg i.v.) were measured at - 20, 0, 30, 60 and 90 minutes. All the patients developed significant hypoglycemia with a decrease in blood glucose from 79.8 ± 8.9 to 34.1 ± 9.8 mg/dl. We found a significant inverse correlation between basal Cortisol and peak increment of Cortisol, (r=-0.79, p<0.0001). Patients were divided into two groups according to the level of basal normal Cortisol for age and sex. Group A (n=13): basal Cortisol levels within the normal range; Group B (n=18): basal Cortisol above 2 SD from the normal mean levels. In group A we found a significant increment in Cortisol during the ITT (ANOVA, p<0.0001), while group B did not show a significant increment in Cortisol during the test in spite of having similar hypoglycemia as Group A (ANOVA). There were no differences in peak GH during the test between the groups.In summary, we found that the basal level of Cortisol influences significantly its increment during ITT, the greater the basal levels, the lower the increment. We believe that this finding, as well as the documentation of the degree of hypoglycemia, is important to interpret the results of an insulin tolerance test.

EFFECT OF GROWTH HORMONE (GH) ON GONADOTROPIN CONCENTRATIONS IN ADOLESCENT KALES WITH GROWTH HORMONE DEFICIENCY: A PRELIMINARY REPORT

The in vivo and in vitro effects of GH on the gonads are well known, but there are scant data about their possible influence on gonadotropin secretion. We studied five male patients with idiopathic growth hormone deficiency, 14.8 - 18.7 years of age, all of them with normal spontaneous adult pubertal development. They were studied in two opportunities: A) under GH treatment (0.5 IU/Kg/week), B) after discontinuing GH treatment. Blood samples were drawn every 20 minutes during the night for LH and FSH measurements. After the 12 hour sampling period was completed, a sample for testosterone was drawn. LH, FSH and testosterone were measured by RIA and LH was also measured by IFMA. The detection limits for LH and FSH (RIA) were 1.0 IU/L, and 0.02 IU/L for LH (IFMA). CLUSTER program was used for the analysis of spontaneous gonadotropin concentrations. Results showed that there were no differences in the levels of testosterone, LH and FSH measured by RIA, between the periods with or without GH treatment. In addition, there were no differences in the mean LH levels, the mean peak amplitude and frequency measured by IFMA, but the area under the curve and the average of nadir points were significantly lower during GH treatment (p< 0.025 and p< 0.04 respectively). These preliminary data suggest a role of GH on the regulation of LH secretion in growth hormone deficient patients, although the site at which this regulation may be exerted is not known.

QUALITY OF LIFE IN HYPOPITUITARY ADULT PATIENTS DIAGNOSED DURING CHILDHOOD

Fifty-three adult patients (14 women and 39 men), with a mean age of 23.7 ± 6.1 years (range 18 - 45 yr) with idiopathic hypopituitarism (77% MPHD) diagnosed during childhood and treated with growth hormone for different periods of time, were interviewed. Each of the patients answered a questionnaire and the Beck Depression Inventory (BDI) was used to determine depression status. Men had attained a final heiaht of 154.9 ± 8.7 cm and women 145.8 ± 7.2 cm. Results. Social Aspects, 43 of 53 patients are still livino witn their parents. Only 4 (7.5%) are married and 2 of them have one son each. Fifty per cent have never dated, and more than 61% have never experienced sexual relationships. 35 of 53 patients have very few friends. More than 2/3 of the patients are not satisfied with their appearance. The most frequently cited complaints were related to poor height and excess weight in females, and poor virilization, reduced muscle mass and strength in men. Almost all patients complained of being treated as younger than their chronological age. Half of the total sample showed depression symptoms in the BDI test. 2/3 of the patients with gonadotropin deiiciency felt that sex hormone replacement therapy was started later than they would have desired. Laboral Aspects. 30% of the patients are unemployed and have never worked. Employment was obtained through relatives in 60% of the cases. Educational Aspects. Primary school was finished bv 20% of the patients. Half of the patients did not finish secondary school and 11% finished or are still at the University. 64.2% were held back at school for one or more years. 36% complained or being overprotected by teachers and more than 50% of being “teased” by their peers. In soite of being disappointed with their final height, 95% of patients think that treatment with growth hormone helped them and they would recommend it to younger patients. Hormone treatment is not enough, however, so psychosocial support must be considered to help these patients go through life.