Paulina M. Merino

Expanding the Phenotype and Genotype of Female GnRH Deficiency

CONTEXT GnRH deficiency is a rare genetic disorder of absent or partial pubertal development. The clinical and genetic characteristics of GnRH-deficient women have not been well-described. OBJECTIVE To determine the phenotypic and genotypic spectrum of a large series of GnRH-deficient women. DESIGN, SETTING, AND SUBJECTS Retrospective study of 248 females with GnRH deficiency evaluated at an academic medical center between 1980 and 2010. MAIN OUTCOME MEASURES Clinical presentation, baseline endogenous GnRH secretory activity, and DNA sequence variants in 11 genes associated with GnRH deficiency. RESULTS Eighty-eight percent had undergone pubarche, 51% had spontaneous thelarche, and 10% had 1-2 menses. Women with spontaneous thelarche were more likely to demonstrate normal pubarche (P = 0.04). In 27% of women, neuroendocrine studies demonstrated evidence of some endogenous GnRH secretory activity. Thirty-six percent (a large excess relative to controls) harbored a rare sequence variant in a gene associated with GnRH deficiency (87% heterozygous and 13% biallelic), with variants in FGFR1 (15%), GNRHR (6.6%), and PROKR2 (6.6%) being most prevalent. One woman had a biallelic variant in the X-linked gene, KAL1, and nine women had heterozygous variants. CONCLUSIONS The clinical presentation of female GnRH deficiency varies from primary amenorrhea and absence of any secondary sexual characteristics to spontaneous breast development and occasional menses. In this cohort, rare sequence variants were present in all of the known genes associated with GnRH deficiency, including the novel identification of GnRH-deficient women with KAL1 variants. The pathogenic mechanism through which KAL1 variants disrupt female reproductive development requires further investigation.

When Genetic Load Does Not Correlate with Phenotypic Spectrum: Lessons from the GnRH Receptor (GNRHR)

CONTEXT A broad spectrum of GnRH-deficient phenotypes has been identified in individuals with both mono- and biallelic GNRHR mutations. OBJECTIVE The objective of the study was to determine the correlation between the severity of the reproductive phenotype(s) and the number and functional severity of rare sequence variants in GNRHR. SUBJECTS Eight hundred sixty-three probands with different forms of GnRH deficiency, 46 family members and 422 controls were screened for GNRHR mutations. The 70 subjects (32 patients and 38 family members) harboring mutations were divided into four groups (G1-G4) based on the functional severity of the mutations (complete or partial loss of function) and the number of affected alleles (monoallelic or biallelic) with mutations, and these classes were mapped on their clinical phenotypes. RESULTS The prevalence of heterozygous rare sequence variants in GNRHR was significantly higher in probands vs. controls (P < 0.01). Among the G1-G3 groups (homozygous subjects with successively decreasing severity and number of mutations), the hypogonadotropic phenotype related to their genetic load. In contrast, subjects in G4, with only monoallelic mutations, demonstrated a greater diversity of clinical phenotypes. CONCLUSIONS In patients with GnRH deficiency and biallelic mutations in GNRHR, genetic burden defined by severity and dose is associated with clinical phenotype. In contrast, for patients with monoallelic GNRHR mutations this correlation does not hold. Taken together, these data indicate that as-yet-unidentified genetic and/or environmental factors may combine with singly mutated GNRHR alleles to produce reproductive phenotypes.

Contraception, and pregnancy in adolescents with type 1 diabetes: a review.

Codner E, Soto N, Merino PM. Review of puberty, contraception, and pregnancy in adolescents with type 1 diabetes.

Diagnóstico del Síndrome de Ovario Poliquístico: nuevos fenotipos, nuevas incógnitas

Polycystic ovarian syndrome (PCOS), includes a wide spectrum ofclinical symptoms and signs. Three different diagnostic classifications have been proposed todefine this disease. The first one, published in 1990, known as the “NIH criteria” requires thesimultaneous presence of hyperandrogenism and menstrual dysfunction in order to diagnosePCOS. Later on, in 2004, an expert panel met in Rotterdam and added to the previous criteria thepresence of polycystic ovarian morphology (PCOM) detected by transvaginal ultrasonography. Thelater classification broadened the spectrum of PCOS and also included women witholigomenorrhea and PCOM without hyperandrogenism or hyperandrogenism and PCOM withoutmenstrual dysfunction. Finally, the Androgen Excess Society, published in 2006 new diagnosticcriteria which required the presence of clinical or biochemical hyperandrogenism, with eitherPCOM or menstrual dysfunction to diagnose PCOS. We review the different classificationsemployed in the diagnosis of PCOS, the diverse phenotypes that may lead to the diagnosis of PCOSand their association with cardiovascular and metabolic complications (Rev Med Chile 2009;137: 1071-80).(

Hirsutism and oligomenorrhea are appropriate screening criteria for polycystic ovary syndrome in adolescents

Abstract We evaluated the association of hirsutism and oligomenorrhea (persistent menstrual cycles > 45 days) as screening criteria for the detection of biochemical hyperandrogenism (BH) and polycystic ovaries (PCOM) during adolescence and determined which androgens, granulosa cell hormone, ultrasonographic parameters have the best association with polycystic ovary syndrome (PCOS). Hirsute girls with oligomenorrhea (N = 26 Hirs/Oligo group) and non-hirsute girls with regular cycles (N = 63, C group) were studied. Prevalence of BH and PCOM, diagnostic performance of androgens and ultrasound parameters for PCOS diagnosis were analyzed. BH and PCOM prevalence were higher in the Hirs/Oligo girls than in the C girls (76.9% versus 25.5%; 92.3% versus 33.3%, respectively; p < 0.0001). A complete PCOS phenotype (Hirs/Oligo with BH and PCOM) was observed in 73.1% of the Hirs/Oligo group. The presence of both BH and PCOM was observed in 7.9% of the C group. The parameters with the best diagnostic performance were free androgen index ≥6.1, testosterone ≥2.4 nmol/L, follicle number ≥12 and ovarian volume ≥10 ml anti-Müllerian hormone (AMH) exhibited a low diagnostic accuracy. Hirsutism and persistent menstrual cycle over 45 days are highly associated with BH and PCOM suggesting that the presences of both criteria are necessary for the diagnosis of PCOS during adolescence. Chinese abstract 我们评估多毛合并月经稀发（持续的月经周期超过45天）作为生化高雄激素（BH）和青春期多囊卵巢（PCOM）筛选标准的情况，并确定雄激素，颗粒细胞激素，超声参数中哪个与多囊卵巢综合征（PCOS）联系最为密切。本文研究了多毛合并月经稀发的女孩（N=26 多毛/月经稀发组）和非多毛并且月经规律女孩（N=63 C组）BH和PCOM的患病率，并分析了雄性激素和超声参数对PCOS的诊断性作用。BH和PCOM在多毛/月经稀发女孩组的患病率高于C 组女孩（分别是76.9%和25.5%；92.3%和33.3%；P＜0.0001）。73.1%的多毛/月经稀发组患者呈现了一个完整的PCOS表型（多毛/月经稀发合并BH和PCOM）。仅有7.9%的C组患者出现了BH和PCOM。最好的诊断性参数是游离雄激素指数≥6.1，睾酮≥2.4 nmol/L，卵泡数≥12和卵巢体积≥10ml,而抗苗勒管激素（AMH）诊断准确性低。多毛和持续性月经周期超过45天与BH和PCOM高度相关表明了这两个标准在诊断青春期PCOS中是必要的。

Experiencia con un método de autotoma de muestra vaginal para la detección de infección por Chlamydia trachomatis y Neisseria gonorrhoeae en mujeres jóvenes

Chlamydia trachomatis y Neisseria gonorrhoeae son causantes de 3 a 10% de las infecciones de transmision sexual en adolescentes. Las normas internacionales recomiendan su deteccion anual en mujeres sexualmente activas menores de 26 anos. La adherencia a este tamizaje en mujeres jovenes esta limitada por el temor al examen ginecologico y alto costo del examen. Objetivo: Determinar la frecuencia de deteccion de C. trachomatis y N. gonorrhoeae por un metodo de auto-toma de muestra vaginal y su aceptabilidad en un grupo de adolescentes y jovenes adultas. Pacientes y Metodo: Se incluyeron mujeres de 18 a 25 anos atendidas en Clinica Las Condes y el Servicio de Salud Estudiantil de la Universidad de Chile, que fueron instruidas para autotoma de muestra vaginal. Luego de dar su consentimiento, las muestras fueron estudiadas mediante reaccion de polimerasa en cadena para la deteccion de C. trachomatis y N. gonorrhoeae. Se recopilaron datos sobre conductas sexuales y percepcion de la autotoma mediante encuesta. Se determino la relacion entre estos factores y la aceptabilidad del metodo. Resultados: Se reclutaron 344 mujeres, con una edad promedio de 21,7 anos. La deteccion de C. trachomatis fue de 7,9% y no se encontro muestra positiva para N. gonorrhoeae. El reporte de flujo vaginal por la paciente se asocio a 1,5 veces mayor riesgo de C. trachomatis. El 98% considero las instrucciones de la autotoma faciles de entender, 87,5% se sintio comoda al tomar la muestra. Conclusiones: La prevalencia de C. trachomatis en la poblacion estudiada fue similar a lo descrito en otras series nacionales e internacionales; no se encontro N. gonorrhoeae en esta serie, lo que coincide con lo reportado en el extranjero. La tecnica de autotoma de muestra vaginal fue bien aceptada por las pacientes; sin embargo, manifestaron ansiedad acerca de la seguridad de una toma adecuada. De acuerdo a nuestros resultados, es importante insistir en la deteccion anual de estos patogenos siendo la tecnica de autotoma una alternativa valida.INTRODUCTION Chlamydia trachomatis and Neisseria gonorrhoeae are responsible for 3-10% of sexually transmitted diseases in adolescents. 75% are asymptomatic. International standards recommend annual screening for C. trachomatis in sexually active women under 26 years. Self-collected vaginal swab is one of the less invasive screening methods, it is well accepted by patients and rarely used in our country. AIM To determine the frequency of C. trachomatis and n. gonorrhoeae by a self-sampling method of vaginal swab and its acceptability in a group of adolescents and young adults. PATIENTS AND METHODS Women 18 to 25 years old. Vaginal samples were processed by nucleic acid amplification tests, Gen Probe APTIMA Combo2. Data were collected on sexual behavior and perception of self-sampling by survey. RESULTS We studied 344 patients with an average age of 21.7 years. Detection of C. trachomatis was positive in 7.9% women and it was not found in any of the patients studied for N. gonorrhoeae. 98% considered self-sampling instructions easy to understand, 87.5% felt comfortable taking the sample. CONCLUSIONS Prevalence of C. trachomatis in the study population was similar to that described in other national and international studies. N. gonorrhoeae was not found in this series, which is consistent with literature reports. The self-sampling technique of vaginal sample was well accepted by the patients. However, they were anxious about the quality of the sample. According to our results, it is important to emphasize the importance of annual detection of these pathogens and that self-sampling technique is a valid alternative.

Oestrogen activity of the serum in adolescents with Type 1 diabetes

To assess serum oestrogen levels and oestrogenic activity in adolescents with Type 1 diabetes compared with a healthy control group.

New Diagnostic Criteria of Polycystic Ovarian Morphology for Adolescents: Impact on Prevalence and Hormonal Profile

Background: The ultrasonographic criteria used to identify polycystic ovarian morphology (PCOM) during adolescence have changed over time. Recently, a Worldwide Pediatric Consensus (PedC) defined PCOM using stricter criteria than the previous recommendations of the Rotterdam Consensus (RC) and Androgen Excess-Polycystic Ovarian Syndrome Society (AES/PCOS) criteria. The aim of this study was to determine the prevalence of PCOM in healthy adolescents according to the 3 reported diagnostic criteria and compare the hormonal profile in females with and without PCOM based on the PedC criteria. Methods: Nonobese adolescents (n = 102) with regular menstrual cycles were studied. Transabdominal ultrasound and hormonal profiles were assessed during the follicular phase. PCOM was defined on the basis of the 3 published criteria. Results: On the basis of the PedC, RC, and AES/PCOS criteria, PCOM was diagnosed in 13, 34, and 24% of adolescents, respectively. Adolescents with and without PCOM according to the PedC criteria had similar androgen levels. Serum anti-Müllerian hormone (AMH) levels were elevated in adolescents with PCOM, irrespective of the criteria used. Conclusions: Use of the new PedC diagnostic criteria for PCOM results in a lower prevalence of this ultrasonographic pattern in adolescents, but this condition is not associated with hyperandrogenism. Elevated AMH is associated with PCOM in adolescents regardless of the criteria used to determine the ultrasonographic pattern.

Discordance in the Dependence on Kisspeptin Signaling in Mini Puberty vs Adolescent Puberty: Human Genetic Evidence

Context Hypothalamic kisspeptin signaling plays a critical role in the initiation and maintenance of reproductive function. Biallelic mutations in the coding sequence of KISS1R (GPR54) have been identified in patients with idiopathic hypogonadotropic hypogonadism, but it is unknown whether biallelic variants can also be associated with related reproductive disorders. Case Description A missense homozygous variant (c.890G>T p.R297L) in KISS1R was identified in a child who presented with microphallus and bilateral cryptorchidism. This variant has been reported to reduce, but not abolish, postreceptor signaling in vitro. Biochemical evaluation during the neonatal period revealed low testosterone levels. By 11 years and 8 months, the boy began demonstrating increases in testicular volume. By 17 years and 3 months, his testicular volume was 20 mL; his penile length was 7.3 cm; and he had adult levels of circulating gonadotropins and testosterone. Conclusion This case report associates biallelic loss-of-function mutations in KISS1R with normal timing of adolescent puberty. Because these coding sequence variants occurred in a patient with microphallus and cryptorchidism, they demonstrate different levels of dependence of the hypothalamic-pituitary-gonadal cascade on kisspeptin signaling at distinct times in the reproductive life span. The suppression of the hypothalamic-pituitary-gonadal cascade during early life but not adolescence suggests that the mini puberty of infancy depends more on kisspeptin-induced, gonadotropin-releasing hormone-induced luteinizing hormone secretion than does adolescent puberty.

C-Reactive protein and insulin growth factor 1 serum levels during the menstrual cycle in adolescents with Type 1 diabetes.

To evaluate C–reactive protein, insulin growth factor 1 and lipid levels during the follicular and luteal phases in adolescents with Type 1 diabetes.