Induction of Puberty in Adult Endocrinology:What do I need to know?<br />Kate Lissett<br />Torbay Hospital<br />
Induction of puberty in adults<br />Who<br />When<br />How<br />Hazards<br />
Who<br />Which doctor?<br />Which patient?<br />
How many of you have been involved in taking patients through puberty.........<br />Can anyone give a brief case history.....
AM<br />18.5 years<br />Attending Cardiology for regular follow up of VSD, PMH IUGR.<br />Referred 18 months ago with prim...
On examination:<br />Very limited axillary and pubic hair, breasts stage 2<br />External genitalia normal, P.V. not perfor...
CA<br />33 years<br />Presented on acute medical take with severe heart failure. <br />Investigations go on to reveal seve...
What is normal<br />
Stages of Pubertal Development<br />Pubertal Sequence<br />Accelerated growth->breast development->adrenarche->menarche<br...
Signs of Puberty:  Tanner Staging <br />
Tanner Staging<br />
How....<br />What estrogen<br />At what dose<br />How  would you monitor<br />
Be aware<br />Emotional /psychological  as well as physical impact<br />
Difficulties/Risks<br />Drug availability – prescribe in secondary care<br />Prescription of “adult dose” estrogens by non...
Men<br />
Do you have any case histories<br />
PC<br />23 years<br />Referred by GP , as couple have primary infertility<br />Patient denies any symptoms or signs<br />O...
What are the aims of treatment<br />
What options do you have in this man to induce puberty?<br />
GHRH pump – not something I’ve used but available at some centres<br />200-500 IU (c.f. Adult doses of 1250–5000) hCG – wi...
Induction of puberty using testosterone esters<br />Increasing dose schedule every 6 months:<br />50 mg monthly i.m.<br />...
And for fertility<br />Most patients with IHH and KS require a combination of hCG and FSH to stimulate sperm production.<b...
Monitor every 3 months until an adequate level of replacement is documented.<br />Pregnancy has occurred with counts as lo...
Upcoming SlideShare
Loading in …5
×

Induction of puberty in adult endocrinology

3,872 views

Published on

Published in: Education, Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,872
On SlideShare
0
From Embeds
0
Number of Embeds
140
Actions
Shares
0
Downloads
23
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Induction of puberty in adult endocrinology

  1. 1. Induction of Puberty in Adult Endocrinology:What do I need to know?<br />Kate Lissett<br />Torbay Hospital<br />
  2. 2. Induction of puberty in adults<br />Who<br />When<br />How<br />Hazards<br />
  3. 3. Who<br />Which doctor?<br />Which patient?<br />
  4. 4. How many of you have been involved in taking patients through puberty.........<br />Can anyone give a brief case history......<br />
  5. 5. AM<br />18.5 years<br />Attending Cardiology for regular follow up of VSD, PMH IUGR.<br />Referred 18 months ago with primary amenorrhoea, but failed to make /attend appointments due to embarrassment.<br />Also complains of lack of breast development. <br />
  6. 6. On examination:<br />Very limited axillary and pubic hair, breasts stage 2<br />External genitalia normal, P.V. not performed<br />Trans abdominal ultrasound; v small uterus, ovaries could not be identified.<br />Bloods LH 80, FSH 60, estradiol 44<br />Karyotype repeated (had been done at birth) normal<br />
  7. 7. CA<br />33 years<br />Presented on acute medical take with severe heart failure. <br />Investigations go on to reveal severe AR and dilated aortic root. Clinical evidence suggestive of previously undiagnosed Turners syndrome. Goes on to have composite aortic valve and root replacement.<br />Now attending clinic, with a view to further endocrine management (NB karyotype mosaic, 46 X with an isodicentric Y (dominant cell line) and 45 XO )<br />
  8. 8. What is normal<br />
  9. 9. Stages of Pubertal Development<br />Pubertal Sequence<br />Accelerated growth->breast development->adrenarche->menarche<br />requires 4.5 years (range 1.5 to 6 years)<br />
  10. 10. Signs of Puberty: Tanner Staging <br />
  11. 11. Tanner Staging<br />
  12. 12. How....<br />What estrogen<br />At what dose<br />How would you monitor<br />
  13. 13.
  14. 14. Be aware<br />Emotional /psychological as well as physical impact<br />
  15. 15.
  16. 16. Difficulties/Risks<br />Drug availability – prescribe in secondary care<br />Prescription of “adult dose” estrogens by non specialist<br />May have long term impact on breast /uterine development <br />Psychological implications<br />
  17. 17. Men<br />
  18. 18.
  19. 19. Do you have any case histories<br />
  20. 20. PC<br />23 years<br />Referred by GP , as couple have primary infertility<br />Patient denies any symptoms or signs<br />On examination, eunachoidal phenotype, 5’10’’, prepubertal<br />Further investigation suggests hypogonadotrophic hypogonadism<br />
  21. 21. What are the aims of treatment<br />
  22. 22. What options do you have in this man to induce puberty?<br />
  23. 23. GHRH pump – not something I’ve used but available at some centres<br />200-500 IU (c.f. Adult doses of 1250–5000) hCG – will normalize testosterone levels and induced testicular growth. <br />Cost and need for regular injections means this is not usual option, but may be appropriate in some circumstances.<br />
  24. 24. Induction of puberty using testosterone esters<br />Increasing dose schedule every 6 months:<br />50 mg monthly i.m.<br />Increased approximately every 6 months<br />Adult dose Sustanon 250 per 3–4 weeks<br />Imperfect – first pass metabolism and profile over month not good.<br />Gel seem an ideal alternative – but I am not aware of specialist centres using as yet.....<br />Inducing puberty with testosterone rather than hCG does not appear adversely affect fertility. <br />
  25. 25. And for fertility<br />Most patients with IHH and KS require a combination of hCG and FSH to stimulate sperm production.<br />The starting dose for hCG is 1000 IU, and FSH is 75-150 IU alternate days <br />Dosage adjusted based on trough T level, testicular growth, sperm production, and avoidance of adverse effects (monitored every 3 months)<br />Gynecomastia common - 30%<br />
  26. 26. Monitor every 3 months until an adequate level of replacement is documented.<br />Pregnancy has occurred with counts as low as 2.5 X 106, but 20-40 X 106/mL produces higher pregnancy rates. <br />Median time to induction of spermatogenesis is 6-8 months – may take 2 years. <br />Remember to cryopreserve sperm should fertility be achieved.<br />Safer and cheaper to than IVF for couple.<br />

×