Diagnostic test for testicular and ovarian disorders in children 2.pptx

1. azad82d@gmail.com
azad.haleem@uod.ac
Dr.Azad A Haleem AL.Mezori
MRCPCH,DCH, FIBMS
Assistant Professor
University Of Duhok
College of Medicine
Pediatrics Department
Diagnostic test for testicular and
ovarian disorders in children
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2. Key points
• Luteinizing hormone (LH)
• Follicle stimulating hormone (FSH)
• Gonadotropin-releasing hormone
(GnRH) agonist test
• HCG test
• Estradiol
• Testosterone
• Dihydrotestosterone
• Androstenedione
• Anti Mullerian Hormone (AMH).

3. Introduction
• The Testis has following three functions.
• First, it produces spermatozoa, the male
gametes.
• Second, it synthesizes testosterone, the
principal male sex hormone.
• Third, it participates with the hypothalamus-
pituitary unit in regulating reproductive
function.

4. • Paired ovaries serve the following functions,
• First, they cyclical produce gametes,
• Second they cyclically secrete hormones
principally estrogen and progestins that prepare
the reproductive tract for oocyte transport
fertilization, implantation and pregnancy
• Third quickly secrete hormones principally
estrogens and progestins.
• Fourth they control the hypothalamic-pituitary
unit through negative and positive feedback
mechanisms.
Introduction

5. Luteinizing hormone (LH)
• Role
• To determine the cause of precocious and delayed puberty.
• Timing
• Any time of day
• Collect pooled sample in triplicate over 15 min apart to
avoid the problem of pulsatility
• In menstruating girls, the level should be assessed between
2-5 days of the menstrual cycle.
• Container
• Plain tube (serum).
• Transport
• Transport refrigerated.

6. Luteinizing hormone (LH)
• Reference range
• Male & female
• Prepubertal- <0.3 mIU/ml (<0.3 IU/L)
• Male
• Pubertal
• Stage 2 & 3- 0.3–4.9 mIU/ml (0.3–4.9 IU/L)
• Stage 4 & 5- 0.4–7 mIU/ml (0.4–7 IU/L)
• Female
• Pubertal-
• Stage 2- 0.3–4.7 mIU/ml (0.3–4.7 IU/L)
• Stage 3,4 & 5- 0.4-12 mIU/ml (0.4-12 IU/L)
• Interpretation
• Level greater than 0.2 mIU/ml suggest pubertal onset. Level between 0.1-0.2
mIU/ml are indeterminate needs further evaluation by gonadotropin stimulation
test.
• LH levels below 0.1 mIU/ml in a girl with precocious puberty are suggestive of
gonadotropin independent cause.

7. Follicle stimulating hormone (FSH)
• Role
• Determining the cause of hypogonadism
• Identification of premature ovarian insufficiency
• Timing
• Anytime of day.
• Collect pooled sample in triplicate over 15 min apart to
avoid problem of pulsatility.
• In menstruating girls, level should be assessed between
2-5 day of menstrual cycle.
• Container: Plain tube (serum).
• Transport: Transport refrigerated

8. Follicle stimulating hormone (FSH)
• Reference range
• Male
• Prepubertal- Less than3 mIU/ml (<3 IU/L)
• Pubertal-
• Stage 2- 0.3–4.6 mIU/ml (0.3–4.6 IU/L)
• Stage 3 & 4- 1.2–5.4 mIU/ml (1.2–5.4 IU/L)
• Stage 5- 1.5–6.8 mIU/ml (1.5–6.8 IU/L)
• Female
• Prepubertal- 0.5–4.5 mIU/ml (0.5–4.5 IU/L)
• Pubertal-
• Stage 2- 0.7–6.7 mIU/ml (0.7–6.7 IU/L)
• Stage 3 & 4- 1–7.4 mIU/ml (1–7.4 IU/L)
• Stage 5- 1–9.2 mIU/ml (1–9.2 IU/L)
• Interpretation
• FSH is detectable throughout childhood and during puberty increase by 2.5 times
making it less reliable marker of pubertal onset.
• Rise in FSH after maturity of the Hypothalamo-pituitary axis by bone age of 12
years suggest gonadal failure.

9. Gonadotropin-releasing hormone
(GnRH) agonist test
• Role
• To assess pituitary responsiveness to GnRH.
• Rationale
• Gonadotropin-releasing hormone (GnRH) stimulates secretion and
production of luteinizing hormone (LH) and follicle stimulating
hormone (FSH).
• Inadequate response to GnRH suggests prepubertal status, effective
treatment with GnRH agonist or hypogonadotropic hypogonadism.
• Indication
• Precocious puberty (diagnosis and classification).
• Delayed puberty with low gonadotropin (differentiation of
constitutional delay from permanent hypogonadism).
• Monitoring of response to GnRH analog therapy in central
precocious puberty.

10. Gonadotropin-releasing hormone
(GnRH) agonist test
• Prerequisite
• Fasting is not required.
• Collect baseline samples for LH and FSH before the test.
• Stimulus
• Injection leuprolide 20 µg/kg subcutaneous.
• Injection triptorelin 100 µg subcutaneous.
• Sampling- Sample for LH and FSH 120 minutes after injection.
• Interpretation
• Stimulated LH level above 5 IU/L in delayed puberty suggests
constitutional delay while higher levels indicate suggest permanent
hypogonadotropic hypogonadism.
• Stimulated LH level above 5 IU/L in precocious puberty suggests
central precocious puberty while lower levels indicate peripheral
precocious puberty.

11. HCG test
• Role
• Assessment of testicular functions in prepubertal boys.
• Rationale
• Testosterone is undetectable in infancy and childhood due to the quiescent
hypothalamic-pituitary-gonadal axis.
• HCG stimulated testosterone levels to provide insight into testicular
functions in this age.
• Indication
• Undescended testis (to differentiate anorchia from abdominal testis).
• XY disorder of sexual development (to differentiate 5 alpha-reductase
deficiency from androgen insensitivity).
• Delayed puberty in boys with low LH levels. (to differentiate constitutional
delay from permanent hypogonadism).
• Stimulus
• Injection HCG 5000 IU/m2 intramuscular single dose.

12. HCG test
• Sampling
• Serum testosterone, dihydrotestosterone, androstenedione at baseline and
72 hours after injection.
• Interpretation
• The rise in testosterone concentration 2--10 fold from baseline value with a
peak between 2.5-8.5 nmol/L suggests functional testicular tissue.
• An increase in androstenedione, testosterone, dihydrotestosterone after
HCG stimulation suggests androgen insensitivity syndrome.
• Rise in androstenedione level but no rise testosterone and
dihydrotestosterone indicate 17 beta-hydroxysteroid dehydrogenase II
defects.
• An increase in stimulated androstenedione and testosterone with no change
in dihydrotestosterone indicates 5 alpha-reductase deficiency.
• Steroidogenic defects (3 beta-hydroxysteroid dehydrogenase, StAR,
CyP450 oxidoreductase defect), LHCG receptor defects are associated with
no change in stimulated androgen levels.

13. Estradiol
• Indication
• Assessment of precocious and delayed puberty.
• To evaluate oligo-amenorrhea.
• Timing
• Morning sample in triplicate with pooled sample.
• In menstruating girls, level should be assessed between day 2 to 5 of menstrual
cycle.
• Container
• In plain-tube (serum).
• Transport
• Separate serum within 1 hour of draw and transfer to plastic transport tube.
• Transport refrigerated.
• Interpretation
• Estradiol level more than 10 pg/ml (36.7 pmol/L) indicates pubertal onset.
• Limitations
• Most commercially available estradiol assay have a high coefficient of variation at
lower levels observed in young girls and boys. GCMS based assays are preferred in
these situations.

14. Estradiol
• Reference range
• Male
• 1 to 2 months- 10–32 pg/mL (36.71–117.5 pmol/L)
• Pre pubertal- <15 pg/mL (55.1 pmol/L)
• Pubertal stage
• 2 and 3- 5–25 pg/mL (18.4–91.8 pmol/L)
• 4 and 5- 10–36 pg/mL (36.7–231.3 pmol/L)
• Female
• 1 to 2 months- 5–50 pg/mL (18.4–183.5 pmol/L)
• Prepubertal- <15 pg/mL (55.1 pmol/L)
• Pubertal stage
• 2- 10–24 pg/mL (36.7–88.1 pmol/L)
• 3- 7–60 pg/mL (25.7–220.2 pmol/L)
• 4- 21–85 pg/mL (77.1–312.03 pmol/L)
• 5- 34–170 pg/mL (124.8–624.1 pmol/L)

15. Testosterone
• Indications
• Delayed or precocious puberty in boys
• Hyperandrogenism, virilization, oligo-amenorrhea.
• Disorder of sexual development.
• Timing
• Collect morning pooled sample in triplicate at 15 min interval.
• Container
• In plain-tube (serum).
• Transport
• Separate serum within 1 hour of draw and transfer to a plastic transport tube.
• Transport refrigerated.
• Interpretation
• Level above 20 ng/dL indicates pubertal onset in male.
• In girls, a level above 60 ng/dL suggests hyperandrogenism while level more than
150 ng/dL indicates virilizing disorder.

16. Testosterone
• Reference range
• Male
• Newborn- 75–400 ng/dl (2.6–13.8 nmol/L)
• 1st week- 20–60 ng/dl (0.7–2.1 nmol/L)
• 1-3 months- 60–400 ng/dl (2.1–13.8 nmol/L)
• Prepubertal- <10 ng/dl (<0.35 nmol/L)
• Pubertal stage
• Stage 2- 18–150 ng/dl (0.62–5.2 nmol/L)
• Stage 3- 100–320 ng/dl (3.46–11.1 nmol/L)
• Stage 4- 200–620 ng/dl (6.9-21.5 nmol/L)
• Stage 5- 350–970 ng/dl (12.1–33.6 nmol/L)
• Female
• Newborn- 20–64 ng/dl (0.7–2.21 nmol/L)
• Prepubertal - <10 ng/dl (<0.35 nmol/L)
• Pubertal Stage
• Stage 2- 7–28 ng/dl (0.24–0.97 nmol/L)
• Stage 3–5- 15–38 ng/dl (0.52–1.31 nmol/L)

17. Dihydrotestosterone
• Indication
• 46 XY DSD to differentiate 5 α reductase deficiency and androgen
insensitivity syndrome.
• Timing
• At any time of the day.
• Container
• In plain-tube (serum)
• Transport
• Transport refrigerated.
• Interpretation
• High testosterone and low DHT in XY disorder of sexual
development indicates 5 α reductase deficiency while high DHT
suggests androgen insensitivity syndrome.

18. Dihydrotestosterone
• Reference range
• <1 week- <3-20 ng/dL (<0.1–0.7 nmol/L)
• 2 week - 2 month- <3-75 ng/dL (<0.1–2.6 nmol/L)
• 3-5 month- <3-23 ng/dL (<0.1–0.8 nmol/L)
• 6-11 month- <3-12 ng/dL (<0.1–0.4 nmol/L)
• 1-3 years- <3-38 ng/dL (0.1–1.3 nmol/L)
• 4-6 years- 3-23 ng/dL (0.1–0.8 nmol/L)
• 7-9 years- 3-17 ng/dL (0.1–0.6 nmol/L)
• 10-12 years- 3-55 ng/dL (0.1 – 1.9 nmol/L)
• 13-15 years- 3-93 ng/dL (0.1 – 3.2 nmol/L)
• 16-18 years- 3-55 ng/dL (0.1 – 1.9 nmol/L).

19. Androstenedione
• Role
• Indicator of ovarian androgen production.
• Indication
• Hyperandrogenism.
• XY disorder of sexual development
• Timing
• Early morning.
• Container
• In plain-tube (serum).
• Transport
• Transport refrigerated.
• Interpretation
• Elevated level indicates ovarian cause of hyperandrogenism.
• Level above 500 ng/dL suggests androgen-secreting adrenal or
rarely gonadal tumor.

20. Androstenedione
• Reference range
• Premature infant (26-28 week), day 4- 92-282 ng/dL (3.2–
9.8 nmol/L)
• Premature infant (31-35 week), day 4- 80-446 ng/dL (2.8–
15.6 nmol/L)
• Full term (1 to 7 days)- 20-290 ng/dL (0.7–10.1 nmol/L)
• Full term (1 month to 1 year)- Less than 69 ng/dL (2.4 nmol/L)
• Male
• Prepubertal - Less than 51 ng/dL (1.8 nmol/L)
• Stage 2- 31-65 ng/dL (1.1–2.3 nmol/L)
• Stage 3- 50-100 ng/dL (1.7–3.5 nmol/L)
• Stage 4- 48-140 ng/dL (1.7–4.9 nmol/L)
• Stage 5- 65-210 ng/dL (2.3–7.3 nmol/L)
• Female
• Prepubertal- Less than 51 ng/dL (1.8 nmol/L)
• Stage 2- 40-200 ng/dL (1.4–6.9 nmol/L)
• Stage 3- 80-190 ng/dL (2.8–6.6 nmol/L)
• Stage 4- 77-225 ng/dL (2.7–7.9 nmol/L)
• Stage 5- 80-240 ng/dL (2.8–8.4 nmol/L)

21. Anti Mullerian Hormone AMH (AMH)
• Role: Marker of testicular or ovarian function.
• Indications
• Bilateral undescended testis
• Hyperandrogenism
• Premature ovarian insufficiency
• Timing: At any time of the day.
• Container: In plain-tube (serum)
• Transport: Transport frozen.
• Interpretation:
• Detectable AMH in male suggests functional testicular tissue.
• High AMH level in a girl with hyperandrogenism suggests PCOS.
• Low AMH level indicates a diminished ovarian reserve.

22. Anti Mullerian Hormone AMH (AMH)
• Reference range
• Male
• Less than 1 year- 37.20–345.67 ng/ml (5.2-48.4 pmol/L)
• 1–6 years- 59.54–320.65 ng/ml (8.3-44.9 pmol/L)
• 7–11 years- 40.99–203.67 ng/ml (5.7-28.5 pmol/L)
• 12–17 years- <128.29 ng/ml (<17.9 pmol/L)
• Above 18 years- 1.15–15.23 ng/ml (0.2-2.1 pmol/L)
• Female
• Less than 14 years- 0.49–3.15 ng/ml (0.1-0.4 pmol/L)
• 14–19 years- 1.28–16.37 ng/ml (0.2-2.3 pmol/L)
• 20–29 years- 0.76–11.34 ng/ml (0.1-1.6 pmol/L)
• 30–39 years- <9.24 ng/ml (<1.3 pmol/L)
• 40–49 years- <4.50 ng/ml (<0.6 pmol/L)
• Above 50 years- <0.45 ng/ml (<0.1 pmol/L)

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