Being an Official Blogger has its privileges. Yesterday, I saw a live Press Conference where 3 experts spoke about their cutting-edge research in adolescent health. Read on.
Gender Dysphoria in Children and Adolescents
Dr. Henriette Delemarre-van de Waal of the Leiden University Medical Center in Leiden, The Netherlands discussed the treatment of gender dysphoria. This condition, also known as transgender, often presents early, and can be present in pre-pubertal children. Once puberty sets in, and the secondary sexual characteristics such as breast development and testicular enlargement are noted by the patient, the stress of this dysphoria worsens. An Endocrine Society Guideline paper from 2009 recommends the use of leuprolide to halt puberty in those who have started puberty (Tanner stage II). Puberty is also a time of decreased insulin sensitivity, worsening lipid profile, and increasing bone mass, and Dr. Delemarre-van de Waal’s group looked at the safety profile of GnRH agonists in 12-16 year-olds with regards to these issues. Over a 24-month treatment period, no changes were noted with regard to the ratio of total cholesterol to HDL or in LDL, and this consistency was noted even when cross-sex hormones were added.
Gender dysphoric females transferring to males can be treated with oxandrolone to augment height velocity to achieve a mean height in the male normal range. Similarly, gender dysphoric males transferring to females will note a decrease in height velocity on GnRH therapy. Initial addition of estrogen will increase height velocity, but as levels increase to that of normal adult women, the growth velocity slows to zero, achieving a height closer to that of an average female. In these patients, it was noted that adequate peak bone mass was achieved, even with use of cross-sex hormones.
I have to admit this is an area with which I have very little comfort. A recent request was made of my services to help an adolescent with this condition, and I have been reluctant. However, I think a review of the guideline paper (see link above), as well as knowledge that I can help a patient, will help nudge me along in this still-controversial area.
Anxiety in Anorexia Nervosa
Dr. Madhumsmita Misra of Harvard Medical School has studied the endocrine manifestations of anorexia nervosa (AN) at length. Her newest work was to investigate the effect of estrogen replacement on anxiety in adolescents with AN. Using ovariectomized rats as a model, these animals were noted to have increase in anxious behaviors that abated with use of estrogen treatment. For this reason, it was thought patients, in the hypoestrogenic state due to AN, may also benefit from estrogen replacement to treat the anxiety component of this difficult-to-treat disease. Her group studied teen girls meeting DSM-IV criteria for diagnosis of AN and with bone age >15. In addition to other tests, they were given questionnaires to assess their levels of anxiety, as well as propensity toward anxiety, and randomized them either to treatment with estrogen patches and oral progesterone for 10 days each month or placebo patches and pills. They followed 72 girls for 18 months, then questionnaires were repeated for the 37 that completed the study. Although no change was noted in weight, BMI, % body fat, or eating attitudes, the TRAIT anxiety score of tendency to anxiety, was improved in those who had received estrogen treatment. In addition, the use of estrogen and progesterone prevented the increase of current anxiety that frequently occurs in these patients when weight increases. While the use of birth control pills (OCPs) has not been studied in this population for this purpose, prior work revealed OCPs did not have benefit on bone health, whereas physiologic replacement with estrogen patches and progesterone was effective. More studies are being planned with this preliminary data in mind.
Vitamin D Deficiency: Nothing at Which to Sneeze
Dr. Candace Percival, an endocrine fellow training at the Walter Reed National Military Medical Center, reviewed the increase of rates of obesity across the US, and that the military population is not spared. Higher rates of allergy and asthma are seen in the obese population, and their team sought to investigate this further.
Vitamin D is activated by immune cells, and deficiency is associated with increase in allergy, asthma, and increased levels of IgE. Adipose tissue, far from being just a storage organ, secretes leptin and adiponectin. Leptin, increased in obesity, suppresses appetite, and increases inflammatory markers. Adiponectin, decreased in obesity, appears protective for coronary artery disease, and when present in low levels, is associated with asthma. Additionally, adipose tissue serves as a “sponge” for vitamin D, collecting it and keeping it from circulating.
The study compared 19 obese 10-18 year-olds with 20 normal-weight controls. Leptin was increased in those with BMI z-scores>1.5, and adiponectin was lower in this population. The obese children also had higher levels of allergy-associated cytokines IL-6 and IL-13, IgE, and lower levels of Vitamin D. While this study associates the two conditions, studies planned to see the effect on these cytokines and antibody levels with Vitamin D treatment will help determine if the relationship is causal.
I frequently test vitamin D levels in both my adult and pediatric patients sent for evaluation of endocrine disease, and treat it aggressively as benefits far outweigh the risks. Although this relationship between vitamin D and allergies is only an association, the low risks of treatment offer another possibility to decrease the severity of allergies and asthma in the obese population.
On lunch break on Saturday, was treated to hula dancing and lovely weather while eating soup in the Yerba Buena Gardens. It was a lovely break amidst all the high-level science.
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