Impact of different doses of ethinyl oestradiol on reduction of final height in constitutionally tall girls

MANAGEMENT OF ENDOCRINE DISEASE: Diagnostic and therapeutic approach of tall stature

Tall stature is defined as a height of more than 2 standard deviations (s.d.) above average for same sex and age. Tall individuals are usually referred to endocrinologists so that hormonal disorders leading to abnormal growth are excluded. However, the majority of these patients have familial tall stature or constitutional advance of growth (generally associated with obesity), both of which are diagnoses of exclusion. It is necessary to have familiarity with a large number of rarer overgrowth syndromes, especially because some of them may have severe complications such as aortic aneurysm, thromboembolism and tumor predisposition and demand-specific follow-up approaches. Additionally, endocrine disorders associated with tall stature have specific treatments and for this reason their recognition is mandatory. With this review, we intend to provide an up-to-date summary of the genetic conditions associated with overgrowth to emphasize a practical diagnostic approach of patients with tall stature and to discuss the limitations of current growth interruption treatment options.

Evaluation and phenotypic characteristics of 293 Danish girls with tall stature: effects of oral administration of natural 17β-estradiol

BACKGROUND

Reduction of adult height by sex steroid treatment was introduced decades ago in tall statured children, but controlled trials are lacking and treatment is controversial. In this study, we wanted to evaluate the phenotypic characteristics in girls referred due to tall stature and the effect of oral administration of 17β-estradiol on predicted adult height in girls.

METHODS

A single-centre retrospective observational study of 304 girls evaluated consecutively due to tall stature between 1993 and 2013. 207 patients diagnosed with constitutionally tall stature (CTS), 60 (29%) girls ended up being treated with 17β-estradiol with a duration of 1.7 y (1.2; 2.5) (median (25; 75 percentile)), and final height was available in 26 girls.

RESULTS

At baseline, 20% of girls with CTS had supranormal IGF-I, whereas reproductive hormones were within the normal range. Final adult height was reduced with 1.6 ± 2.1 cm in the girls treated with 17β-estradiol when compared to initial prediction. Chronological age, bone age, estradiol, and IGF-I at baseline or estrogen dose did not predict height reduction.

CONCLUSIONS

Serum IGF-I was elevated tall statured children, but did not predict the effect of treatment with 17β-estradiol, which caused a modest reduction in final adult height.

Oestrogen treatment of constitutional tall stature in girls: is there a risk of thrombosis or bleeding?

AIM

To evaluate haemostatic effects and clinical outcome of oestrogen treatment of constitutionally tall stature in girls.

METHODS

We conducted a single-centre cohort study, 63 girls referred over a period of 15 years were investigated. The girls were given oestrogen treatment for constitutional tall stature at a median initial dose of 300 ug ethinyl estradiol/day and were consecutively examined for changes in coagulation. Medical records were retrospectively reviewed, additional data were collected at follow-up by blood sampling and interviews.

RESULTS

After 1 year of treatment, levels of antithrombin and von Willebrand factor (VWF) were significantly decreased (p<0.001 and p=0.015, respectively), whereas there was no significant change in levels of plasminogen inhibitor type 1. No venous thromboembolism (VTE) or major side effects were observed. Genetic risk factors for thrombosis were present, as was expected. The mean height reduction was 5.5 cm. The height-reducing effect was inversely correlated with chronological age (r=-0.44, p<0.01) and bone age (r=-0.61, p<0.01).

CONCLUSIONS

Changes in coagulation parameters occurred both towards pro- and anticoagulation. Treatment with high-dose ethinyl estradiol can successfully limit final height, and it is most effective when started at a younger bone age.

Effects of growth reduction therapy using high-dose 17beta-estradiol in 26 constitutionally tall girls

OBJECTIVE

The efficacy and safety of height-limiting therapy with high-dose 17beta-oestradiol in girls with constitutionally tall stature (CTS) are controversial. We evaluated the effectiveness of high-dose 17beta-oestradiol in premenarchal girls with CTS treated until their bone age reached 14 years.

DESIGN

We retrospectively reviewed the medical records of the girls managed between 1989 and 2000 with high-dose 17beta-estradiol for CTS with a predicted final height greater than +3SDs.

PATIENTS

Twenty-six girls met our inclusion criteria. At baseline, mean chronological age was 12.06 +/- 1.51 years and mean height was 171.1 +/- 6.5 cm with a height standard deviation score of 4.5 +/- 0.24, and mean predicted final height was 183.0 +/- 4.2 cm. Treatment was stopped when bone age reached 14 years; mean treatment duration was 1.62 +/- 0.76 years.

MEASUREMENTS

The following were obtained at 6-month intervals: height, body weight, Tanner stage, bone age, plasma cholesterol and triglycerides, plasma glucose and side effects. A mailed questionnaire on final height and satisfaction was sent 2 years after treatment discontinuation (response rate, 24/26). Results Final height was significantly (P < 0.001) reduced, by 2.4 +/- 3.2 cm, as compared to predictions. High-dose 17beta-estradiol therapy decreased growth velocity and significantly increased skeletal maturation (P < 0.001). Linear growth after treatment discontinuation was 3.3 +/- 1.9 cm. No serious side effects were recorded. Most of the patients were satisfied with the treatment.

CONCLUSION

High-dose 17beta-estradiol was moderately effective in reducing final height and should probably be reserved for selected patients, particularly as knowledge on potential long-term side effects is lacking.

Growth-reductive therapy in children with marfan syndrome

OBJECTIVES

To determine the accuracy and precision of 2 height-prediction methods in Marfan syndrome and to assess the growth-reductive effect and side effects of sex hormone treatment.

STUDY DESIGN

In a retrospective study in 31 untreated (17 boys) and 43 treated patients (21 boys) with Marfan syndrome, we assessed bone age and predicted adult height by 2 methods. The accuracy of the methods was assessed in the untreated group. The effect of therapy was corrected for outcome in the untreated group and other confounding variables with multivariate analysis.

RESULTS

Accuracy strongly varied with sex, chronological age, and prediction method. Overall precision was low. Treatment was started at a mean age of 12.8 +/- 1.4 years (boys) and 11.4 +/- 1.2 years (girls). With multiple regression analysis, a statistically significant effect was observed only in boys using a pharmacologic dosage (5.5 cm, 95% CI 0.96-10.1 cm; P = .02). Side effects were worsening of acne and weight and muscle gain.

CONCLUSIONS

In adolescents with Marfan syndrome, the accuracy and precision of 2 height-prediction methods were limited. The apparent growth-reductive effect of sex hormone treatment appears similar to earlier reports on adolescents with constitutional tall stature. There were no clinically important short-term side effects.

Long term sequelae of sex steroid treatment in the management of constitutionally tall stature

AIM

To evaluate possible long term side effects of high doses of sex steroids in the management of constitutionally tall stature, with special attention to hypothalamic-gonadal function.

METHODS

Sixty four tall adult men and 180 tall adult women, who received supraphysiological doses of sex hormones during puberty, were interviewed in a standardised way at a mean follow up period of 10 years after cessation of treatment. Sixty one untreated tall adult men and 94 untreated tall adult women served as controls.

RESULTS

The majority of the subjects were satisfied with their decision regarding hormone treatment. Seventy seven per cent of the women and 78% of the men reported one or more side effects during treatment. Most side effects were mild. In women, only 3% stopped treatment because of an adverse event; in men, the reported side effects never stopped treatment. The frequency of reported side effects in women was higher during treatment with high doses of oestrogens than during oral contraceptive use, indicating a dose dependent relationship. Amenorrhoea of longer than six months after cessation of therapy was found in 5%. Menstrual cycle characteristics of previously treated women were comparable with controls. Malignancy was not reported. Information about a total of 127 pregnancies was obtained and revealed no distinct differences in details and outcome between previously treated women and men, and controls.

CONCLUSIONS

At a mean follow up of 10 years there is no evidence that pharmacological doses of sex hormones have a long term effect on reproductive function. However, this period is still too short to draw definite conclusions.