Behavioral assessment of females with congenital adrenal hyperplasia

Glucocorticoid therapy in classic congenital adrenal hyperplasia: traditional and new treatment paradigms

INTRODUCTION

Classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is a rare genetic condition characterized by cortisol deficiency and excess adrenal androgens. CAH treatment is a lifelong balancing act between the need to reduce excess androgens, typically with supraphysiologic glucocorticoid (GC) doses, and concerns about potentially serious GC-related adverse events. Tradeoffs between the consequences of excess androgens versus GCs must be constantly reassessed throughout each patient's lifetime, based on current clinical needs and treatment goals. Adding to this burden are limited treatment options and the need for new CAH medications.

AREAS COVERED

This narrative review describes the current challenges of CAH treatment, the potential of new non-GC therapies to reduce excess androgens and thereby allow for lower GC doses, and the potential implications of decreasing GC doses to a more physiologic range (i.e. sufficient to replace missing cortisol, but without the need to reduce androgens).

EXPERT OPINION

Even with non-GC therapies, patients' needs will continue to shift throughout their lifetimes. Treatment will therefore always require joint decision-making between physicians and patients. However, over the lifetimes of patients with CAH, any reduction in GC daily dose may have a large cumulative impact in decreasing the GC-related burden of this disease.

Prevalence of psychiatric comorbidities in females with classic congenital adrenal hyperplasia

CONTEXT

Although the increased burden of mental health problems among patients with classic 46,XX congenital adrenal hyperplasia (CAH) is well-documented, it remains unclear if this comorbidity is attributable to the burden of living with a chronic medical condition or the potential psychosocial/sexual consequences of being born with a difference of sex development (DSD) and its associated clinical management.

OBJECTIVES

To compare the prevalence of psychiatric diagnoses among CAH patients and three reference groups: matched males and females from the general population, and females with type-1 diabetes mellitus (T1DM).

DESIGN

Retrospective cross-sectional study.

SETTING

Three large integrated health systems.

PARTICIPANTS

CAH patients (n=115), general population male and female referents (n=1150 per group), and 66,002 female T1DM referents.

RESULTS

The prevalence of depression, anxiety, personality disorders, and suicidal ideation was higher among CAH participants than in males and females from the general population, but similar to or lower than in T1DM referents. CAH patients were more likely to be diagnosed with neurodevelopmental disorders compared to both female reference groups, whereas the prevalence of elimination disorders (predominantly enuresis) and gender dysphoria was higher in the CAH cohort than in all reference groups.

CONCLUSION

Females with classic CAH experience a higher burden of psychiatric illness, including anxiety and depression, compared to demographically similar men and women in the general population. The similar psychiatric burden between females with CAH and T1DM suggests that morbidity may be influenced by the challenges associated with managing a chronic condition. Investigating long-term mental health trajectories in this population will require longitudinal studies.

Quality of Life in Children and Young People With Congenital Adrenal Hyperplasia-UK Nationwide Multicenter Assessment

CONTEXT

Quality of life (QoL) has been inconsistently reported in children and young people (CYP) with congenital adrenal hyperplasia (CAH).

OBJECTIVE

Assess QoL in CYP with CAH in the UK alongside biometric and androgen profiles.

DESIGN

To define the evidence base for health care delivery, we conducted a cross-sectional study in CYP with CAH in the UK. Questionnaire results were compared with normative data and between groups, and modelled for association with sex, height, weight, body mass index, or steroid biomarkers of CAH control.

SETTING

Tertiary care in 14 UK centers.

PATIENTS

Results from 104 patients, 55% female, mean age 12.7 years (SD 3.0), paired responses from parents.

INTERVENTIONS

Strengths and Difficulties questionnaire (SDQ) and pediatric QoL questionnaire.

MAIN OUTCOME MEASURE

Total QoL scores as assessed by SDQ and a pediatric QoL questionnaire in comparison to normative data.

RESULTS

Total scores were worse in parents than normative data, but similar in patients. Patient QoL was rated better in social functioning but worse in emotional, school, and peer domains by patients, and worse in total scores and domains of peer problems, and psychosocial, emotional, and school functioning by parents. Parents consistently scored QoL of their children lower than their child. Larger height-SD score and lower weight-SD score were associated with better QoL. Girls with lower steroid biomarkers had worse SDQ scores.

CONCLUSIONS

In CYP with CAH, reduced height, increased weight, and hormonal biomarkers consistent with overtreatment were associated with worse QoL; addressing these problems should be prioritized in clinical management.Clinical Trials Registration Number: SCH/15/088.

Psychological stress, emotions, and quality of life in men and women with congenital adrenal hyperplasia

AIM

The aim was to assess perceived psychological stress, emotional state, and quality of life (QoL) in men and women with congenital adrenal hyperplasia (CAH) in comparison to age- and sex-matched control individuals.

METHODS

Participants: 26 patients with CAH (11 men, 15 women, age 14-48 years) and 26 age- and sex-matched control individuals without CAH. Psychological assessment: Perceived Stress Scale, Profile of Mood States2, and WHO Brief Quality of Life Questionnaire.

RESULTS

There were no significant differences in perceived stress, emotional state and QoL scores between men with CAH and control men. Perceived distress (median 14.0 score vs. 10.0 score, p = 0.020), tension-anxiety (median 9.0 score vs. 3.5 score, p = 0.026), depression-dejection (median 12.0 score vs. 5.0 score, p = 0.040), fatigue-inertia (median 13.0 score vs. 7.5 score, p = 0.007) were higher and environmental domain of QoL (median 16.0 score vs. 17.0 score, p = 0.001) was lower in women with CAH than in control women.

CONCLUSION

Women with congenital adrenal hyperplasia have higher perceived distress, tension-anxiety, depression dejection, fatigue-inertia, and worse environmental aspect of quality of life than age-matched control women, while perceived psychological stress, emotional state and quality of life in men with congenital adrenal hyperplasia do not differ from that of age-matched control men.

Homozygous SHBG Variant (rs6258) Linked to Gonadotropin-Independent Precocious Puberty in a Young Girl

Sex hormone-binding globulin (SHBG) in the blood is a major determinant of bioactivity for key sex steroids such as testosterone and estradiol. Low serum levels of SHBG have been associated with obesity, polycystic ovaries, and metabolic syndrome, and other states associated with hyperandrogenemia. A 9-year, 6-month-old girl presented with a history of peripheral precocious puberty and aggressive behavior. The patient's SHBG level was remarkably low for her age, at less than 5 nmol/L (reference range for a girl with a bone age of 10 years, 73 nmol/L [SEM = 10]) [1]. On genetic and protein analysis, the patient was found to have a homozygous missense potentially pathogenic variant in the SHBG gene (c.554C>T, p.P185L); her parents were asymptomatic heterozygote carriers. Laboratory investigations supported the possible involvement of this genetic alteration in the patient's phenotype. Various analyses of this variant support its pathogenicity, although the exact mechanism remains unclear. In conclusion, we present a genetic SHBG variant in the homozygote state that may have been associated with gonadotropin-independent precocious puberty in a young girl.