The current use of estrogens for growth-suppressant therapy in adolescent girls

Effect of the Aqueous Extract of Ganoderma lucidum on the Haematology, Oestradiol, Cholesterol and Protein Levels of Wistar Rats Fed with Monosodium Glutamate

Monosodium glutamate (MSG) at high concentration has been reported to alter the physiological and biochemical states of animals and humans. Ganoderma lucidum (G. lucidum) is a polypore mushroom reported to possess many medicinal attributes such as anticholesterolemia and the control of hormonal disorders. The present study investigated the effect of water extract of G. lucidum in the changes of haematology, oestradiol, cholesterol and protein levels of Wistar rats induced by MSG. Haematological analysis was determined from plasma, while oestrogen, serum total protein and cholesterol levels were determined from the serum of the rats. Results showed that MSG significantly raised the level of oestrogen (62.5 ± 0.28 pg/mL) in the rats which was significantly reduced in the rats fed with MSG for 30 days before treating them with the extracts of G. lucidum (30.85 ± 12.94 pg/mL–44.15 ± 0.92 pg/mL) and in rats fed concurrently with MSG and G. lucidum. The cholesterol level was significantly reduced in the rats treated with MSG and G. lucidum (200 mg/kg) concurrently compared to rats fed with MSG alone. The white blood cell (WBC) and red blood cell (RBC) levels were within normal in rats fed with both MSG and G. lucidum as in the control group while the rats fed with MSG only had low WBC, neutrophil (NEU) and RBC. This could imply that G. lucidum ameliorates the effect of MSG on serum oestrogen, serum cholesterol, WBCs, NEU, platelets and lymphocytes.

Risks of malignant and non-malignant tumours in tall women treated with high-dose oestrogen during adolescence

BACKGROUND/AIM

High-dose oestrogen treatment has been used to reduce growth in tall adolescent girls. The long-term safety with regard to cancer has not been clarified. Our aim was to study if this growth reduction therapy affects cancer risk later in life.

METHODS

A cohort study of 369 (172 treated, 197 untreated) Swedish women who in 1973-1993 were assessed for tall adolescent stature was designed. Data were collected from university hospital records, patient questionnaires, and the Swedish Cancer Register.

RESULTS

Risks are presented as odds ratios (ORs) with 95% confidence intervals comparing treated to untreated subjects. In treated subjects, the overall OR for having a tumour (malignant or non-malignant) was 1.7 (0.8-3.8). The ORs were 2.3 (0.4-12.8) for breast tumours, 0.8 (0.2-2.6) for gynaecological tumours, and 6.1 (1.04-∞) for melanoma. When limiting to malignant tumours, the crude ORs were of similar magnitude.

CONCLUSION

The OR for any melanoma was higher in treated than in untreated women, suggesting an increased risk of melanoma associated with high-dose oestrogen treatment during adolescence. Although the risk estimates were increased for overall tumours, breast tumours, malignant gynaecological tumours, and malignant melanoma, these associations were not statistically significant. Our results need to be verified in a larger cohort.

Looking back in time: conducting a cohort study of the long-term effects of treatment of adolescent tall girls with synthetic hormones

Objective

Public health research is an endeavour that often involves multiple relationships, far-reaching collaborations, divergent expectations and various outcomes. Using the Tall Girls Study as a case study, this paper will present and discuss a number of methodological, ethical and legal challenges that have implications for other public health research.

Approach

The Tall Girls Study was the first study to examine the long-term health and psychosocial effects of oestrogen treatment for tall stature.

Results

In undertaking this study the research team overcame many hurdles: in maintaining collaboration with treating clinicians and with the women they had treated as girls - groups with opposing points of view and different expectations; using private practice medical records to trace women who had been patients up to forty years earlier; and exploring potential legal issues arising from the collection of data related to treatment.

Conclusion

While faced with complex challenges, the Tall Girls Study demonstrated that forward planning, ongoing dialogue between all stakeholders, transparency of processes, and the strict adherence to group-developed protocols were keys to maintaining rigour while undertaking pragmatic research.

Implications

Public health research often occurs within political and social contexts that need to be considered in the planning and conduct of studies. The quality and acceptability of research findings is enhanced when stakeholders are engaged in all aspects of the research process.

Efficacy and Safety of Percutaneous Epiphysiodesis Operation around the Knee to Reduce Adult Height in Extremely Tall Adolescent Girls and Boys

Objective. The aim was to determine efficacy and safety of a surgical method to reduce adult height in extremely tall adolescents. Methods. Data for all girls (n = 12) and boys (n = 9) in our center subjected to bilateral percutaneous epiphysiodesis around the knee who had reached final height were included. Final height predictions were based on hand and wrist X-rays before surgery. Results. When compared to prediction, adult height was reduced by 4.1 ± 0.7 cm in treated girls (P < .001) and 6.4 ± 0.7 cm in treated boys (P < .001) corresponding to a 33.6 ± 3.4% and 33.6 ± 4.2% reduction of remaining growth, respectively. Besides mild to moderate postoperative pain reported in 9 operated individuals, no other side effects were reported. Postoperative X-rays confirmed growth plate closure and absence of leg angulations. Conclusions. Bilateral epiphysiodesis is an effective and safe method to reduce adult height in extremely tall girls and boys.

Ashley revisited: a response to the critics

The case of Ashley X involved a young girl with profound and permanent developmental disability who underwent growth attenuation using high-dose estrogen, a hysterectomy, and surgical removal of her breast buds. Many individuals and groups have been critical of the decisions made by Ashley's parents, physicians, and the hospital ethics committee that supported the decision. While some of the opposition has been grounded in distorted facts and misunderstandings, others have raised important concerns. The purpose of this paper is to provide a brief review of the case and the issues it raised, then address 25 distinct substantive arguments that have been proposed as reasons that Ashley's treatment might be unethical. We conclude that while some important concerns have been raised, the weight of these concerns is not sufficient to consider the interventions used in Ashley's case to be contrary to her best interests, nor are they sufficient to preclude similar use of these interventions in the future for carefully selected patients who might also benefit from them.

Growth-attenuation therapy: principles for practice

Publication of an account of growth attenuation with high-dose estrogen in a child with profound physical and cognitive disability brought widespread attention to a common and complex issue faced by families caring for similarly affected children, namely, the potentially negative effect of the increasing size of a child on the ability of his or her family to provide independent care, which in turn makes it more difficult for parents to keep the child in the home and involved in family activities. In this article we explore the scientific rationale for, effectiveness and safety of, and ethical considerations bearing on growth-attenuation treatment of children with profound and permanent cognitive disability. Informed responses to key clinically relevant questions are proposed. Our analysis suggests that growth attenuation is an innovative and sufficiently safe therapy that offers the possibility of an improved quality of life for nonambulatory children with profound cognitive disability and their families. Pediatricians and other care providers should include discussion of these options as part of anticipatory guidance around the age of 3 years so that, if elected, potential clinically meaningful benefits of growth-attenuation therapy can be realized. Because of the publicity and debate surrounding the first reported case, ethics consultation is recommended.

Ethinyl estradiol treatment for growth limitation in girls with Marfan's syndrome--experience from a single center

OBJECTIVES

Tall stature, a major characteristic of Marfan's syndrome, may be of concern to the family, particularly if the patient is a girl. Experience with treatment options-sex steroid or somatostatin analogue-for height reduction in girls is limited. We have evaluated our experience of estrogen treatment in girls with Marfan's syndrome attending the pediatric endocrine clinic in Glasgow between 1989 and 2005.

DESIGN AND METHODS

Retrospective case note analysis combined with ascertainment of final/near final height, comparing outcome in treated and untreated girls. Cardiovascular health was assessed by examining aortic root diameter and blood pressure.

RESULTS

The study cohort comprised four treated and five untreated girls, of whom three were sisters. Treatment was started in the four girls at chronological age 10.0 (2.1) years, mean (SD) height 155.0 (9.8) cm, and Tanner breast stage B1 in three and B2 in one. Ethinyl estradiol was administered in stepwise incremental regimens, starting at 10 microg/day and reaching 100 microg/day after 10 weeks in two girls and starting at 2 microg/day and reaching a maximum of 30-50 microg/day over a 2- to 3-year period in two girls. Mean +/- SD (range) final/near final height of the four treated girls was 174.3 (2.6) (170.6-176.6) cm compared with 183.0 (6.9) (171.5-190.3) cm in the five untreated girls. No deaths occurred in the treated group while one untreated girl died from presumed arrhythmia aged 18 years. Aortic root diameter increased with age, by mean (SD) 5.0 (2.1) and 5.8 (4.5) mm in treated and untreated groups, respectively, but with no between-group differences after treatment.

CONCLUSIONS

The estrogen doses used in this study are lower than in previous reports. The results, although unsuitable for statistical analysis due to small numbers, are encouraging with no adverse events being recorded. Future research should be multicenter in design.

Casuística de pacientes com queixa principal de alta estatura atendidos em serviço de referência em Salvador, Bahia

OBJETIVO: Descrever uma casuística de pacientes atendidos em serviço de referência em endocrinologia pediátrica com queixa principal de alta estatura. MÉTODOS: Revisão de prontuários de 1.980 pacientes atendidos no período de janeiro de 2003 a janeiro de 2007, incluindo apenas os indivíduos cuja queixa principal, na primeira consulta, fosse sua alta estatura. RESULTADOS: Foram encontrados 16 pacientes (0,8% do total de primeiras consultas). Destes, 12 preenchiam critérios diagnósticos de alta estatura (escore Z do indicador estatura para idade-ZE/I>2). Sete (58%) eram do sexo masculino. A idade em primeira consulta variou entre 3 anos e 4 meses e 13 anos e 3 meses. O ZE/I variou de 2,18 a 5,99 e a altura-alvo, de -1,10 a 1,24. Em relação às causas da alta estatura, concluiu-se que: sete pacientes (58%) tinham alta estatura familiar; dois (17%) idiopática e três (25%) sofriam de causas patológicas (síndrome de Marfan em um e adenoma hipofisário em dois deles). Nos quatro demais, o ZE/I variou de 1,86 a 1,98, não preenchendo critérios para alta estatura. Nestes, a etiologia do crescimento excessivo foi idiopática em dois, familiar em um e causado pela síndrome de Weaver em outro. CONCLUSÕES: A distribuição das etiologias de pacientes avaliados com a queixa de alta estatura está de acordo com a literatura, que relata ser familiar a principal causa. Embora alta estatura seja uma queixa principal pouco freqüente no consultório de endocrinologia pediátrica, a investigação deve ser cuidadosa a fim de se afastarem causas patológicas, que constituíram 25% dos casos.

Oestrogen treatment for tall stature in girls: estimating the effect on height and the error in height prediction

OBJECTIVE

To determine the effect of oestrogen treatment on attenuating the growth of tall girls after adjusting for error in height prediction.

DESIGN

Retrospective cohort study.

PATIENTS

Tall girls assessed by Australian paediatric endocrinologists between 1959 and 1993. A total of 279 girls received oestrogen treatment (diethylstilboestrol or ethinyl oestradiol) and 367 girls were assessed but not treated.

MEASUREMENTS

Estimated mature height (EMH) was calculated using radiographic assessment of bone age in adolescence. Final adult height was self-reported at follow-up. To control for error in the EMH predictions and their different distributions by treatment status, pairs of treated and untreated girls, matched on EMH within 1 cm, were selected for analysis. Covariate adjusted estimates of treatment effect (final height - EMH) were calculated. RESULTS In the sample of 108 matched pairs, the mean difference between the final height and EMH was -1.4 cm (SE 0.29) in the treated group and 1.1 cm (SE 0.23) in the untreated group, giving an unadjusted treatment effect of -2.5 cm (95% CI -3.2 to 1.8). A regression model based on 107 pairs of treated and untreated girls contained a significant interaction between bone age at treatment initiation and treatment, which estimated an approximately 1 cm per year decrease in treatment effect. The treatment effect was greatest in those commencing treatment at an early bone age and was significant if initiated before a bone age of 15 years.

CONCLUSIONS

On average, oestrogen treatment resulted in an adult height that was less than predicted. Although treatment was more effective in the least mature girls, the mean height difference was relatively modest for most treated girls.

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.

Ashley X

The recent case of Ashley X has sparked much recent public debate and controversy, and raises critical questions for physiatrists and rehabilitation professionals. The case came to light when Gunther and Diekema published an article in the October 2006 issue of Archives of Pediatric and Adolescent Medicine describing a novel growth attenuation treatment for Ashley X, a 6-yr-old girl with developmental disabilities. Her parents also published a blog about Ashley, with detailed explanations for their rationale in choosing this treatment on behalf of Ashley which involved beliefs about her future and quality of life. Ashley's parents refer to the series of interventions as the Ashley Treatment in their blog, and this phrase has also been adopted by the popular press and others who have commented on the case. In this article we present an analysis of the Ashley X treatment and use a disability ethics approach to examine the perspectives of various stakeholders involved, including Ashley and other girls with extensive disabilities, parents, physicians, and bioethics committees. We conclude with critical questions for physiatrists and other disability specialists who are in a unique position to examine medical controversies involving people with disabilities.

Oestrogen receptors and linear bone growth

In this review we summarize available data regarding linear growth in oestrogen receptor alpha (ERalpha)- and oestrogen receptor beta (ERbeta)-deficient mice. We discuss these findings in relation to known oestrogenic effects in humans and the possibility of applying this knowledge for the therapeutic modulation of longitudinal bone growth employing selective oestrogen receptor modulators (SERMs). We conclude that SERMs potentially could offer new possibilities to modulate bone growth by specifically targeting different oestrogen receptors within the growth plate.

Tall women's satisfaction with their height: general population data challenge assumptions behind medical interventions to stunt girls' growth

One-third of American pediatric endocrinologists offer growth-suppression treatments for tall girls despite serious medical risks and little or no evidence of benefit to psychosocial functioning. A survey of 59,632 adults shows that most tall women are satisfied with their height, which raises questions about the continued use of growth-suppression treatments.

The swimsuit issue: Correlates of body image in a sample of 52,677 heterosexual adults

Past research on adults' body image has typically used small convenience samples, limiting the ability to examine associations of personal characteristics to body satisfaction. This study of 52,677 heterosexual adults ages 18-65 examined associations of body satisfaction to age, height, gender, and body mass index (BMI). Age and height were mostly unrelated to body satisfaction. Consistent with an Objectification Theory perspective, fewer men than women reported being too heavy (41% versus 61%), rated their body as unattractive (11% versus 21%), or avoided wearing a swimsuit in public (16% versus 31%). Men felt better about their bodies than women across most of the weight span, although among underweight individuals, women felt better than men. Slender women (BMIs 14.5-22.49) were more satisfied than most other women (BMIs 22.5-40.5). Among men, underweight and obese men were least satisfied. These findings highlight gender differences in the association of weight to body satisfaction.

Concern about tall stature during adolescence and depression in later life

OBJECTIVE

This retrospective cohort study aimed to examine the long-term psychosocial outcomes for women assessed or treated during adolescence for tall stature.

METHOD

Women assessed or treated for tall stature identified from the records of Australian paediatricians were eligible to participate. Psychosocial outcomes were measured using the depression, mania and eating disorders modules of the Composite International Diagnostic Interview (CIDI), the SF-36, and an index of social support.

RESULTS

There was no significant difference between treated and untreated women in the prevalence of 12 month or lifetime major depression, eating disorders, scores on the SF-36 mental health summary scale, or the index of social support. However, compared with the findings of population-based studies, the prevalence of major depression in both treated and untreated tall girls was high (12 month prevalence: untreated 10.7%, treated 11.2%; lifetime prevalence: untreated 29.4%, treated 26.6%). Factors significantly associated with lifetime major depression in this study were self-reported difficulties during adolescence being the reason for seeking a medical assessment of height (OR 2.25, 95% CI 1.4-3.6) and a negative experience of the assessment or treatment procedures (OR 2.04, 95% CI 1.4-3.0).

CONCLUSION

Long-term follow-up of a large cohort of tall girls showed that psychological outcomes among both treated and untreated women were poor and that the intended psychosocial benefit of treatment may not have been realized. The findings highlight the importance of attending to the mental health of adolescents presenting for management of conditions where self-concept and body image are a primary focus.

Using hormone treatment to reduce the adult height of tall girls: Are women satisfied with the decision in later years?

Treatment with synthetic oestrogens to reduce adult height has been available for tall girls since the 1950s. Treatment aims to reduce psychosocial problems associated with tall stature that might occur in adolescence or adulthood, but little is known about the long-term outcomes. This retrospective cohort study identified 1248 eligible women from the medical records of Australian paediatricians who assessed or treated tall girls between 1959 and 1993, and 184 women from self-referrals. They included girls who received oestrogen treatment (diethylstilbestrol or ethinyl estradiol) in adolescence (treated group) and those who had been assessed but did not receive treatment (untreated group). A total of 1243 (86.8%) women were traced and invited to participate in the study, and 67.9% of these women (396 treated and 448 untreated) agreed. This paper reports on women's satisfaction with the decision that was made to have treatment to reduce their adult height. In a postal questionnaire women were asked to comment on a range of issues including how they felt about their current height, the assessment and treatment procedures, and the decision whether or not to have treatment. While untreated women were almost unanimously glad they were not treated (99.1%), no matter how tall they became, 42.1% of the treated women expressed dissatisfaction with the decision that was made. There was no clear association between satisfaction with treatment and the women's final height. However, dissatisfaction was related to: (a) whether or not the girls had an active say in the decision-making; (b) to negative experiences of the assessment or treatment procedures; (c) to side effects experienced during the treatment period; and (d) to later side effects women believed were associated with the treatment. The study finds that qualitative analysis of comments made by treated women helps to explain their dissatisfaction with the decision to have treatment.

Oestrogen treatment to reduce the adult height of tall girls: long-term effects on fertility

BACKGROUND

Treatment with oestrogen to reduce the adult height of tall girls has been available since the 1950s. We undertook a retrospective cohort study to assess the long-term effects of this treatment on fertility.

METHODS

Eligible participants were identified from the records of Australian paediatric endocrinologists who assessed tall girls from 1959 to 1993, and from self-referrals. Individuals included girls who had received oestrogen treatment (diethylstilboestrol or ethinyl oestradiol) (treated group) and those who were assessed but not treated (untreated group). Information about reproductive history was sought by telephone interview.

FINDINGS

1432 eligible individuals were identified, of whom 1243 (87%) could be traced. Of these, 780 (63%) completed interviews: 651 were identified from endocrinologists' records, 129 were self-referred. Treated (n=371) and untreated (n=409) women were similar in socioeconomic and other characteristics. After adjustment for age, treated women were more likely to have ever tried for 12 months or more to become pregnant without success (relative risk [RR] 1.80, 95% CI 1.40-2.30); more likely to have seen a doctor because they were having difficulty becoming pregnant (RR 1.80, 1.39-2.32); and more likely to have ever taken fertility drugs (RR 2.05, 1.39-3.04). Time to first pregnancy analysis showed that the treated group was 40% less likely to conceive in any given menstrual cycle of unprotected intercourse (age-adjusted fecundability ratio 0.59, 95% CI 0.46-0.76). These associations persisted when self-referred women were excluded.

INTERPRETATION

High-dose oestrogen treatment in adolescence seems to reduce female fertility in later life. This finding has implications for current treatment practices and for our understanding of reproductive biology.

Seeking SOCS and sex steroids

In seeking to explain why oral estrogen inhibits the GH-IGF-I axis, a recent study has unearthed a new way that steroid hormones can influence growth hormone action. This involves suppressors of cytokine signalling (SOCS), which offer a new level of understanding in signal control and crosstalk.

Raloxifene acts as an estrogen agonist on the rabbit growth plate

Estrogen treatment has been used to induce growth plate fusion, thereby reducing the final height in girls expected to achieve extreme tall stature. The treatment is effective, in terms of limiting final height, but concerns have been raised that it might also increase the risk for malignancies later in life. Raloxifene, a selective estrogen receptor modulator, has been shown to act as an estrogen agonist on bone density but as an estrogen antagonist on breast and uterine tissue. The effect of raloxifene treatment on growth plate fusion and final height is unknown. The aim of this study was to determine whether raloxifene would act as an estrogen agonist or antagonist on growth plate cartilage. Ovariectomized immature rabbits were treated for 4 wk with vehicle (controls), estradiol cypionate (E2), or raloxifene. Tibial growth velocity was decreased in both E2- (P < 0.001) and raloxifene-treated animals (P < 0.001), compared with controls. E2 and raloxifene treatment also decreased chondrocyte proliferation and the height of the proximal tibial growth plate. In addition, E2 and raloxifene hastened fusion of the distal tibial growth plate (P < 0.05) and decreased the number of proliferative and hypertrophic chondrocytes per column in the proximal tibial growth plate. As expected, the uterus was enlarged by estrogen, but not raloxifene, treatment. We conclude that raloxifene acts as an estrogen agonist on the growth plate, accelerating growth plate senescence and thus hastening epiphyseal fusion.