Hypogonadism in beta-thalassemic adolescents: a characteristic pituitary-gonadal impairment. The ineffectiveness of long-term iron chelation therapy

Iron overload disorders: Growth and gonadal dysfunction in childhood and adolescence

Hemochromatosis (HC) is characterized by the progressive accumulation of iron in the body, resulting in organ damage. Endocrine complications are particularly common, especially when the condition manifests in childhood or adolescence, when HC can adversely affect linear growth or pubertal development, with significant repercussions on quality of life even into adulthood. Therefore, a timely and accurate diagnosis of these disorders is mandatory, but sometimes complex for hematologists without endocrinological support. This is a narrative review focused on puberty and growth disorders during infancy and adolescence aiming to offer guidance for diagnosis, treatment, and proper follow-up. Additionally, it aims to highlight gaps in the existing literature and emphasizes the importance of collaboration among specialists, which is essential in the era of precision medicine.

Fertility and Pregnancy in Women with Transfusion-Dependent Thalassemia

Because women with transfusion-dependent thalassemia are seeking pregnancy, ensuring the best outcomes for both mother and baby require concerted and collaborative efforts between the hematologist, obstetrician, cardiologist, hepatologist, and genetic counselor among others. Proactive counseling, early fertility evaluation, optimal management of iron overload and organ function, and application of advances in reproductive technology and prenatal screening are important in ensuring a healthy outcome. Many unanswered questions remain requiring further study, including fertility preservation, non-invasive prenatal diagnosis, chelation therapy during pregnancy, and indications and duration of anticoagulation.

Fertility and Pregnancy in Women with Transfusion-Dependent Thalassemia

As more women with transfusion-dependent thalassemia are seeking pregnancy, ensuring the best outcomes for both the mother and baby requires concerted, collaborative efforts between practitioners and the family. Proactive counseling, early fertility evaluation, recent developments in reproductive technology, and optimal management of iron overload, have resulted in more successful pregnancies and the birth of healthy newborns. With advances in technology for prenatal screening and increased awareness to perform screening for hemoglobinopathies, healthy pregnancy outcomes have become the expectation. Topics that require further study include management that allows fertility preservation, improved non-invasive prenatal diagnosis methods for affected fetuses, the use of chelation therapy during pregnancy, and indications for and duration of anticoagulation.

Testosterone replacement therapy: role of pituitary and thyroid in diagnosis and treatment

Crosstalk among hormones characterizes endocrine function, and assessment of the hypogonadal man should take that into consideration. In men for whom testosterone deficiency is a concern, initial evaluation should include a thorough history and physical exam in which other endocrinopathies are being considered. Hypogonadism can be associated with both pituitary and thyroid dysfunction, for which appropriate biochemical evaluation should be undertaken in certain clinical scenarios. If low serum testosterone is confirmed measurement of luteinizing and follicle stimulating hormones (LH and FSH respectively) is essential to establish whether the hypogonadism is primary or secondary. In secondary hypogonadism measurement of prolactin is always necessary, and measurement of other pituitary hormones, along with pituitary imaging, may be indicated. Checking thyroid function may also be enlightening, and can raise additional therapeutic considerations. Correction of other pituitary axes may attenuate the need for testosterone replacement therapy in some cases.

Intravenous iron replacement therapy in eugonadal males with iron-deficiency anemia: Effects on pituitary gonadal axis and sperm parameters; A pilot study

AIM OF THE STUDY

To evaluate semen parameters and to assess serum FSH, LH, Testosterone (T) concentrations before and 12 weeks after intravenous iron therapy (800-1200 mg elemental iron therapy - IVI) in adults with iron-deficiency anemia (IDA).

MATERIALS AND METHODS

We studied 11 eugonadal adults with IDA, aged 40 ± 5 years, due to defective intake of iron. Anemia was diagnosed when hemoglobin (Hb) was equal or below 10 g/dl. Serum iron, total iron-binding capacity (TIBC) and ferritin concentrations confirmed the diagnosis of IDA. Basal serum concentrations of FSH, LH, and T were measured. Semen parameters were evaluated before and 6-7 weeks after IVI therapy.

RESULTS

After IVI therapy and correction of anemia, a significant increase of Hb from 8.1 ± 1.17 g/dL to 13.1 ± 0.7 g/dL was observed and was associated with an increase of T (from 12.22 ± 1.4 nmol/L to 15.9 ± 0.96 nmol/L; P < 0.001), FSH (from 2.82 ± 0.87 to 3.82 ± 1.08 IU/L; P = 0.007), and LH (from 2.27 ± 0.9 to 3.82 ± 1.5 IU/L; P = 0.0002). Total sperm count (TSC) increased significantly from 72 ± 17.5 million/ml to 158 ± 49 million/mL (P < 0.001), rapid progressive sperm motility (RPM) increased from 22 ± 9.4 to 69 ± 30 million/ml (P < 0.001), and sperms with normal morphology (NM) increased from 33 ± 5 to 56 ± 7 million/ml (P < 0.001). Increment in Hb concentration was correlated significantly with LH, FSH, and T concentrations after IVI (r = 0.69 and r = 0.44, r = 0.75, respectively; P < 0.01). The increment in serum T was correlated significantly with increments in the TSC and total sperm motility and RPM (r = 0.66, 0.43, and 0.55, respectively; P < 0.001) but not with gonadotrophin levels.

CONCLUSION

Our study proved for the first time, to our knowledge, that correction of IDA with IVI is associated with significant enhancement of sperm parameters and increased concentrations of serum LH, FSH, and T. These effects on spermatogenesis are reached by an unknown mechanism and suggest a number of pathways that need further human and/or experimental studies.

Fertility potential in thalassemia major women: current findings and future diagnostic tools

Preserving fertility, preventing early menopause, and predicting reproductive ability have become crucial for many adult thalassemia major females. Luteinizing hormone/follicle-stimulating hormone (LH/FSH) and estradiol, commonly used for assessment of fertility potential in thalassemia, have a poor predictive value. Current reproductive practice uses markers of ovarian reserve testing, which were not yet studied in thalassemia women. We explored the relationship between liver iron concentration (LIC) and fertility status in 26 females (mean 30 years old). Seventeen (65%) of them experienced primary or secondary amenorrhea. Levels of LH/FSH and estradiol were low or undetectable in 48% and 35% of patients, respectively and did not correlate with age, presence of amenorrhea, and LIC. This further addresses the need for utilization of current available methods for assessment of fertility capacity in thalassemia, which will also allow future correlation with pituitary iron measures by MRI as well as early intervention for fertility preservation.

Growth and endocrine function in thalassemia major in childhood and adolescence

BACKGROUND

Thalassemia major is an inherited hemoglobin disorder characterized by chronic anemia and iron overload due to transfusion therapy and gastrointestinal absorption. Iron overload causes most of the associated mortality and morbidity and frequently involves the endocrine glands.

AIM

To review the most pertinent literature on the topic.

METHODS

One hundred and twenty-three papers were evaluated.

RESULTS

Disproportionate short stature is frequent and becomes more evident at puberty because of the lack of growth spurt. Later on, partial height recovery may occur. Long-term treatment with recombinant human GH seems ineffective to improve final height. Pubertal development is characterized by a clinical spectrum ranging from hypogonadism to a simple delay in starting and developing of puberty. Hormonal replacement is mandatory in cases of absent or arrested puberty. Pancreatic beta-cells function may be impaired during adolescence or later on. Its impairment ranges from hyperinsulinemia, secondary to insulin resistance, with normal glucose tolerance to beta-cells failure with insulin-dependent diabetes mellitus. Primary hypothyroidism may affect thalassemic patients from the second decade of life. The thyroid dysfunction may be reversible (if an intensive chelation therapy regimen is started in the precocious phase), stationary, or slowly progressive. Central hypothyroidism is less common and autoimmune thyroiditis absent.

CONCLUSION

Despite the improvement of the treatment, the involvement of the endocrine system still burdens the life of these patients. Further therapeutic improvement would reasonably reduce morbidity and, hopefully, mortality of thalassemic patients and make the endocrine disorders easier to treat.

Hypothalamic-pituitary-gonadal function in adolescent females with beta-thalassemia major

OBJECTIVE

To evaluate the function of the hypothalamic-pituitary-gonadal axis in adolescent female patients with beta-thalassemia major.

MATERIALS AND METHODS

A prospective study of the function of the hypothalamic-pituitary-gonadal axis function of 31 beta-thalassemia major females aged between 13 and 22 years and in 12 control females aged between 12 and 22 years. All were treated at Princess Rahma Teaching Hospital, Irbid, Northern Jordan between April 2001 and April 2003.

RESULTS

Of the 31 beta-thalassemia major females, 13 (41.9%) had delayed puberty. Hypothalamic-pituitary-ovarian axis dysfunction was found in 15 patients (48.4%). Twelve patients (38.7%) had hypogonadotropic hypogonadism and 5 (16.1%) had ovarian failure. High levels of serum ferritin were significantly higher in patients with delayed puberty.

CONCLUSION

Pituitary and ovarian dysfunction are common problems in beta-thalassemia major patients. The main possible cause is iron overload. This stresses the need for intensive and regular use of chelation therapy to prevent damage to the hypothalamic-pituitary-ovarian axis.

Reproductive health in individuals with homozygous beta-thalassemia: knowledge, attitudes, and behavior

OBJECTIVE

To review the reproductive health knowledge, attitudes, and behaviors of persons with homozygous beta-thalassemia.

DESIGN

Case-control study.

SETTING

Patients treated at a tertiary hospital and community-based healthy controls.

PARTICIPANT(S)

One hundred and thirty persons, 16 years of age or older, who had homozygous beta-thalassemia and were attending hospital for regular blood transfusion, and 99 demographically matched persons without thalassemia. ASSESSMENT TOOL: Reproductive health questionnaire.

RESULT(S)

104 (80%) persons with homozygous beta-thalassemia completed the questionnaire and were compared with 99 controls. Persons with homozygous beta-thalassemia were as likely as healthy peers to be in a relationship, employed full-time, sexually active, and using contraception and to have had children. Hypogonadotrophic hypogonadism was present in 55 (52.8%) patients, 46 (83.6%) of whom were compliant with hormone replacement therapy. Understanding of genetics and reproductive potential was suboptimal among persons with homozygous beta-thalassemia, and this group had a higher rate of unplanned pregnancy.

CONCLUSION(S)

This study suggests that with optimal therapy, most young adults with homozygous beta-thalassemia can achieve reproductive, sexual, and social experiences similar to those of their healthy peers.

Increased levels of redox-active iron in follicular fluid: a possible cause of free radical-mediated infertility in beta-thalassemia major

OBJECTIVE

Our purpose was to investigate the follicular fluid parameters associated with redox activity and the consequent production of the deleterious hydroxyl radical in beta-thalassemia major.

STUDY DESIGN

The levels of ferritin, total iron, total copper, and redox-active iron were measured in follicular fluid aspirated from three follicles during three consecutive ovum pickups from a patient with beta-thalassemia major and were compared with the levels in nine follicles aspirates from nine healthy control patients. The redox activity in the follicular fluid samples was monitored by the extent of follicular fluid-mediated deoxyribonucleic acid degradation and salicylate hydroxylation.

RESULTS

Total iron and ferritin concentrations were elevated in thalassemic follicular fluid samples compared with control samples (6.7 fold, and 53.3-fold, respectively), whereas the total copper concentration was similar. Thalassemic follicular fluid samples exhibited a marked increase of redox activity, indicating a higher potential of free radical production leading to deoxyribonucleic acid degradation. Likewise, free radical-induced conversion of salicylate to dihydroxybenzoic acid derivatives was enhanced in the thalassemic follicular fluid samples compared with controls (2,3-dihydroxybenzoic acid: 67.7 +/- 22 vs 20.3 +/- 12.9 ng/mg protein; 2,5-dihydroxybenzoic acid: 101.6 +/- 25.9 vs 4.42 +/- 2.7 ng/mg protein).

CONCLUSIONS

The increased level of redox activity found in the follicular fluid from a patient with beta-thalassemia major focuses the attention on the small fraction of redox-active iron ions as mediators of free radical production, inducing tissue injury and possibly contributing to impairment of reproduction in these patients.

Short stature in homozygous beta-thalassaemia is due to disproportionate truncal shortening

BACKGROUND AND OBJECTIVE

Growth failure in homozygous beta-thalassaemia has been recognized for many years, and has persisted despite major treatment advances. In this cross-sectional study, sitting and standing height were measured to determine whether growth failure was disproportionate.

DESIGN

Patient data were analysed in three age groups, 2-10 years, 11-18 years and 19 and over. Sitting height and subischial leg length were also determined in a cohort of parents (n = 19) and normal Greek adolescents (n = 32).

PATIENTS AND MEASUREMENTS

Of the known 156 patients with homozygous beta-thalassaemia in the State of Victoria, 154 (98.7%) attend our institution. Sitting and standing heights were measured, using Harpenden stadiometers, in 57 of 60 (95%) patients aged 2-18 years and in a random selection of 51 of 89 patients aged 19 and over (57%). Measurements are expressed as mean +/- SDS. Other data analysed included serum concentrations of ferritin, zinc, copper, FSH, LH, oestradiol and testosterone, according to standard laboratory assays, together with pubertal status and bone age in patients aged less than 19 years.

RESULTS

Standing height standard deviation scores in the 2-10 age group were -0.687 +/- 0.861 (n = 9), in the 11-18 age group were -1.838 +/- 1.413 (n = 48) and in the age group 19 and over were -1.175 +/- 1.126. In individuals aged 2-10 years, sitting height standard deviation scores (SDS) were -1.56 +/- 1.02, in individuals 11-18 years were -3.76 +/- 1.51 (n = 48), and in individuals 19 years and over were -2.77 +/- 1.20 (n = 51), compared with subischial leg length SDS which were, in individuals aged 2-10 years 0.214 +/- 0.91; in 11-18 years, -0.063 +/- 1.347, and in individuals 19 and over, 0.37 +/- 1.18. These data show that the reduction in standing height was the result of truncal shortening. Mean sitting height SDS was significantly lower in children with homozygous beta-thalassaemia, compared with their parents (P < 0.001), and in a subgroup of Greek adolescents with homozygous beta-thalassaemia compared with age and sex matched normal Greek adolescents (P < 0.001). No correlation was found between truncal shortening and other clinical and biochemical variables measured.

CONCLUSIONS

Short stature in our patients with homozygous beta-thalassaemia is due to disproportionate truncal shortening. The aetiology of truncal shortening in this patient group is likely to be multifactorial, although hypogonadism and chelation therapy may be contributory factors.