Low Pretreatment Bone Mineral Density in Gender Diverse Youth

Gender diverse adolescents have low pretreatment bone mineral density (BMD), with variable changes in BMD after initiation of gender-affirming treatment. We aimed to assess factors associated with low BMD in gender diverse youth. Sixty-four patients were included in our analysis (73% assigned male at birth). Subtotal whole-body BMD Z-scores were low in 30% of patients, and total lumbar spine BMD Z-scores low in 14%. There was a positive association with body mass index, and no association with vitamin D level. Male sex assigned at birth was associated with lower pretreatment BMD, with lower average BMD Z-scores compared to previous studies.

Leuprolide Acetate for Puberty Suppression in Transgender and Gender Diverse Youth: A Comparison of Subcutaneous Eligard Versus Intramuscular Lupron

PURPOSE

To compare the efficacy of intramuscular Lupron and subcutaneous Eligard, two formulations of leuprolide, for puberty suppression in transgender and gender diverse (TGD) youth.

METHODS

A retrospective chart review of TGD youth receiving Lupron or Eligard 22.5 mg every 3 months was conducted to determine hormone levels obtained 1 hour after an injection (1hrPost) and patient-reported clinical puberty suppression.

RESULTS

Forty eight patients were analyzed: 33% assigned female at birth of which 25% were premenarchal, mean age at first injection 13.7 years, and 50% received concurrent gender affirming hormones. Of these, 13% received Lupron, 52% Eligard, and 35% initially received Lupron then transitioned to Eligard due to drug shortages. There were 55 incidents of 1hrPost levels, 42 after Eligard and 13 after Lupron. Clinical puberty suppression occurred in all patients; however, biochemical suppression occurred in 90% of Eligard and 69% of Lupron (p = .06).

DISCUSSION

Eligard and Lupron were both effective in suppressing clinical puberty progression in our population of TGD youth, of which 50% were receiving concurrent gender affirming hormones.

Gender-affirming endocrine care for youth with a nonbinary gender identity

Nonbinary individuals, or those who identify outside of the traditional gender binary, are currently present in up to 9% of the general population of youth or up to 55% of gender-diverse youth. Despite the high numbers of nonbinary individuals, this population continues to experience barriers to healthcare due to providers' inability to see beyond the transgender binary and lack of competence in providing nonbinary care. In this narrative review, we discuss using embodiment goals to individualize care of nonbinary individuals, and review hormonal and nonhormonal treatment options for gender affirmation. Hormonal treatments include those often used in binary transgender individuals, such as testosterone, estradiol, and anti-androgens, but with adjustments to dosing or timeline to best meet a nonbinary individual's embodiment goals. Less commonly used medications such as selective estrogen receptor antagonists are also discussed. For nonhormonal options, alterations in gender expression such as chest binding, tucking and packing genitalia, and voice training may be beneficial, as well as gender-affirming surgeries. Many of these treatments lack research specific to nonbinary individuals and especially nonbinary youth, and future research is needed to ensure safety and efficacy of gender-affirming care in this population.

The Structured Oral Examination: A Method to Improve Formative Assessment of Fellows in Pediatric Endocrinology

OBJECTIVE

A structured oral exam (SOE) can be utilized as a formative assessment to provide high-quality formative feedback to trainees, but has not been adequately studied in graduate medical education. We obtained fellow and faculty perspectives on: 1) educational effectiveness, 2) feasibility/acceptability, and 3) time/cost of a SOE for formative feedback.

METHODS

Four pediatric endocrinology cases were developed and peer-reviewed to generate a SOE. The exam was administered by faculty to pediatric endocrinology fellows individually, with feedback after each case. Fellow/faculty perspectives of the SOE were obtained through a questionnaire. Qualitative thematic analysis was utilized to analyze written comments generated by faculty and fellows.

RESULTS

Seven of 10 pediatric endocrinology fellowship programs and all 18 fellows within those programs agreed to participate. Thematic analysis of fellow and faculty comments resulted in 5 perceived advantages of the SOE: 1) improved identification of clinically relevant knowledge deficits, 2) improved assessment of clinical reasoning, 3) immediate feedback/teaching, 4) assurance of adequate teaching/assessment of uncommon cases, and 5) more clinically relevant assessment. Mean time to administer one case was 15.8 minutes (2.0) and was mentioned as a potential barrier to implementation. Almost all fellows (17/18, 94%) and faculty (6/7, 86%) would recommend or would most likely recommend implementation of the SOE into their curriculum.

CONCLUSIONS

The SOE utilized for formative feedback was perceived by fellows and faculty to have several educational advantages over current assessments and high acceptability. Objective educational advantages should be assessed on future studies of the SOE.

Adolescent Polycystic Ovary Syndrome: An Update

Menstrual irregularities and cutaneous signs of androgen excess are commonly encountered when caring for adolescent girls. Polycystic ovary syndrome (PCOS) is the most common cause of these symptoms in adult women, and it can be diagnosed in adolescents as well. Diagnostic criteria used to diagnose adult women are not applicable in adolescents, as some diagnostic criteria overlap with the normal physiology of a maturing reproductive system. Thus, application of adult criteria will overdiagnose adolescents with PCOS. Two recent guidelines on the diagnosis and treatment of PCOS in adolescence were created to provide clarity in the diagnosis of PCOS in adolescent girls and to guide best practices in treatment. This review summarizes the recommendations and gives practical advice on the application of these recommendations to everyday pediatric practice. [Pediatr Ann. 2019;48(8):e304-e310.].

Youth and Parent Experiences in a Multidisciplinary Gender Clinic

Purpose: To assess youth and parent/caregiver satisfaction with care at a pediatric multidisciplinary gender clinic.

Methods: Transgender/gender nonconforming youth (n=33) and their parent/caregiver (n=29) completed self-report questionnaires and individual interviews (n=20) about experiences and satisfaction with care.

Results: Quantitatively, participants reported being extremely satisfied with care experiences (parents 97%; youth 94%). Qualitatively, main themes included (1) affirmation due to use of preferred name/pronouns, (2) access barriers due to scheduling and readiness assessments, and (3) positive interactions with Care Navigator.

Conclusion: Youth and parents/caregivers are highly satisfied with multidisciplinary, coordinated health care for transgender/gender nonconforming youth; however, some challenges remain.

Consequences of Early Life Programing by Genetic and Environmental Influences: A Synthesis Regarding Pubertal Timing

Sexual maturation is closely tied to growth and body weight gain, suggesting that regulative metabolic pathways are shared between somatic and pubertal development. The pre- and postnatal environment affects both growth and pubertal development, indicating that common pathways are affected by the environment. Intrauterine and early infantile developmental phases are characterized by high plasticity and thereby susceptibility to factors that affect metabolic function as well as related reproductive function throughout life. In children born small for gestational age, poor nutritional conditions during gestation can modify metabolic systems to adapt to expectations of chronic undernutrition. These children are potentially poorly equipped to cope with energy-dense diets and are possibly programmed to store as much energy as possible, causing rapid weight gain with the risk for adult disease and premature onset of puberty. Environmental factors can cause modifications to the genome, so-called epigenetic changes, to affect gene expression and subsequently modify phenotypic expression of genomic information. Epigenetic modifications, which occur in children born small for gestational age, are thought to underlie part of the metabolic programming that subsequently effects both somatic and pubertal development.

Deletion of Otx2 in GnRH neurons results in a mouse model of hypogonadotropic hypogonadism

GnRH is the central regulator of reproductive function responding to central nervous system cues to control gonadotropin synthesis and secretion. GnRH neurons originate in the olfactory placode and migrate to the forebrain, in which they are found in a scattered distribution. Congenital idiopathic hypogonadotropic hypogonadism (CIHH) has been associated with mutations or deletions in a number of genes that participate in the development of GnRH neurons and expression of GnRH. Despite the critical role of GnRH in mammalian reproduction, a comprehensive understanding of the developmental factors that are responsible for regulating the establishment of mature GnRH neurons and the expression of GnRH is lacking. orthodenticle homeobox 2 (OTX2), a homeodomain protein required for the formation of the forebrain, has been shown to be expressed in GnRH neurons, up-regulated during GnRH neuronal development, and responsible for increased GnRH promoter activity in GnRH neuronal cell lines. Interestingly, mutations in Otx2 have been associated with human hypogonadotropic hypogonadism, but the mechanism by which Otx2 mutations cause CIHH is unknown. Here we show that deletion of Otx2 in GnRH neurons results in a significant decrease in GnRH neurons in the hypothalamus, a delay in pubertal onset, abnormal estrous cyclicity, and infertility. Taken together, these data provide in vivo evidence that Otx2 is critical for GnRH expression and reproductive competence.

Approach to the growth hormone-deficient child during transition to adulthood

The observation that some adults with childhood-onset GH deficiency have low bone mineral density, low lean body mass, diminished quality of life, abnormal lipids, and impaired cardiac function, all of which may improve after treatment with GH, has prompted pediatric endocrinologists to reevaluate the practice of discontinuing GH in all patients after attainment of final adult height. The treatment of adolescents to prevent the metabolic complications of GH deficiency is an emerging practice. Studies addressing the evaluation and care of adolescents during this period and the benefits of GH in this setting are conflicting. Our approach in determining which adolescents to retest, when and how to test for persistent GH deficiency, and which subjects to treat is discussed in the context of available clinical data.