Sep 8, 1987 - Until recently, patients with ,B thalassaemia major presenting with sexual infantilism were (invariably) given hormone replacement therapy or ...
J Clin Pathol 1988;41:133-137
Gonadal function in patients with thalassaemia major V DE SANCTIS,* C VULLO,* M KATZ,t B WONKE,t R TANAS,* B BAGNItt From the *Department of Paediatrics, Arcispedale S Anna, Ferrara, Italy, the tDepartment of Obstetrics and Gynaecology, University College Hospital and Middlesex Medical School, London, the tDepartment of Haematology, Whittington Hospital, London and the ttDepartment ofNuclear Medicine, Arcispedale S Anna, Ferrara, Italy
SUMMARY Endocrine studies were made on 23 female patients aged 13 to 29 years, with delayed puberty or primary amenorrhoea and ,B thalassaemia major, and 12 healthy controls, of whom six were prepubertal and six were in Tanner's stage 3-4. Each patient and control received a single intravenous dose of 100 pg gonadotrophin releasing hormone (GnRH), and one week later, 10 U/kg body weight of human menopausal gonadotrophin (hMG) to stimulate ovarian function. The patients had decreased gonadotrophin reserves when compared with those of normal controls, only one of 23 patients had an intact luteinising hormone and follicle stimulating hormone response. M-ost of the thalassaemic patients with delayed puberty showed normal gonad response to human menopausal gonadotrophin (hMG), but three had very low responses, when compared with that ofcontrols. The gonadal failure was even more severe in four of six patients with primary amenorrhoea. It is important to assess hypothalamic-pituitary-gonadal function in young women with f thalassaemia major, so that those with glandular dysfunction may be started on replacement therapy. Delayed puberty is extremely common in patients with f thalassaemia major. Recent advances in treatment have improved the long terrn survival of such patients, and it is therefore of considerable importance to evaluate their hypothalamic pituitary gonadal axis. There is a great deal of indirect evidence implicating a primary hypothalamic or pituitary defect in this condition,' but to date, gonadal function has not been adequately assessed. We report the results of basal stimulated gonadotrophin and oestradiol secretion in 14 thalassaemic patients who presented with delayed puberty or primary amenorrhoea. All patients were receiving regular monthly blood transfusions and long term desferrioxamine chelation. Patients and methods Twenty three female patients with j3 thalassaemia major, aged 13 to 29 years (mean (SD) age 16-7 (4.1)) with delayed puberty or primary amenorrhoea were studied. P thalassaemia major was diagnosed on the basis of clinical and laboratory findings.2 Sexual maturation was assessed using the criteria proposed by Tanner.3 Delayed puberty was defined as Accepted for publication 8 September 1987
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the absence of breast development by 13 years of age, and any female who had not begun menstruating by the age of 18 years was said to have primary amenorrhoea. Table 1 details the age, morphometric measurements, and pubertal staging of individual patients. All patients had received repeated blood transfusions at regular intervals from early infancy to maintain the pretransfusional haemoglobin concentrations between 10-1 1-5 g/l. From 1971 onwards, desferrioxamine mesylate was given intramuscularly in doses of 20 mg/kg body weight two to three times a week. Between 1977 and 1978 this was changed to subcutaneous infusion (10- 12 hours a day) in doses of 20-50 mg/kg body weight/day as home management. Not all patients complied consistently with this treatment. Seventeen patients had no evidence of breast development, and, by implication, prepubertal gonads. The remaining six patients had variable breast development indicative of present or past gonadal function, but had not started menstruating by the age of 20 (table 1). Liver disease was present in 20 patients confirmed either by abnormal liver enzyme activity (serum aspartate transaminase (AST) and serum gamma glutamyl transpeptidase (yGT)) or by liver biopsy
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Table 1 Main clinical characteristics ofpubertal development in 23 thalassaemic patients Case No
Age
Bone age
Height* (cm)
Patients with delayed puberty 12-4 147-1 (3-10) 1 13 141-2(< 3) 2 13 121 3 13-2 12 1425(< 3) 4 9-7 131 (< 3) 13-3 14-1 11-8 140(< 3) 5 14-4 142-9(< 3) 6 10-2 148-7(< 3) 15 13-2 7 15-1 11 139(< 3) 8 12-8 147(< 3) 15-3 9 137(< 3) 15-7 11-1 10 150(< 3) 11 15-8 13-2 145-5(< 3) 12 15-8 13-3 145-7(< 3) 15-10 11-2 13 148-1 (< 3) 14 15-10 11 131 (< 3) 16 11-6 15 144-8(< 3) 16 16-4 11-4 17 12-9 148-8(< 3) 16-6 Patients with primary amenorrhoea 151-8 (3-10) 20-8 14-6 18 158 (25) 21-1 14-1 19 14-5 167 (75-90) 20 22-7 21 22-7 15-1 156-1 (10-25) 153 (3-10) 22 24-1 14-6 23 29-6 15 164-2 (50-75)
U:Lt
Stage of puberty,
149 144 144 134 140 140 148 132 146 138 150 148 148 157 129 142 150
0-97 0-93 0-97 0-97 0-89 1 0-86 0-95 0-88 0-95
BI/PHI BI/PH2 BI/PH3 Bl/PH3 BI/PH2 BI/PHI BI/PH2 BI/PHI BI/PH3 BI/PH3 BI/PHI
0-92 0-97 1
B1/PH2 BI/PH3 BI/PHI BI/PH3 B1/PH4
156 164 168 156 155 168
1 0 97 0-97 0-95 0-90 0-93
B4/PH4 B4/PH4 B5/PH5 B3/PH4 B5/PH3 B3/PH3
Weight* (kg)
Mid parental height (cm)
Span (cm)
43 (25) 38(3-10) 33(< 3) 30(< 3) 38(< 3) 36(< 3) 40(< 3) 38(< 3) 47 (3-10) 36(< 3) 54(25-50) 37(< 3) 40(< 3) 45(< 3) 35(< 3) 38(< 3) 58(50-75)
167 160 169 163 160 163 160 162 161 164 161 159 -
157 158 163 159 -
46 (3) 66 (75-90) 52 (25) 48 (3-10) 53 (25) 57 (50)
165 -
160 163 165
0-94 0-97 1
0-92
Bi/PHI
*Figures in parentheses measured in percentile of height or weight tRatio of upper to lower body segments (from symphysis) tAccording to the classification of Tanner (B 1-5: breast; PH 1-5: pubic hair)3
studies. Eight patients had abnormal glucose tolerance, and five patients were hypothyroid (compensated in cases 3, 12, and 14; uncompensated in cases 5 and 7); two patients (cases 11 and 16) had hypoparathyroidism (table 2). Patients with hypothyroidism and hypoparathyroidism were all well controlled on replacement therapy. The results were compared with those obtained in 12 normal subjects of whom six were prepubertal (mean (SD) age 11 (0-6) years; bone age 10-1 (0 8) years), and six were in Tanner's stage 3-4 (mean) age 13-8 (0-8) years; bone age 13-6 (0-4) years), all control subjects were the sisters of the thalassaemic patients. Pituitary-gonadal function was assessed before and after an intravenous pulse of 100 Mg gonadotrophin releasing hormone (GnRH) (Relisorm 100-Biodata). Blood samples were assayed for follicle stimulating hormone and luteinising hormone before and 20, 40, 60 and 120 minutes after injection. One week later 10 U/kg body weight human menopausal gonadotrophin (hMG, Pergonal-Serono) was given on three alternate days (maximum dose 450 units) to stimulate ovarian function. Blood was taken before each injection and 48 hours after the last injection for oestradiol measurements. Peak oestradiol response was assessed as normal if it fell within the normal range for our prepubertal control subjects. The basal and peak hormonal response (independent of time) was used to compare the responses
between thalassaemic patients and controls. The hypothalamic pituitary axis was further evaluated in one patient (case 8) with augmented luteinising hormone response to GnRH and normal oestradiol response to hMG, by sampling blood every 20 minutes for seven hours, starting at 22.00 hours. A pulse of luteinising hormone or follicle stimulating hormone was considered to have occurred if the concentrations of two consecutive samples (peak samples) were greater than that of the two previous samples and the value of one peak sample exceeded the 95% confidence limits of the mean on the two previous basal samples.4 Serum concentrations of luteinising hormone and follicle stimulating hormone were defined using double antibody radioimmunoassay kits obtained from Bio-Rad (Segrate, Milan, Italy) using assay standards. Serum gonadotrophin concentrations were expressed in mU/ml. The intra- and interassay coefficient of variation was 7% and 9% for luteinising hormone, and 4% and 9% for follicle stimulating hormone, respectively. The lower limit of assay sensitivity was 1-0 mIU/ml for both gonadotrophins. Serum 17 P-oestradiol was measured with kits purchased from Diagnostic Products (Los Angeles, California). The results were expressed in pg/ml. The sensitivity of the assay was 10 pg/ml, the intraassay variation was 7%, and the interassay variation was 8%. Bone age was assessed in all the younger women by
Gonadalfunction in patients with P thalassaemia major
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Table 2 Main laboratory and clinicalfeatures in 23 thalassaemic patients Case No
AST
(lU/i)
yGT (IU/I)
Patients with delayed puberty 18 30 1 110 260 2 14 71 3 34 55 4 6 29 5 91 22 6 8 15 7 69 8 268 61 9 68 12 16 10 16 129 11 16 12 70 29 115 13 35 14 116 149 43 15 14 75 16 25 17 26 Patients with primary amenorrhoea 24 38 18 50 19 164 15 35 20 20 21 45 52 57 22 24 23 23
Serum ferritin
(Jsg/l)
1527 2182 2360 3445 2600 1140 2082 6400 1710 1185 7740 1200 2600 1670 9800 2700 2400
1795 2259 3120 1200 943 1269
Clinical complications*
Impaired glucose tolerance Primary compensated hypothyroidism; impaired glucose tolerance Primary hypothyroidism, impaired glucose tolerance
Primary hypothyroidism
Impaired glucose tolerance Chronic active hepatitis, primary hypothyroidism Primary compensated hypothyroidism Primary compensated hypothyroidism Hypoparatiroidism, impaired glucose tolerance Chronic active hepatitis
Impaired glucose tolerance
Impaired glucose tolerance Impaired glucose tolerance Normal range: serum ferntin 14-148 ug/l; serum aspartate transaminase (AST) 7-40 IU/1; serum y glutamyl transpeptidase (yGT) 0-16 IU/1.
The heights of thalassaemic patients varied from 132 to 168 cm. Sixteen patients with delayed puberty had heights below the third centile on the Tanner and Whitehouse growth chart.6
subjects. Mean luteinising hormone responses were also lower in thalassaemic patients compared with controls (p < 0-005), although five of these subjects had peak luteinising hormone values within the normal range. The basal oestradiol values in both the thalassaemic patients and prepubertal controls were at or below the sensitivity of the assay, hence they could not be analysed. Administration of hMG elicited a variable oestradiol response: six patients responded normally, eight had inadequate response, and three had very low response, compared with those of controls.
GONADOTROPHIN AND 17 fi-OESTRADIOL SECRETION IN PATIENTS WITH DELAYED
GONADOTROPHIN AND OESTRADIOL SECRETION IN PATIENTS WITH PRIMARY AMENORRHOEA
PUBERTY (table 3) Basal serum luteinising hormone values in the thalassaemic patients did not differ significantly from those found in prepubertal controls. On the other hand, basal serum follicle stimulating hormone values were lower in thalassaemic patients than controls (p < 0-002). This follicle stimulating hormone deficiency was further magnified after the administration of GnRH when, unlike the controls, follicle stimulating hormone rose minimally, and not at all in two patients (cases 4 and 7). An almost threefold increase was observed in the normal prepubertal
(table 3) Basal luteinising hormone and follicle stimulating hormone were significantly lower compared with those values in normal pubertal controls (p < 0-002), and the same pattern emerged after administration of GnRH. The basal serum oestradiol concentrations of all thalassaemic patients with primary amenorrhoea were below the detection limit for our assay (< 10 pg/ ml). After hMG administration one of six patients showed a normal oestradiol response, two had inadequate response, and one failed to respond. Fig I shows the nocturnal secretory pattern of
the same observer (VDS) using a TW2 method.5 Statistical analysis of the results was carried out by the Mann-Whitney U test (p < 0 05 was chosen as the limit of significance). Linear regression was used to evaluate correlations between variables. Results
De Sanctis, Vullo, Katz, Wonke, Tanas, Bagni Table 3 GnRH test and hMG test: serwn gonadotrophins (luteinising hormone andfollicle stimulating hormone) and serwn 136
oestradiol (E2) in 23 thalassaemic patients and in controls Serum luteinising hormone (mU/ml)
Case No
Basal
Peak
Patients with delayed puberty 5 137 1 11-6 2 45 52 19.3 3 4 3-4 4-3 183 5 6-2 4 6 13.9 7 2-5 3-1 4-7 8 24-2 175 9 58 8-3 10 78 12-1 11 6-4 12 53 10-6 11-6 13 2-8 14 20-4 3-8 15 83 4-1 16 52 69 17 5 11-6 Median 5 11-6 3 1-24 2 Range 2-5-7-8 Controls Median 8-7 20-1 16-4-21-4 Range 1-3-63 < 0005 p value NS Patients with primary amenorrhoea 14-7 3 18 19 2-8 137 5.3 3-5 20 8-4 21 1-5 2-6 53 22 9.9 2-9 23 Median 2-8 9-1 5 3-147 1 5-3 5 Range Controls 32-2 Median 7-6 25-46-5 5-5-10-1 Range < 0-002 < 0-002 p value
Serwn follicle stinulating hormone (mU/mi)
Serum E2 (pg/ml)
Basal
Peak
Basal
Peak
3-7 3-3 2-7 2-7 17 7-8 6-8 7-4 3 5-1 4-8 3-6 4-3 3-2 2 3-1 3 33 1-7-7-4
4-2 4-8 53 2-9 3-4 94 6-6 146 8-8 5-4 10-1 4-7 58 3-7 3-8 48 58 5.3 2-9-14-6
< 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10 < 10
