RE: questions to understand premature puberty treatment...

[Guest guest]

Inga,

This is a tricky subject and I hope I explain my thoughts to you in

a clear manner. The Lupron you are using with your son is to delay

puberty. That means it delays the onset of facial hair, increase in

size of the testicles, deepening of the voice, and all the other

stuff that goes along with puberty. It is delayed for several

reasons, one being that a boy (or girl) showing these signs of

development at an early age will stand out and look too different

than his peers. It is also a time when growth speeds up - you know,

like when you look at a teen in July (especially boys) and then see

him again in September and it looks like he has grown several feet!

Now, as Pat explained, Lupron, Zoladex, Lupron Depot, etc. are not

associated with adrenarche which is responsible for advancing bone

age. For that you would need to use Armidex, an aromatase

inhibitor. This drug reduces and/or stops the production of

estrogen, an enemy for a child with growth problems because of the

advancement of bone age. As you know, once those growth plates

fuse, no further growth can be obtained.

Max showed signs of both puberty and adrenarche when he was in 5th

grade, I believe. He immediately began taking Armidex and his bone

age, which was catching up to his chronological age, began to slow

down. As his chronological age went on, his bone age slowed down to

the point where he is now 3 years delayed. He is 17, but his bone

age is 14. That is great because it will give him that much more

time to grow. (I think he is almost 5'5 " now!)

Soon after starting the Armidex, Dr. H. decided to start him on

Zoladex. Because of Max's uncontrolled and precarious anxiety at

that time, she thought it would be a better choice than Lupron. The

Zoladex would be placed every 86 days vs. the Lupron which would be

painful and need to be injected every 28 days. Even though she had

never placed the pellet herself before, we trusted her and let her,

once again, use Max as her " guinea pig. "

The medications worked very well. We happily followed the routine

until a little over a year ago. Max at that point was in high

school and looked like a baby compared to the huge and developed

boys he was in school with. The decision was made to stop the

Zoladex so that he could go into puberty and look more like his

peers. The timing was right. Kids can be cruel and we did not want

him teased because he still looked so young, besides being so much

shorter than the others.

But we continued to use the Armidex and we still do.

Max's voice is deep, he has hairy legs, he shaves now and I know

that his testicular development has advanced. When he was in the

hospital last fall, I had to help him use the bathroom because he

was too weak to go by himself and I got a good look. Man, was I

surprised! I was actually embarrassed 'cause he looked like a MAN!

He facial features are more sculpted, he has acne, he has muscles

and he just looks older all around. (The acne got to the point

where I had to take him to the doctor in August for medication. Now

that is under control, thank goodness.)

My point in all of this long message is that socially it is

important to consider puberty and the correct time to let it

happen. But medically it is important to keep that estrogen from

developing too rapidly so our kids have more time to grow.

You mentioned that you have seen weight gain with the increased

Lupron dose, too. Yes, that can be a side effect, but you should

also have him checked for Type 2 diabetes. Our kids are at risk for

that condition and the weight gain can be a sign of that as well.

An oral glucose tolerance test would be the thing to do for that.

I hope I have helped you understand this better. It is so confusing

and even I get mixed up every now and then. Gosh, there is so much

to remember and to understand.

Jodi Z

[Guest guest]

Thanks so much. I wonder if the endos knew all this and I just missed

something in our conversations or they didn't really know. Oh well, it

looks like I'll be attempting to educate them on some possibilities...

Inga

At 01:32 AM 9/18/2005 +0000, you wrote:

>Inga,

>

>This is a tricky subject and I hope I explain my thoughts to you in

>a clear manner. The Lupron you are using with your son is to delay

>puberty. That means it delays the onset of facial hair, increase in

>size of the testicles, deepening of the voice, and all the other

>stuff that goes along with puberty. It is delayed for several

>reasons, one being that a boy (or girl) showing these signs of

>development at an early age will stand out and look too different

>than his peers. It is also a time when growth speeds up - you know,

>like when you look at a teen in July (especially boys) and then see

>him again in September and it looks like he has grown several feet!

>

>Now, as Pat explained, Lupron, Zoladex, Lupron Depot, etc. are not

>associated with adrenarche which is responsible for advancing bone

>age. For that you would need to use Armidex, an aromatase

>inhibitor. This drug reduces and/or stops the production of

>estrogen, an enemy for a child with growth problems because of the

>advancement of bone age. As you know, once those growth plates

>fuse, no further growth can be obtained.

>

>Max showed signs of both puberty and adrenarche when he was in 5th

>grade, I believe. He immediately began taking Armidex and his bone

>age, which was catching up to his chronological age, began to slow

>down. As his chronological age went on, his bone age slowed down to

>the point where he is now 3 years delayed. He is 17, but his bone

>age is 14. That is great because it will give him that much more

>time to grow. (I think he is almost 5'5 " now!)

>

>Soon after starting the Armidex, Dr. H. decided to start him on

>Zoladex. Because of Max's uncontrolled and precarious anxiety at

>that time, she thought it would be a better choice than Lupron. The

>Zoladex would be placed every 86 days vs. the Lupron which would be

>painful and need to be injected every 28 days. Even though she had

>never placed the pellet herself before, we trusted her and let her,

>once again, use Max as her " guinea pig. "

>

>The medications worked very well. We happily followed the routine

>until a little over a year ago. Max at that point was in high

>school and looked like a baby compared to the huge and developed

>boys he was in school with. The decision was made to stop the

>Zoladex so that he could go into puberty and look more like his

>peers. The timing was right. Kids can be cruel and we did not want

>him teased because he still looked so young, besides being so much

>shorter than the others.

>

>But we continued to use the Armidex and we still do.

>

>Max's voice is deep, he has hairy legs, he shaves now and I know

>that his testicular development has advanced. When he was in the

>hospital last fall, I had to help him use the bathroom because he

>was too weak to go by himself and I got a good look. Man, was I

>surprised! I was actually embarrassed 'cause he looked like a MAN!

>He facial features are more sculpted, he has acne, he has muscles

>and he just looks older all around. (The acne got to the point

>where I had to take him to the doctor in August for medication. Now

>that is under control, thank goodness.)

>

>My point in all of this long message is that socially it is

>important to consider puberty and the correct time to let it

>happen. But medically it is important to keep that estrogen from

>developing too rapidly so our kids have more time to grow.

>

>You mentioned that you have seen weight gain with the increased

>Lupron dose, too. Yes, that can be a side effect, but you should

>also have him checked for Type 2 diabetes. Our kids are at risk for

>that condition and the weight gain can be a sign of that as well.

>An oral glucose tolerance test would be the thing to do for that.

>

>I hope I have helped you understand this better. It is so confusing

>and even I get mixed up every now and then. Gosh, there is so much

>to remember and to understand.

>

>Jodi Z

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Jodi - I'm barging in here - but, I want to thank you for being so

helpful and willing to offer so much information that is very much

needed for those of us who especially need a refresher now and then.

I've copied your post into a document for future reference. Hope you

don't mind. I, as many others here, are very fortunate for your

ability to explain things in such laymen terms - it's quite

refreshing. Thank you so much. And as far as forgetting things -

based on your posts - you don't strike me as the kind of person who

forgets much. That's actually very refreshing as well. There is so

much to remember and your guidance is quite reassuring.

Thanks again Jodi.

- H

> Inga,

>

> This is a tricky subject and I hope I explain my thoughts to you

in

> a clear manner. The Lupron you are using with your son is to

delay

> puberty. That means it delays the onset of facial hair, increase

in

> size of the testicles, deepening of the voice, and all the other

> stuff that goes along with puberty. It is delayed for several

> reasons, one being that a boy (or girl) showing these signs of

> development at an early age will stand out and look too different

> than his peers. It is also a time when growth speeds up - you

know,

> like when you look at a teen in July (especially boys) and then

see

> him again in September and it looks like he has grown several

feet!

>

> Now, as Pat explained, Lupron, Zoladex, Lupron Depot, etc. are not

> associated with adrenarche which is responsible for advancing bone

> age. For that you would need to use Armidex, an aromatase

> inhibitor. This drug reduces and/or stops the production of

> estrogen, an enemy for a child with growth problems because of the

> advancement of bone age. As you know, once those growth plates

> fuse, no further growth can be obtained.

>

> Max showed signs of both puberty and adrenarche when he was in 5th

> grade, I believe. He immediately began taking Armidex and his

bone

> age, which was catching up to his chronological age, began to slow

> down. As his chronological age went on, his bone age slowed down

to

> the point where he is now 3 years delayed. He is 17, but his bone

> age is 14. That is great because it will give him that much more

> time to grow. (I think he is almost 5'5 " now!)

>

> Soon after starting the Armidex, Dr. H. decided to start him on

> Zoladex. Because of Max's uncontrolled and precarious anxiety at

> that time, she thought it would be a better choice than Lupron.

The

> Zoladex would be placed every 86 days vs. the Lupron which would

be

> painful and need to be injected every 28 days. Even though she

had

> never placed the pellet herself before, we trusted her and let

her,

> once again, use Max as her " guinea pig. "

>

> The medications worked very well. We happily followed the routine

> until a little over a year ago. Max at that point was in high

> school and looked like a baby compared to the huge and developed

> boys he was in school with. The decision was made to stop the

> Zoladex so that he could go into puberty and look more like his

> peers. The timing was right. Kids can be cruel and we did not

want

> him teased because he still looked so young, besides being so much

> shorter than the others.

>

> But we continued to use the Armidex and we still do.

>

> Max's voice is deep, he has hairy legs, he shaves now and I know

> that his testicular development has advanced. When he was in the

> hospital last fall, I had to help him use the bathroom because he

> was too weak to go by himself and I got a good look. Man, was I

> surprised! I was actually embarrassed 'cause he looked like a

MAN!

> He facial features are more sculpted, he has acne, he has muscles

> and he just looks older all around. (The acne got to the point

> where I had to take him to the doctor in August for medication.

Now

> that is under control, thank goodness.)

>

> My point in all of this long message is that socially it is

> important to consider puberty and the correct time to let it

> happen. But medically it is important to keep that estrogen from

> developing too rapidly so our kids have more time to grow.

>

> You mentioned that you have seen weight gain with the increased

> Lupron dose, too. Yes, that can be a side effect, but you should

> also have him checked for Type 2 diabetes. Our kids are at risk

for

> that condition and the weight gain can be a sign of that as well.

> An oral glucose tolerance test would be the thing to do for that.

>

> I hope I have helped you understand this better. It is so

confusing

> and even I get mixed up every now and then. Gosh, there is so

much

> to remember and to understand.

>

> Jodi Z

[Guest guest]

My pleasure. Ask away at any time.

Jodi Z

> > Inga,

> >

> > This is a tricky subject and I hope I explain my thoughts to you

> in

> > a clear manner. The Lupron you are using with your son is to

> delay

> > puberty. That means it delays the onset of facial hair,

increase

> in

> > size of the testicles, deepening of the voice, and all the other

> > stuff that goes along with puberty. It is delayed for several

> > reasons, one being that a boy (or girl) showing these signs of

> > development at an early age will stand out and look too

different

> > than his peers. It is also a time when growth speeds up - you

> know,

> > like when you look at a teen in July (especially boys) and then

> see

> > him again in September and it looks like he has grown several

> feet!

> >

> > Now, as Pat explained, Lupron, Zoladex, Lupron Depot, etc. are

not

> > associated with adrenarche which is responsible for advancing

bone

> > age. For that you would need to use Armidex, an aromatase

> > inhibitor. This drug reduces and/or stops the production of

> > estrogen, an enemy for a child with growth problems because of

the

> > advancement of bone age. As you know, once those growth plates

> > fuse, no further growth can be obtained.

> >

> > Max showed signs of both puberty and adrenarche when he was in

5th

> > grade, I believe. He immediately began taking Armidex and his

> bone

> > age, which was catching up to his chronological age, began to

slow

> > down. As his chronological age went on, his bone age slowed

down

> to

> > the point where he is now 3 years delayed. He is 17, but his

bone

> > age is 14. That is great because it will give him that much

more

> > time to grow. (I think he is almost 5'5 " now!)

> >

> > Soon after starting the Armidex, Dr. H. decided to start him on

> > Zoladex. Because of Max's uncontrolled and precarious anxiety

at

> > that time, she thought it would be a better choice than Lupron.

> The

> > Zoladex would be placed every 86 days vs. the Lupron which would

> be

> > painful and need to be injected every 28 days. Even though she

> had

> > never placed the pellet herself before, we trusted her and let

> her,

> > once again, use Max as her " guinea pig. "

> >

> > The medications worked very well. We happily followed the

routine

> > until a little over a year ago. Max at that point was in high

> > school and looked like a baby compared to the huge and developed

> > boys he was in school with. The decision was made to stop the

> > Zoladex so that he could go into puberty and look more like his

> > peers. The timing was right. Kids can be cruel and we did not

> want

> > him teased because he still looked so young, besides being so

much

> > shorter than the others.

> >

> > But we continued to use the Armidex and we still do.

> >

> > Max's voice is deep, he has hairy legs, he shaves now and I know

> > that his testicular development has advanced. When he was in

the

> > hospital last fall, I had to help him use the bathroom because

he

> > was too weak to go by himself and I got a good look. Man, was I

> > surprised! I was actually embarrassed 'cause he looked like a

> MAN!

> > He facial features are more sculpted, he has acne, he has

muscles

> > and he just looks older all around. (The acne got to the point

> > where I had to take him to the doctor in August for medication.

> Now

> > that is under control, thank goodness.)

> >

> > My point in all of this long message is that socially it is

> > important to consider puberty and the correct time to let it

> > happen. But medically it is important to keep that estrogen

from

> > developing too rapidly so our kids have more time to grow.

> >

> > You mentioned that you have seen weight gain with the increased

> > Lupron dose, too. Yes, that can be a side effect, but you

should

> > also have him checked for Type 2 diabetes. Our kids are at risk

> for

> > that condition and the weight gain can be a sign of that as

well.

> > An oral glucose tolerance test would be the thing to do for

that.

> >

> > I hope I have helped you understand this better. It is so

> confusing

> > and even I get mixed up every now and then. Gosh, there is so

> much

> > to remember and to understand.

> >

> > Jodi Z

[Guest guest]

Hi Inga,

You ask such great questions......

My understanding of aromotase inhibitors is that they act independent of

Lupron and do very different things. Here is an email Dr. Stanhope wrote to

...I think he does a nice job of summarizing some of the issues with

AI and Lupron! But it is a very complex concept.

Also, do order the convention tapes!!!

Katy

From Dr. Stanhope:

Dear

Puberty is the result of gonadarche. Adrenarche is a separate

process. Puberty is the process of gonadal maturation associated with

the

acquisition of secondary sexual characteristics in a growth spurt,

resulting in fertility. Of course, adrenarche does not result in

fertility and so is nothing to do with puberty. I realise this is

probably

a difficult concept to understand. You are right about the adrenal

androgens as a marker. LH and FSH are markers of the activation of the

hypothalamic pituitary axis which results in gonadarche. However, the

initial increase in pulsatile gonadotrophin secretion (LH and FSH)

occur at

night and so these are not too useful during out-patients. Menarche is

a

late event of puberty but, of course, does not result in fertility as

usually the first 18 months or so after menarche are anovulatory

cycles.

I would consider the age-range for normal puberty to be 9.5 - 13.5

years

for girls and 10 - 14 years for boys. However, Professor Tanner showed

many years ago that bone age is not a good marker for the onset of

puberty.

What Silver syndrome children manifest is a very rapid advance

in

bone age in the middle childhood years. In my experience, this is not

usually associated with clinical features of adrenarche and so is

somewhat

mysterious. However, it has been demonstrated that children with

Silver syndrome do have an earlier puberty than would be expected, and

a

few even have precocious puberty. However, they do not get an

appropriate

growth spurt.

GnRH analogues suppress gonadotrophin secretion from the pituitary

gland. They suppress gonadarche, but have no effect on adrenarche. I

hope that makes sense. Aromatase inhibitors block the conversion of

testosterone to oestrogen so, although oestrogen concentrations usually

fall, testosterone levels may rise. As you have appreciated, the data

about aromatase inhibitors and growth are all theoretical and in the

clinical trial phase and there is very little evidence, except in boys

with

constitutional delay of growth and puberty.

You are correct in that there are numerous GnRH analogues available,

either

subcutaneously or intramuscular administration. They can be either

4-weekly or three-monthly, although the latter does not usually last

for a

full three months, and only for about 2 1/2 months.

I hope this makes sense, but it is a very complex area.

[Guest guest]

Thanks for the good info!!! I'm planning to bring this along with Jodi's

email to our endo and see about getting on an aromatase inhibitor. Sounds

pretty important for Tim, since his bone age has already passed his

chronological age, and he's 4 foot 2 inches....

Inga

At 08:37 AM 9/19/2005 -0400, you wrote:

>Hi Inga,

>

>You ask such great questions......

>

>My understanding of aromotase inhibitors is that they act independent of

>Lupron and do very different things. Here is an email Dr. Stanhope wrote to

>...I think he does a nice job of summarizing some of the issues with

>AI and Lupron! But it is a very complex concept.

>

>Also, do order the convention tapes!!!

>

>Katy

>

>From Dr. Stanhope:

>

>Dear

>

>Puberty is the result of gonadarche. Adrenarche is a separate

>process. Puberty is the process of gonadal maturation associated with

>the

>acquisition of secondary sexual characteristics in a growth spurt,

>resulting in fertility. Of course, adrenarche does not result in

>fertility and so is nothing to do with puberty. I realise this is

>probably

>a difficult concept to understand. You are right about the adrenal

>androgens as a marker. LH and FSH are markers of the activation of the

>hypothalamic pituitary axis which results in gonadarche. However, the

>initial increase in pulsatile gonadotrophin secretion (LH and FSH)

>occur at

>night and so these are not too useful during out-patients. Menarche is

>a

>late event of puberty but, of course, does not result in fertility as

>usually the first 18 months or so after menarche are anovulatory

>cycles.

>

>I would consider the age-range for normal puberty to be 9.5 - 13.5

>years

>for girls and 10 - 14 years for boys. However, Professor Tanner showed

>many years ago that bone age is not a good marker for the onset of

>puberty.

>

>What Silver syndrome children manifest is a very rapid advance

>in

>bone age in the middle childhood years. In my experience, this is not

>usually associated with clinical features of adrenarche and so is

>somewhat

>mysterious. However, it has been demonstrated that children with

>

>Silver syndrome do have an earlier puberty than would be expected, and

>a

>few even have precocious puberty. However, they do not get an

>appropriate

>growth spurt.

>

>GnRH analogues suppress gonadotrophin secretion from the pituitary

>gland. They suppress gonadarche, but have no effect on adrenarche. I

>hope that makes sense. Aromatase inhibitors block the conversion of

>testosterone to oestrogen so, although oestrogen concentrations usually

>fall, testosterone levels may rise. As you have appreciated, the data

>about aromatase inhibitors and growth are all theoretical and in the

>clinical trial phase and there is very little evidence, except in boys

>with

>constitutional delay of growth and puberty.

>

>You are correct in that there are numerous GnRH analogues available,

>either

>subcutaneously or intramuscular administration. They can be either

>4-weekly or three-monthly, although the latter does not usually last

>for a

>full three months, and only for about 2 1/2 months.

>

>I hope this makes sense, but it is a very complex area.

>