Advice in ABC of adolescence is potentially misleading
http://www.100md.com
《英国医生杂志》
EDITOR—Christie and Viner say that delayed puberty in boys can be quite distressing but is almost always a normal variant.1 They say that boys aged 15 or over with a testicular volume of 4 ml or more can be reassured that puberty is beginning and, by inference, do not require referral to a specialist. This advice is potentially misleading.
For all that it is a variant of normality, constitutional delay in growth and puberty can have adverse psychosocial and skeletal consequences.2-4 To deny an apubertal teenager the opportunity to choose low dose androgen treatment until he is into his 16th year would be unusual by present standards. Given the likely ensuing timescale, his doctor might as well refer him straight to an endocrinologist instead of a paediatrician.
A testicular volume of 4 ml is well within the range found in boys with irreversible hypogonadotrophic hypogonadism and therefore by no means necessarily indicates that puberty is beginning. Many boys with hypogonadotrophic hypogonadism start puberty but fail to progress beyond the early stages.5 Moreover, a history of cryptorchidism (especially if bilateral) or anosmia should prompt an even earlier referral.4 Neither does a family history of pubertal delay necessarily support a diagnosis of constitutional delay in growth and puberty, given the high prevalence of constitutional delay in growth and puberty among first degree relatives of patients with hypogonadotrophic hypogonadism.
A recurring theme in the personal stories posted on the www.Kallmanns.org website by men with irreversible hypogonadotrophic hypogonadism is of just how difficult it was for them as teenagers to screw up the courage to go to see their family doctor about a lack of secondary sexual characteristics. On being told "not to worry, because it's only pubertal delay," many felt (or were made to feel) so crushed and foolish that they then put off seeing a doctor until many years later.
Richard Quinton, consultant endocrinologist
Royal Victoria Infirmary, Newcastle on Tyne NE3 2NJ richard.quinton@nuth.nhs.uk
Competing interests: None declared.
References
Christie D, Viner R. ABC of adolescence: Adolescent development. BMJ 2005;330: 301-4. (5 February.)
Skuse D. The psychological consequences of being small. J Child Psychol Psychiat 1987;28: 641-50.
Crowne EC, Shalet SM, Wallace WH, Eminson DM, Price DA. Final height in boys with untreated constitutional delay in growth and puberty. Arch Dis Child 1990;65: 1109-12.
Finkelstein JS, Klibanski A, Neer RM. A longitudinal evaluation of bone mineral density in adult men with histories of delayed puberty. J Clin Endocrinol Metab 1996;81: 1152-5.
Quinton R, Duke VM, Robertson A, Kirk JMW, Matfin G, de Zoysa PA, et al. Idiopathic gonadotrophin deficiency: genetic questions addressed through phenotypic characterisation. Clin Endocrinol 2001;55: 163-74.
For all that it is a variant of normality, constitutional delay in growth and puberty can have adverse psychosocial and skeletal consequences.2-4 To deny an apubertal teenager the opportunity to choose low dose androgen treatment until he is into his 16th year would be unusual by present standards. Given the likely ensuing timescale, his doctor might as well refer him straight to an endocrinologist instead of a paediatrician.
A testicular volume of 4 ml is well within the range found in boys with irreversible hypogonadotrophic hypogonadism and therefore by no means necessarily indicates that puberty is beginning. Many boys with hypogonadotrophic hypogonadism start puberty but fail to progress beyond the early stages.5 Moreover, a history of cryptorchidism (especially if bilateral) or anosmia should prompt an even earlier referral.4 Neither does a family history of pubertal delay necessarily support a diagnosis of constitutional delay in growth and puberty, given the high prevalence of constitutional delay in growth and puberty among first degree relatives of patients with hypogonadotrophic hypogonadism.
A recurring theme in the personal stories posted on the www.Kallmanns.org website by men with irreversible hypogonadotrophic hypogonadism is of just how difficult it was for them as teenagers to screw up the courage to go to see their family doctor about a lack of secondary sexual characteristics. On being told "not to worry, because it's only pubertal delay," many felt (or were made to feel) so crushed and foolish that they then put off seeing a doctor until many years later.
Richard Quinton, consultant endocrinologist
Royal Victoria Infirmary, Newcastle on Tyne NE3 2NJ richard.quinton@nuth.nhs.uk
Competing interests: None declared.
References
Christie D, Viner R. ABC of adolescence: Adolescent development. BMJ 2005;330: 301-4. (5 February.)
Skuse D. The psychological consequences of being small. J Child Psychol Psychiat 1987;28: 641-50.
Crowne EC, Shalet SM, Wallace WH, Eminson DM, Price DA. Final height in boys with untreated constitutional delay in growth and puberty. Arch Dis Child 1990;65: 1109-12.
Finkelstein JS, Klibanski A, Neer RM. A longitudinal evaluation of bone mineral density in adult men with histories of delayed puberty. J Clin Endocrinol Metab 1996;81: 1152-5.
Quinton R, Duke VM, Robertson A, Kirk JMW, Matfin G, de Zoysa PA, et al. Idiopathic gonadotrophin deficiency: genetic questions addressed through phenotypic characterisation. Clin Endocrinol 2001;55: 163-74.