Delayed Puberty and Incidental Hypertension in a 14-year-old Girl

A previously well 14-year-old Chinese girl from Singapore presents with lack of pubertal development (absence of breast development, no vaginal discharge, no menarche, and no pubic or axillary hair development). She does not complain of any neurologic or constitutional symptoms. Her appetite remains normal. There is no polydipsia, polyuria, polyphagia, or symptoms of thyroid disease. She is the only child of nonconsanguineous parents. There is no family history of endocrinopathies or delayed puberty. Her mother had her menarche at 12 years old.Examination reveals a nondysmorphic prepubertal girl (Tanner stage 1 for both breast and pubic hair development). Her height and weight are at the 50th to 75th percentile (62.6 in [159 cm]) and 10th to 25th percentile (98.3 lb [44.6 kg]), respectively, and her BMI is at the 10th to 25th percentile (17.6). Her midparental height is 64.4 in (163.5 cm), which is at the 50th percentile for an adult female. Her blood pressure is high at 166/126 mm Hg, with a heart rate of 90 beats/min. There is a single urethral opening and an infantile labia with a small clitoris. There is no vaginal opening visualized and no palpable gonads. No skin hyperpigmentation is seen. The rest of her systemic examination findings are normal.Initial biochemical analysis reveals hypokalemic metabolic alkalosis and hypergonadotropic hypogonadism (Table 1). Transabdominal pelvic ultrasonography (Fig 1) reveals a blind-ending vaginal pouch with absence of Müllerian structures and inability to visualize gonads. Subsequent evaluation with pelvic magnetic resonance imaging (MRI) shows two intra-abdominal gonads adjacent to the external iliac vessels (Fig 1) with uterine agenesis. Her bone age is delayed at 7 years 10 months old. Anti-Müllerian hormone level is also elevated, indicating the existence of testicular tissue with functional Sertoli cells.Chromosomal analysis shows a karyotype of 46,XY, with a single SRY gene detected in region Yp11.2 on in situ hybridization. Further evaluation with serum steroid analysis via liquid chromatography–tandem mass spectrometry (LC-MS/MS) reveals the working diagnosis.Delayed puberty refers to the lack of pubertal changes by a defined age cutoff, or failure of appropriate progression after puberty has begun. (1) In girls, this is indicated by the absence of breast development (thelarche) by age 13 years or failure to attain menarche by age 15 years or within 4 years after thelarche. Adequate functioning of the hypothalamic-pituitary-gonadal axis (Fig 2) is essential for normal pubertal development, including gonadal maturation and subsequent sex steroid production. Any deficiency at the hypothalamic-pituitary-gonadal axis can result in hypogonadism, leading to delayed or absent puberty.A systematic clinical approach (detailed history, accurate anthropometric measurement, and thorough physical examination) is important for establishing a diagnosis in a girl with delayed puberty (Fig 3). The initial evaluation usually includes plasma gonadotropin levels and estradiol levels, as well as obtaining a bone age radiograph. Additional tests may be necessary depending on the working diagnosis, such as MRI of the brain or pituitary fossa, chromosomal analysis, or molecular genetic analysis.Constitutional delay of growth and puberty, the most common cause of delayed puberty in girls (30% of female patients), followed by hypogonadotropic hypogonadism (29%) and hypergonadotropic hypogonadism (26%), (2) is a variant of normal growth in which puberty begins spontaneously at a later-than-typical age and progresses normally thereafter. (3) It is caused by individual genetic variations and tends to have familial patterns of inheritance.Hypergonadotropic hypogonadism, or primary hypogonadism, is characterized by primary gonadal failure (low levels of gonadal steroids) that stimulates the hypothalamus to produce more gonadotropin-releasing hormone, leading to high concentrations of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Hypergonadotropic hypogonadism can be due to ovarian damage secondary to chemotherapy (alkylating agents), radiotherapy, surgery, or autoimmunity. It can also be due to differences in sex development (DSDs), which include sex chromosomal DSDs as in Turner syndrome and 17α-hydroxylase deficiency (17OHD) congenital adrenal hyperplasia.Hypogonadotropic hypogonadism, also called secondary or central hypogonadism, is characterized by low levels of gonadotropin-releasing hormone, LH, and FSH, which lead to low levels of gonadal steroids. It can be due to functional causes secondary to chronic systemic diseases or states of caloric deficiency such as restrictive eating disorders. Central nervous system pathologies, including neoplastic, infiltrative, infective, and traumatic causes, can result in gonadotropin deficiency. Congenital central causes include genetic syndromes such as CHARGE (coloboma, congenital heart disease, choanal atresia, intellectual disability, growth retardation, genital anomalies, ear malformations, and hearing loss), Prader-Willi, and congenital isolated hypogonadotropic hypogonadism, classified into anosmic (Kallmann syndrome) and normosmic variants.Complete gonadal dysgenesis is the most likely diagnosis in a 46,XY phenotypically female patient presenting with hypergonadotropic hypogonadism. Disorders of androgen synthesis, such as Leydig cell hypoplasia and 17OHD should be considered as well.Further evaluation with serum steroid analysis via LC-MS/MS was performed. The analyte results (Table 2) revealed raised 11-deoxycorticosterone levels (419.5 ng/dL [12.7 nmol/L]) (reference range, <30 ng/dL [<0.91 nmol/L]), with low to undetectable values for cortisol, 11-deoxycortisol, 21-deoxycortisol, dehydroepiandrosterone sulfate, androstenedione, and 17-hydroxyprogesterone. The total testosterone level was low (<11.5 ng/dL [<0.4 nmol/L]). A cosyntropin (corticotropin) stimulation test confirmed undetectable cortisol levels (<1.015 µg/dL [<28 nmol/L]) at all time points. Plasma renin activity was low (<0.6 ng/mL per hour) (reference range, 1.2–2.4 ng/mL per hour) and serum aldosterone level was not elevated (<4 ng/dL [<110.96 pmol/L]) (reference range, ≤21 ng/dL [<582.54 pmol/L]). These results, together with her clinical presentation, were consistent with a diagnosis of 17OHD.17OHD is rare, accounting for 1% of all cases of congenital adrenal hyperplasia, with an estimated incidence of 1 in 50,000 newborns. (4) It is caused by mutations in the CYP17A1 gene located on chromosome 10q24.3, which typically result in combined 17α-hydroxylase and 17,20-lyase deficiency (commonest form of 17OHD). This gene mutation can also cause isolated 17,20-lyase deficiency, (5) an extremely rare form of 17OHD that causes ambiguous genitalia in 46,XY without hypertension or hypokalemia.17OHD is a 46,XY DSD that causes defective biosynthesis of glucocorticoids and androgens, concurrently driving massive overproduction of mineralocorticoids (Fig 4). The impairment of fetal androgen production due to 17OHD leads to undervirilization and phenotypically female external genitalia at birth. (6) Anti-Müllerian hormone causes regression of Müllerian structures, together with low estrogen levels, leading to underdevelopment or absence of the upper part of the vagina. The affected patients have phenotypically female features and usually present with absent pubertal changes and hypertension with hypokalemic metabolic alkalosis at later ages. This is due to excess production of 11-deoxycorticosterone and corticosterone, which exert mineralocorticoid effects, causing sodium retention, potassium excretion, and volume expansion. These changes cause negative feedback to the renin-angiotensin system, leading to low plasma renin activity and serum aldosterone. The affected patients are usually cortisol-deficient. Despite the low levels of cortisol, they rarely develop adrenal crisis due to glucocorticoid activity exerted by the elevated corticosterone level. (6)(7)For adolescent girls without any signs of puberty and pubarche, associated with hypertension and hypokalemia, the initial evaluation should include a hormone panel (FSH, LH, estradiol) and a steroid analysis for the consideration of a simultaneous defect in adrenal steroidogenesis. Ultrasonography or MRI of the pelvis can be used to identify the presence or absence of Müllerian structures, followed by chromosomal analysis to identify the karyotype and SRY genes.LC-MS/MS and gas chromatography–mass spectrometry can provide extensive information on steroid profile and biochemistry to establish the diagnosis of congenital adrenal hyperplasia. Both of these methods have high analytical specificity. (8) LC-MS/MS enables a broader and more targeted analysis of steroid hormones, offering faster turnaround times and the benefits of an automated process. Gas chromatography–mass spectrometry, on the other hand, has superior separation capacity and minimal matrix effects, making minor variations in complex evolving metabolomes detectable. (8)The role of molecular genetic analysis is becoming increasingly established and essential in recent years to diagnose patients with 46,XY DSDs. (9) Specific genomic testing can be used to identify the causative variants. The benefits of genetic testing are unequivocal, allowing informed conversations with the patient and family about lifetime gonadal germ cell tumor risk, fertility, and genetic counseling. On the other hand, rapid turnaround time for biochemical evaluation of steroid metabolites may allow the clinician to discern the most likely cause and hence most appropriate targeted genetic test to order for the patient. For example, in the present patient, a targeted genetic analysis of the CYP17A1 gene should be the next appropriate diagnostic step.Individuals with 17OHD should be managed by an experienced multidisciplinary team (10) consisting of an endocrinologist, geneticist, urologist, psychologist, subspecialty resource nurse, and social worker. Reaching a timely and accurate diagnosis is important for acute and long-term management planning. It may shed light early on diagnostic uncertainties, potentially reducing psychosocial distress for the patient and family. Corticosteroid replacement in 17OHD also serves to control hypertension through a negative feedback response on corticotropin, thereby reducing onward synthesis of 11-deoxycorticosterone. Combination of corticosteroid replacement with mineralocorticoid receptor antagonist treatment minimizes the risk of adrenal axis suppression. For prepubertal patients who ultimately choose to maintain a female gender identity, estrogen replacement is used for pubertal induction and development of female sexual characteristics. Gonadectomy is recommended due to an intermediate malignant transformation risk. It can be performed either as a single procedure with a laparoscopic approach or as a staged removal with a biopsy of the gonads first, followed by their removal and a vaginoplasty. Psychosocial stress should be addressed, and early referral to a psychologist and a social worker is paramount.The patient was initially started on amlodipine 5 mg every morning to control her hypertension. Amlodipine was taken off when physiologic hydrocortisone (HC) replacement (10 mg every morning, 5 mg every afternoon, 5 mg every evening) was started after the diagnosis of 17OHD was made. Her family was not interested in pursuing molecular genetic testing. She was discharged with outpatient follow-up after controlling her blood pressure. HC dose was subsequently titrated up during a clinic visit to 10 mg every morning, 10 mg every afternoon, and 5 mg every evening (16.2 mg/m2 per day), and spironolactone 25 mg twice a day (0.5 mg/kg per day) was added for hypertension control. Her gender identity was affirmed as female, and pubertal induction with estrogen was commenced, starting with 0.25 mg of oral estradiol per day, titrating up to 1 mg once daily at subsequent follow-up clinic visits.The patient was reviewed at the pediatric endocrinology clinic at 3-month intervals for titration of the medications and monitoring of blood pressure. It had been 17 months since initial diagnosis and her breast development progressed to Tanner stage 3 with estradiol replacement. Her blood pressure was well-controlled, and she was not cushingoid with the current HC replacement dose (16.2 mg/m2/day).When dealing with patients with DSDs and their families, it is crucial to approach discussions regarding the underlying diagnosis and its long-term implications with sensitivity and thoughtfulness. Providing clear and accurate information in an age-appropriate manner, tailored to the patient’s and family’s level of understanding and maturity, is important.The initial discussion with the family and patient centered around the 17OHD synthesis defect and its treatment. Sufficient time was afforded to them to adapt to the new diagnosis. This was followed by a comprehensive discussion on the patient’s pubertal development, sexual health, and long-term implications. The family faced considerable distress arising from diagnosis and psychosocial issues related to medical and surgical management. These include the need for long-term HC replacement, plans for gonadectomy, and the inability to bear her own children. Psychosocial support and counseling hold equal significance to medical treatment. Self-confidence, social stigmatization, future romantic relationships, and sexual functioning are critical areas that need to be actively assessed for and addressed accordingly.However, the family declined psychology input and genetic assessment at the last clinic review. The plan is to continually present the importance of involving a psychologist and social worker to the family so that they can be better supported and to revisit genetic testing when they are ready and comfortable to, thereby respecting their autonomy.It is important to use a systematic approach in diagnosing the etiology of delayed puberty.Establishing whether delayed puberty is hypergonadotropic or hypogonadotropic is an important step in determining subsequent investigations.In girls presenting with delayed puberty associated with hypertension and hypokalemia, consider steroid analysis, in addition to follicle-stimulating hormone, luteinizing hormone, and estradiol levels, to evaluate for a possible defect in adrenal steroidogenesis, such as in 17α-hydroxylase deficiency.The use of liquid chromatography–tandem mass spectrometry as a second-tier test to analyze steroidogenesis metabolites (glucocorticoids, mineralocorticoids, and androgens) is helpful to diagnose the subtypes of congenital adrenal hyperplasia, especially in late and nonclassical presentations, and in cases where genetic testing is not feasible or accessible.Individuals with 17α-hydroxylase deficiency should be optimally managed by an experienced multidisciplinary team.