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Cross Genotype Sex Hormone Treatment in Two Cases of Hypogonadal Osteoporosis

Pediatric Endocrinology Unit, Institute of Endocrinology, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Address correspondence and reprint requests to: Professor Joseph Sack, Department of Pediatrics, Sheba Medical Center, Tel-Hashomer, 52621 Israel. Email: Igork@cc.huji.ac.il

Background: Sex hormone deficiency is the most common cause of bone loss. Reduced bone mass and an increased risk for osteoporotic fractures have been described in hypogonadal subjects of both sexes. We present here the results of treating two patients showing abnormal sexual differentiation (an XX male and an XY female), who suffered from bone loss related to sex hormone deficiency, with cross genotype sex hormones.

Subjects and Methods: Patient 1 was an asymptomatic 39-yr-old XY female with complete androgen insensitivity. Her testes had been removed, and she later discontinued estrogen treatment. Patient 2, a 37-yr-old XX male, had congenital adrenal hyperplasia, which led to a masculine phenotype. He was ovariectomized and reared as a male. He was treated with glucocorticoids but refused androgen treatment for many years. We treated both patients with phenotypically matched sex hormones (patient 1 received conjugated estrogens 1.25 mg/day, and patient 2 received 250 mg testosterone every 4 weeks) and followed their bone mineral density (BMD) using dual-energy X-ray absorptiometry, urine calcium, and hydroxyproline excretion.

Results: Before treatment both patients had low sex hormones and highly elevated gonadotropins. As a result of treatment urine hydroxyproline excretion decreased from 45 and 26.7 mg/g creatinine to 15 and 15.9 mg/g creatinine in patients 1 and 2 respectively. In patient 1, lumbar BMD rose from 0.912gr/cm² to 0.976gr/cm² and femoral neck BMD rose from 0.716gr/cm² to 0.836gr/cm² after 4 years of treatment. In patient 2, lumbar BMD rose from 0.717gr/cm² to 0.815gr/cm² and the femoral neck BMD rose from 0.509gr/cm² to 0.635gr/cm² after 27 months of treatment.

Conclusions: Phenotypically-matched sex hormone therapy in patients with abnormal sexual differentiation is essential not only to maintain external appearance but also for the preservation of bone mass.