demonstrated that it prevents infertility and recurrent miscarriages [61].
Table 1. Management of patients with classic CAH during transition and adulthood
| Knowledge goals for patients with CAH in transition –Understand that CAH is a lifelong disease that is genetically inherited –Understand the medication regimen, be able to self-manage stress doses of glucocorticoid during illness, including self-administration of parenteral hydrocortisone –Knowledge of surgical history and physical implications for women –Knowledge of infertility risks but also that fertility and satisfying sexual experiences can be achieved |
| Monitoring of the efficacy of glucocorticoid replacement therapy –Early-morning serum concentrations of 17-OHP, Δ4-androstenedione, total testosterone, SHBG approximately every 6 –12 months –Diurnal 17-OHP curve with dried blood spots if available |
| Monit oring of the efficacy of mineralocorticoid replacement –Blood pressure –Plasma electrolytes –Early-morning plasma renin activity concentration |
| Periodic measurements and/or monitoring of the following –Weight –Lipid profile –Blood pressure –Glycemia –Bone mineral density |
| Assessment of male gonadic function and fertility –Testicular adrenal rest by ultrasonography –Sperm analysis –Fertility preservation –Hormonal measurements: total testosterone, LH, FSH |
| Assessment of female gonadic function and fertility –Gynecological care –Clinical and biological hyperandrogenism, menstrual cycle –Sexuality –Hormonal measurements: progesterone, estradiol, FSH |
| Genetic counseling |
| Psychological support |
| CAH, congenital adrenal hyperplasia; 17-OHP, 17-hydroxyprogesterone; SHBG, sexual hormonebinding globulin; LH, luteinizing hormone; FSH, follicle-stimulating hormone. |
At last, considering that 1 mutation responsible for classic CAH is found in nearly 60% of the patients with nonclassic CAH [5, 62], and the high rate of heterozygotes for CYP21A2 mutations in the general population, it is essential to genotype the partner of nonclassic CAH patients carrying a severe mutation, to predict the risk of classic CAH in the offspring and offer genetic counseling [5, 62]. Therefore, transition from pediatric to adult care is also important and warranted in women with nonclassic CAH diagnosed during childhood.
Conclusions
Patients with CAH must experience a transition from pediatric to adult care, because it is a chronic disease with the need of a specific treatment and the risk of various long-term complications. Transition of adolescents to adult care involves changes in treatment goals. Careful monitoring, extensive education, and long-term follow-up should be required for patients with CAH. Optimal management of adults with 21-OHD can be achieved through a multidisciplinary approach. Future prospective studies designed specifically to examine the long-term effects of a successful transition of CAH patients are needed.
Case History
Salt-losing CAH due to 21-OHD was diagnosed in a female infant born with masculinization of her external genitalia (Prader III). She was compound heterozygous with an IVS2 splice mutation and a large lesion of the CYP21A2 gene. Medical treatment with GC and MC replacement was initiated. At 6 months of age, the patient underwent surgical reconstruction, including vaginoplasty. The patient has a regular follow-up and is doing well with GC and MC replacement therapy. She had regular linear growth at –0.5 SD. Breast development started at the age of 12 years and menarche at the age of 14, with regular menstrual cycles, without acne or hirsutism. The final height was 1.67 m for a target height at 1.69 m. The first gynecological evaluation was performed at the age of 15. Only a mild clitoromegaly was noted. She was referred to an adult endocrinologist at the age of 18. Her mother accompanied her for the first consultation. Compliance to replacement therapy was good, but the treatment was managed by her mother. The patient had understood that CAH is a genetically inherited lifelong disease, requiring long-term medication and follow-up. She was unable to self-manage stress doses of GC during illness, including self-administration of parenteral hydrocortisone. She did not know exactly about her surgical history and its physical implication. She presented a normal body mass index of 19.4, regular menstrual cycles, and mild acne. Hormonal assessment showed a good hormonal control of the disease. BMD showed a T score at –1.2 SD at the lumbar level and –1.4 SD at the femoral level. She was included into specific programs of therapeutic education on transition and CAH: the pediatric history was recalled, with a specific highlight on surgery, specific goals of medical management of CAH in adulthood were explained, sexuality and fertility were discussed, and autonomy was assessed. She had an appointment with a gynecologist and the psychologist of the department.
During the follow-up, autonomy improved gradually. At the age of 19, she came alone to her medical appointment and was able to self-manage her treatment. This led to a transient period of poor hormonal control with irregular menstrual cycles and occurrence of hirsutism. The parents were worried about this and contacted the adult endocrinologist, but the compliance resumed quickly. At the age of 20, she began her sexual life and took combined oral contraception. Sexual intercourse was reported by the patient as satisfying. Regular follow-up showed a stabilization of BMD. At the age of 28, she came with her boyfriend to discuss their family plans and have genetic counseling. Her boyfriend did not carry mutations of the CYP21A2 gene. Optimized GC and MC regimes during fertility monitoring resulted in a spontaneous pregnancy. She delivered a healthy term newborn.
1.During transition, it is important to understand that CAH is a lifelong disease that is genetically inherited.
2.The importance of a multidisciplinary follow-up throughout life and of treatment adherence should be emphasized.
3.The patient has to be able to self-manage treatment.
4.Regular monitoring of the efficacy of GC and MC replacement therapy, as well as periodic measurements and/or monitoring of weight, BMD, and CV risk factors should be carried out.
5.On a regular basis, gonadic function, sexuality, and fertility should be assessed.
6.Genetic counseling is warranted.
7.Psychological support is also necessary.
References
1Auchus RJ: The classic and nonclassic congenital adrenal hyperplasias. Endocr Pract 2015;21:383–389.
2Merke DP, Bornstein SR: Congenital adrenal hyperplasia. Lancet 2005;365:2125–2136.
