Talk:Kallmann syndrome/Archive 1

Archive 1

Kallmann's

Kallmann's syndrome is a rare hormonal condition that is chiefly characterised by a failure of a boy or girl to enter puberty at the required time.

It is a form of hypogonadotrophic hypogondasim (HH). In essence this means that the hormonal control of the development of puberty from the brain has been disrupted. The testes or the ovaries do not get the required signals to start puberty so the person will remain in the pre-puberty state. Kallmann's syndrome is HH in addition to having a no sense of smell.

I was diagnosed late with this condition (aged 24) after years of being told to go away and wait and see by doctors, being dismissed as a late developer.

This condition is very under diagnosed and is not even known by a lot of doctors. No boy aged 15 or girl aged 14 should ever be dismissed as a late developer, thet should always be referred to an endocrinologist.

The pyschological damage of being left behind your own peer group can in some cases be immense, and affect the person for the rest of their lives. However with early diagnosis and treatment the condition is easily controlled.

Treatment is available ot replace the missing hormones that should have been produced by the testes or ovaries since puberty. There are also fertility treatments avaialble, which work for a fair percentage of people with Kallmann's or HH.

If left undiagnosed and untreated a person will not produce the required levels of testosterone or oestrogen. They will very likely be infertile and run a hight risk of developing the condition osteoporosis, or brittle bone disease.

For more information go to:

[1]Information web site

There is also a e-mail forum on Yahoo which can be helpful:

[2]Yahoo e-mail forum Neilsmith38 12:17, 5 September 2006 (UTC)

Reversions to text

I have reverted recent edits which converted the name Kallmann syndrome to Kallmann's syndrome. The NIH and WHO have adopted guidelines for eponymous syndromes which removes the possessive naming convention. Thus, Down's syndrome becomes Down Syndrome, Kallmann's syndrome becomes Kallmann syndrome, etc. I have also removed some unreferenced additions such which should be replaced by referenced statements (such as the line stating that "Most specialists now agree that any girl aged 13 or boy aged 15 who has not shown the initial stages of puberty should be referred to an endocrinologist for evaluation." I could find no evidence to support this statement through AAP, several Endocrinologic Societies, and pubmed. In fact, especially for boys, the typical age for diagnosis of delayed puberty is 14 years, not 13. InvictaHOG 21:00, 5 September 2006 (UTC)

I quite appreciate your revision, but the age of diagnosis of delayed puberty comes from one of the leading Kallmann syndrome specialists here in the UK. In a letter to the British Medical Journal:

[3]

He highlights the problems of the late diagnosis of Kallmann syndrome and suggests that cases of delayed puberty at the age of 15 should be referred to an endocrinologist.

All the statements I put do come from conversations I have with specialists over in the UK, and by reading the published medical papers. I will try to link any statement to a specific medical paper in future. Neilsmith38 23:03, 5 September 2006 (UTC)

On further reading I am a little concerned that you took out the statement referring to anosmia and cryptorchidism in conjunction being a good indicator towards Kallmann syndrome. I believe this to be a fair comment. I will access a recent paper and publish a link to it.

I think there could be some changes to the epidemiology section, there are autosomal recessive genes linked to Kallmann syndrome now, most notably the GPR-54 gene on chromosome 19 and the KISS peptide gene on chromosome 1. There was a very good article in New Scientist on this very matter, as the puberty regulation genes. If I can get some references together I may do an edit if this is acceptable.

I do this in a good natured way, I have no wish to argue with anybody, I just want to make sure there is good information on the web. Neilsmith38 23:17, 5 September 2006 (UTC)

I agree - I didn't intend to take out the cryptorchidism, it's just that it was pretty much covered elsewhere. Perhaps I could have just better incorporated it. The article needs a lot of work and I certainly invite you to improve it! The autosomal recessive genes should be added with a discussion (one OMIM page with references is Online Mendelian Inheritance in Man (OMIM): 244200). As for the age of delayed puberty, it might be best to reword it to 14 for boys and, instead of a recommendation for referral, simply stating that a work-up should be initiated (ie a pediatric endocrinologist is not needed until a diagnosis is made!) InvictaHOG 00:11, 6 September 2006 (UTC)

External links

External links on Wikipedia are supposed to be "encyclopedic in nature" and useful to a worldwide audience. Please read the external links policy (and perhaps the specific rules for medicine-related articles) before adding more external links.

The following kinds of links are inappropriate:

• Online discussion groups or chat forums
• Personal webpages and blogs
• Multiple links to the same website
• Fundraising events or groups
• Websites that are recruiting for clinical trials
• Websites that are selling things (e.g., books or memberships)

I realize that some links are helpful to certain users, but they still do not comply with Wikipedia policy, and therefore must not be included in the article. WhatamIdoing (talk) 06:39, 17 January 2008 (UTC)

Kallmann syndrome was described in 1944 by Franz Josef Kallmann, a German-American geneticist.[1][2] However, others, such as the Spanish doctor Aureliano Maestre de San Juan in 1856, had noticed a correlation between anosmia and hypogonadism.[citation needed

Citation: DeGroot Endocrinology Textbook, 5th edition, page 3162 — Preceding unsigned comment added by 77.84.6.22 (talk) 18:09, 5 December 2011 (UTC)

unsourced material

There is substantial content here that has no supporting references, thus violating the principle that entries need to be verifiable (accurate and derived from reliable sources) The relevant sections were tagged some 6 months ago, which is plenty of time for them to have been revised in line with policy. I can see no reason why these sections should not be deleted. - MishMich - Talk - 22:10, 22 October 2011 (UTC)

I have only just noticed my two additional sections have been deleted.

I can see why you deleted the two sections but they were written clearly defined as from a patient's point of view. It is difficult to see how I can get them verified from external sources when they come from extensive personal experience in dealing with this rare condition and talking to and meeting others with the condition. I could cite other websites and blogs with the same information, but on the whole they are written by me which would defeat the object of citing them as references.

I think those two sections contained useful information for people with KS / HH, especially with mentioning my own experiences with the condition. If I can find an addtional source for the information I will try to post the information again. Neilsmith38 (talk) 21:24, 27 May 2012 (UTC)

Updates.

I would like to update this page a bit more in the next few weeks, when I get the time.

The treatment section needs expanding.

My sections on "a patients' view of KS" and "living with KS" were removed due to lack of sources, I will try to put them in again as I think they are important for people with the condition. As a patient with this condition with a lot of experience in talking and meeting other people with the condition I think they are important sections to have in.

Neilsmith38 (talk) 22:35, 17 June 2012 (UTC)

Layman's view

This article is a bit on the technical side at the moment. Certainly no information should be removed, but we might want to include some text on the manifestations, effects, and social significance of KS in terms easily understood by the average audience without further research. I am not equipped to do this myself, but it's something we should keep in mind for the future of this article. 65.190.92.233 (talk) 08:10, 17 June 2008 (UTC)

I think you should talk more about GNRH as treatment, it is not available in the us except as a diagnostic test, which i had once before. should have a source for this line: "For both men and women, an alternative method (but not widely available), is the use of an infusion pump to provide GnRH (or LHRH) in pulsatile doses throughout the day. This stimulates the pituitary gland to release natural LH and FSH in order to activate testes or ovaries."

gnrh should be avaialable, yes for females clomid, hcg, hmg, have all worked, but when they don't gnrh can. — Preceding unsigned comment added by Jtmoy19607 (talk • contribs) 00:35, 6 December 2012 (UTC) →

Shortend fourth metacarspal bone

I came across that; a shortend fourth metacarspal bone can be a symptom of Kallmann syndrome. I found it a Danish medical textbook (a highly regarded one). Can anybody confirm this? And secondly does anybody have a better source for this claim (it is not always popular to use non-english sources)? I have already added a sentence about it in fourth metacarpal bone. If this is incorrect please feel free to remove it, since I know nothing about Kallmann syndrome. JakobSteenberg (talk) 20:04, 18 March 2013 (UTC)

Some Further Issues

The section "A Patient's Perspective" states: "Outwardly there is nothing striking about a person with Kallmann syndrome. They will not look any different from anybody else, and come in all different shapes and sizes". This contradicts established sources and even earlier points in the same article. A person affected by the condition will lack secondary sexual characteristics such as a beard in men or breasts in women. Perhaps teh author is referring to someone who has already received treatment?

Under "Epidemiolgy" it states: "It is believed to be five times more common in males than females but there is no obvious genetic reason for this, even though two of the associated gene defects occur on the x-chromosome." Surely the fact that one of the main causes is x-linked recessive is a factor in this condition being more prevalent among men? I would argue that the x-chromosome recessive defects most definitely are a factor in Kallmann being more common in men. The US National Insitutes of Health (NIH) would appear to agree:

"Kallmann syndrome 1 (caused by KAL1 mutations) has an X-linked recessive pattern of inheritance. The KAL1 gene is located on the X chromosome, which is one of the two sex chromosomes. In males (who have only one X chromosome), one altered copy of the gene in each cell is sufficient to cause the condition. In females (who have two X chromosomes), a mutation must be present in both copies of the gene to cause the disorder. Males are affected by X-linked recessive disorders much more frequently than females." NIH Kallmann Page

I've also edited a number of typos on the page.

Marchino61 (talk) 02:20, 11 September 2013 (UTC)

......The x-linked recessive form of Kallmann Syndrome accounts for less than 10% of all known cases of KS. It is certainly not one of the main causes on the basis of current knowledege of the genetics of KS / CHH. There are now 16 separate gene mutations that have been implicated in causing KS / CHH and only two of them are found on the x-chromosome. These mutations cover all forms of inheritance. KS is not at present primarily a x-linked recessive disorder so it is still fair to say that the gender imbalance is unexplained.

Since still around of 50% of KS / CHH cases have an unknown genetic origin it is quite possible that there is a yet to be discovered gene / allele on the x-chromosome that can be shown to cause KS / CHH which would explain the gender imbalance but at present I think it is a fair comment to say that the imbalance is still unexplained.

References

Neilsmith38 (talk) 11:05, 11 September 2013 (UTC)Neil Smith.

I see your point about the part in a "Patient's Perspective". What I had intended to say is that in normal circumstances, ie fully clothed and not in an intimate situation, it is not possible to tell if a person has KS or not. A lot of people I meet with KS feel that everybody somehow knows they have they condition just by the way they act around people. This is obviously not the case, but it is how some patients with KS think. I will have to re-word that part. Also due ot the fact that KS / CHH does not produce the same range of symptoms in all people and some do go through a partial puberty it is not always clear at first glance even when intimate if a person has the condition or not.

Thank you for the edits. I tend to use UK style spelling throughout as that is where I am writing from so I have changed them back but kept everything else. I hope you do not mind me changing it back to UK spelling but it is just they way I am used to and will keep updating this article when I can.

Neilsmith38 (talk) 12:19, 11 September 2013 (UTC)

Neil, I found a mixture of UK and US spellings on the page. I was not sure whether to go US or UK, but I felt the majority of spellings were US, and thus I chose that for a consistent style. These are examples of US spellings I found when I edited the page:luteinizing hormone (UK: luteinising), amenorrhea (UK: amenorrhoea). Although these are only two examples, they both appear very frequently throughout the page. Would you like to change them to the UK spellings?

Also it seems to me fairly easy to see, even when clothed, if a man has KS (or other health problem) by his lack of a beard. And the lack of breasts would be quite noticeable on a woman, though I know some are naturally small-breasted.

I was also wondering about the large numbers of mentions of HH or "KS/HH" on the page. It kind of makes it hard to read. Have you considered making a general HH page, with perhaps a separate page on KS to point out the specifics of that sub-class of HH?

Regarding whther KAL-1 can account for the sex imbalance in cases: if 1 in 10,000 women has KS, and 10% (i.e. 1 in 100.000) are due to a KAL-1 X-linked recessive mutation, then the prevalence among men (assuming Hardy-Weinberg equilibrium at the KAL-1 locus) would be Square root (1/100,000) = 1 in 316. So you can see that even at 10% (for women), the KAL-1 mutation would more than account for the sex imbalance. Apologies if you are not familiar with genetics, but that's the way it works. Marchino61 (talk) 13:49, 12 September 2013 (UTC)

Equality

In the name of equality, shouldn't the order of male and female organs or systems be switched between sentences? 37.74.56.174 (talk) 19:19, 23 February 2017 (UTC)

Testicular volume normal range.

The normal range for testicular volume is normally quoted in radiography papers as being between 15 and 25 ml (or cubic centimetres) in most articles with an average of about 20 ml, depending on what paper you read. I wrote 30ml as the upper range as that is the upper value that was quoted in the article I was reading at the time. There is always going to be a variation in the volumes stated, depending of whether the measurement was done by ultrasound or Prader orchidometer.

I can change it from 30 to 25 ml.

Testicular volumes of 3ml and less are commonly found in adult patients with Kallmann syndrome, it is a key feature of the syndrome. All the medical papers I have cited in the article would list 3 or 4ml as being the cut off value for testicular volume.

Neilsmith38 (talk) 08:10, 8 June 2017 (UTC)

Intro Para

Introductory paragraph is enormous! Likely it needs a lot of re-working, as there's too much detail in a lot of topics in what should be a concise overview. Cpt ricard (talk) 18:15, 12 June 2017 (UTC)

I agree. Having just read it again the introduction does need tidying up. I have been adding bits to the article as I go along. When I get some free time I will try to edit it down. There is a lot of information to convey for this rare disorder but I want the article to be concise and readable for people who have never heard of the condition before. Thank you for your input.

Neilsmith38 (talk) 20:16, 12 June 2017 (UTC)

I have made some edits to the opening paragraph to try to make it more concise and to prevent repeating the same information.

I did not like the term "olfacto-genital" syndrome so removed it from the first line, but kept it in the article. I asked a couple of the KS medical experts I know and they confirmed the term is not currently used. I can find references to the term in papers published in the 1970's but nothing after that.

There is still work to be done in editing the article, it is something I keep a close eye on.

Neilsmith38 (talk) 05:09, 26 June 2017 (UTC)

Recent edits.

Hello,

I have reverted back a couple of recent edits user:jytdog The physical features mentioned are well known features of specific genetic forms of Kallmann syndrome / CHH. I have added another review article to the top of the section, bringing the total to 4 articles. Any review article will normally mention all the physical features listed.

There was a note in the other talk page about the use of primary sources and it was noted by another editor that this rule does not strictly apply to the rarer conditions such as Kallmann syndrome where there is not going to be number of review papers available for other topics.

I put in a couple of notes in the Research section which I thought were broad enough to be included with references, which might be primary in origin, but in a section labelled "research" they are more likely to be primary sources. I kept the wording as broad as possible. I thought they were ok to use. I will not restore them again until other people have commented. — Preceding unsigned comment added by Neilsmith38 (talk • contribs) 23:23, 10 December 2017 (UTC)

2 recent updates to the page.

I made two recent updates to the page which were immediately changed by an editor with note of see WP: MEDMOS and WP:PROMO and WP:SELFCITE

I thought both were valid, with references and complied with the requirements for a medical article on Wikipedia. One was in the patient perspective section and the other was in the research section.

---

Early diagnosis and early treatment can be of immense benefit to patients with KS / CHH. The ability to be able to be in contact with fellow patients either on line or in person can also be beneficial to patients and help ease the social isolation of having a rare condition can bring. Due to the very nature of the condition with absent or impaired puberty patients can experience a range of psychosexual problems, the severity of which can vary markedly between patients.

---

Improved genetic testing techniques such as next generation sequencing allows researchers to identify more potential genetic causes of KS / CHH by looking at the entire genetic structure and targeting the genes known to be involved in either the development or control of the hypothalamus. At present approximately 50% of KS / CHH cases have an unknown genetic cause.

---

References

I am the patient author of one of the articles I cited, but that was not the article that was removed by the editor. I think both paragraphs are valid. I wanted to include a bit more on the patient perspective while still trying to remain as general as possible. I cited a recent article which involved interviewing many Kallmann syndrome patients.

I wanted to re-submit the paragraphs but did not want to do it until I got a bit of feedback.

Thank you.

Neilsmith38 (talk) 20:15, 28 November 2017 (UTC)

Thank you Neilsmith38 for bringing this to talk, and thank you for reaching out to us at WT:MED. The regular editors of medical articles will tell you of the problems we've experienced in the past with editors who want to raise the profile of a particular condition – with all of the best intentions – but who couldn't see when their close involvement with the topic made it difficult for them to edit the article objectively. Now, you've been around since 2006, and you've managed to be the principal contributor, having added 62% of the text, without running into problems. Nevertheless, I hope you can appreciate Jytdog's concerns. You made four consecutive edits, not two as you thought, and Jytdog reverted all of them, unfortunately including one uncontroversial one, but there's no easy way of rolling back all but one of a series of edits. I've now revamped the Kim et al citation to a full version, as I don't believe there is any dispute about that.

However, I think you will still have to make the case for each of the other three changes you made, the two above and the external link to

• Patient information materials produced by expert clinicians and patients

I don't see a problem with the two pieces of text and sources you give above, but it may be better if someone else took responsibility for the first one as it cites you and WP:SELFCITE tends to discourage adding cites to your own articles. Personally, I don't think you've breached that, but it's always best to err onthe side of caution.

Also, I do worry that the External links section is straying away from the purpose of WP:EL: "Some acceptable links include those that contain further research that is accurate and on-topic, information that could not be added to the article for reasons such as copyright or amount of detail, or other meaningful, relevant content that is not suitable for inclusion in an article for reasons unrelated to its accuracy." Hope that helps. --RexxS (talk) 23:57, 28 November 2017 (UTC)

---

Thank you for your help. The external links section has always bothered me a bit and I quite understand why that link to external patient support material was removed. I might just leave that link on either my Talk page or the article talk page as it might be useful for patients who want to learn more.

The article that was removed on the last edit was not the BMJ article I was the main author for but the new link I added for the paper on Psychosexual development which I was not an author for, I was one of the patient participants in the study but not a cited author. As a patient I liked the revision I made to the "Patient Perspective" paragraph and would like to possibly re-instate it if allowed after others have had chance to review it, with both the cited references. I will leave it for the time being to give people time to respond if they wish. I do not believe the BMJ paper I authored as a patient has ever been removed by an editor.

I think the added content to the "Research" paragraph should not have been controversial, but I will leave that also for the time being. The next generation sequencing is a fairly new trend in KS research and I wanted to mention that there is research going on in the KS world by quoting a fairly recent paper.

I appreciate your feedback and hope I can improve the article further.

Thank you for your advice.

Neilsmith38 (talk) 00:20, 29 November 2017 (UTC)

Maybe a mistake?

Before and after

Bold edit

Reverted version

Early diagnosis and early treatment can be of immense benefit to patients with KS / CHH. The ability to be able to be in contact with fellow patients either on line or in person can also be beneficial to patients and help ease the social isolation of having a rare condition can bring. Due to the very nature of the condition with absent or impaired puberty patients can experience a range of psychosexual problems, the severity of which can vary markedly between patients.

Another aspect of Kallmann syndrome is social isolation. Since it is such a rare condition, a lot of patients with Kallmann syndrome have never even met or talked to a fellow patient. The ability to meet and talk to other people with the condition goes a long way to helping a patient come to terms with the condition.

User:Jytdog, you seem to have reverted to the version of the article that exclusively cites the Wikipedia editor. The edit summary says that you removed the source (=the one that was not written by a Wikipedia editor) because of WP:SELFCITE. Was that just a misclick or something? WhatamIdoing (talk) 21:51, 29 November 2017 (UTC)

this was the diff. it included an extra citation of the editor's paper as an EL, content sourced to a non-MEDRS ref in the Research section, and the bit you cited above. In the content you cite above, the new first paragraph is also sourced to a non-MEDRS ref. Jytdog (talk) 23:06, 29 November 2017 (UTC)

What makes you conclude that the paper is "non-MEDRS"? MEDRS accepts primary sources for some purposes, and being able to write a complete description of rare diseases is one of the main purposes for using them. The idea that we should only use recent review articles is, according to MEDRS itself, only "appropriate for actively researched areas with many primary sources and several reviews". This is definitely the kind of rare disease that we intended to cover less strictly, since it has a prevalence on the order of 0.005% of people and relatively few publications – one or two reviews per year, and several of them in the "case study and narrative review" style.

The journal has one of the highest impact factors in its field. Also, whether a source is reliable depends upon the statement being made, not just the source itself. The statement that an unusual experience with puberty can affect psychosexual development is practically WP:BLUE. What's your problem with using this source for this statement? WhatamIdoing (talk) 05:12, 30 November 2017 (UTC)

They are separate references. The patient materials I used as an external reference is different content from the paragraph I added to and cited in the patient perspective section. I completely accept the external link was not valid and will not put it back in. However I think the statement on psychosexual problems is of relevance to KS patients and merits an inclusion in the article. The Dwyer, Quinton, Pitteloud paper I cited was one I was involved with only as a patient participant, not as an author so thought it was a valid paper to cite.

I take on board your comments on the content and will be extra careful in future but I really want to maintain this article to a good standard.

Neilsmith38 (talk) 23:15, 29 November 2017 (UTC)

Neilsmith38 (talk) 23:32, 10 December 2017 (UTC)== Update the section on male HRT. ==

Hello,

I wish to propose a change to the section on the male HRT:

The text is currently:

For the men testosterone replacement is achieved either by using daily capsules, daily gel or patches, fortnightly injections, three monthly injections, or six monthly implants. Tablet/capsule forms of HRT rarely give sufficient testosterone levels suitable for men with KS/HH. Different formulations of testosterone are available for treatment which will contain single or multiple forms of testosterone.

The three monthly injection of testosterone undecanoate has become very popular over the past ten years. First produced by the Bayer pharmaceutical company and marketed under the names Nebido, Reandron, or Aveed. In early 2014 Aveed was licensed for use in the US by the Food and Drug Administration (FDA), produced in 3ml vials as opposed the regular 4ml vials used elsewhere around the world.

After the first two injections which are six weeks apart, injections are taken every three months and give good testosterone levels throughout the three-month period with no noticeable tailing-off of levels at the end of the injection cycle. Some patients only require the injection every six months. These injection intervals might be adjusted depending on the response of the individual.

Some treatments may work better with some patients than others so it might be a case of personal choice as which one to use.

Replace with:

There are a range of different methods of testosterone delivery available to male patients with KS / CHH; these include daily patches, daily gel use, daily capsules, sub cutaneous or intramuscular injections or six monthly implants. Different formulations of testosterone are used to ensure both the anabolic and androgenic effects of testosterone are achieved.

Testosterone undecanoate is commonly used worldwide, though less so in the US, for treating male KS / CHH patients and has proved to be effective in maintaining good testosterone levels with an increased injection period of up to 12 weeks.

The precise treatment method used and interval between injections will vary from patient to patient and may need to be adjusted to maintain a physiological normal level of testosterone over a longer period of time to prevent the mood swings or adverse effects that can occur if testosterone levels are too high or low. Some treatments may work better with some patients than others so it might be a case of personal choice as which one to use.

As an alternativeHuman chorionic gonadotrophin (hCG) can also be used to stimulate natural testosterone production. It acts in the same way as LH; stimulating the Leydig cells in the testes to produce testosterone. hCG can be used as pre-cursor to male fertility treatments but it can be used in isolation just for testosterone production.

I think we should remove a bit of the detail on Nebido as it focuses too much on one particular brand of medication. The use of hCG is becoming more popular for testosterone delivery only and I think should be mentioned.

Any suggestions / comments would be welcome, thank you.

References

Neilsmith38 (talk) 20:14, 4 December 2017 (UTC)

I fleshed out the ref and added a reflist. The one ref does not fully support the content it has been placed after (it doesn't discuss testosterone patches for example) and most of the content has no source. Please don't propose unsourced content. Everything should be supported by MEDRS refs. Jytdog (talk) 23:24, 10 December 2017 (UTC)

unsourced

moved here per WP:PRESERVE. almost all unsourced. the one ref that is here is placed at the beginning...

Classic CHH

This type of HH is present from birth and is lifelong. Approximately two-thirds of classic CHH cases will have a low level of pulsatile GnRH release from the hypothalamus, which will give rise to partial puberty while the other third of cases will have zero GnRH release and no puberty.

Non-reproductive symptoms are present in approximately half the cases. The most common of these is anosmia, which gives rise to the distinction between KS and normosmic CHH. Males with classic CHH may also have had a history of un-descended testicles and/or micropenis.

This type of CHH has been shown to be caused by autosomal recessive or dominant mutations in males and females, and X chromosome-linked recessive mutations in males mentioned in the table at the end of this article.

Adult-onset HH

This type of HH has only been shown to occur in males. The hypothalamic-pituitary-gonadal axis (HPG axis) functions normally at birth and well into adult life giving normal puberty.

The HPG axis then either fails totally or is reduced to a very low level of GnRH release, in adult life with no obvious cause such as a pituitary tumor. This will lead to a fall in testosterone levels and infertility. This type of HH is not associated with any non-reproductive symptoms, and it has been shown to be caused by monoallelic mutations.

Reversible KS/HH

This type of KS/CHH will appear to be the classic lifelong form at first but at some point in adult life the HPG axis resumes its normal function and GnRH, LH, and FSH levels return to normal levels. Has only been shown to occur in 10% of cases, primarily normosmic CHH cases rather than KS cases and only found in patients who have undergone some form of testosterone replacement therapy. It is only normally discovered when testicular volume increases while on testosterone treatment alone and testosterone levels return to normal when treatment is stopped.

This type of KS/CHH rarely occurs in cases where males have had a history of un-descended testes and/or micropenis, and has been shown to be caused by monoallelic mutations.

Hypothalamic amenorrhoea

This type of HH is seen in females where the HPG axis is suppressed in response to physical or psychological stress or malnutrition. It is reversible with the removal of the stressor.

This type of HH is not associated with any non-reproductive symptoms and has been shown to be caused by monoallelic mutations. A study suggested that there may have been an evolutionary advantage for these mutations to exist where it could have been an advantage for the females not to be fertile at times when food was scarce in the community.

This type of HH has been shown to be caused by monoallelic mutations.

Reproductive features

• Failure to start or fully complete puberty in both men and women
• Lack of testicle development in men (size < 4 ml, whereas the normal range is between 12 and 25 ml)
• Primary amenorrhoea (failure to start menstruation in women)
• Poorly defined secondary sexual characteristics in both men and women.
• Infertility

References

-- Jytdog (talk) 00:21, 11 December 2017 (UTC)

The whole section was probably due for a re-write anyway. I have suitable review articles which I am fairly sure should be suitable. I will re-write and cite the content during the week.

Neilsmith38 (talk) 00:32, 11 December 2017 (UTC)

Update and re-write of signs & symptoms section. Comments / suggestions please.....

This is a version of the Signs and Symptoms section. I have condensed some of the text and added a few more review articles that cover all the symptoms listed.

I could put a reference tag to each symptom but I think they are all covered in the articles I have cited.

Signs and Symptoms.

It is normally difficult to distinguish a case of KS / HH from a straightforward constitutional delay of puberty. However, if puberty has not started by either age 14 (girls) or 15 (boys) and one or more of the non-reproductie features mentioned belowe is present then a referral to reproductive endocrinologist might be advisable.

The features of Kallmann syndrome (KS) and other forms of hypogonadotropic hypogonadism (HH) can be split into two different categories; "reproductive" and "non reproductive".

Reproductive features.

• Failure to start or fully complete puberty in both men and women
• Lack of testicle development in men (size < 4 ml, whereas the normal range is between 12 and 25 ml)
• Primary amenorrhoea (failure to start menstruation)
• Poorly defined secondary sexual characteristics in both men and women.
• Micropenis in 5-10% of male cases
• Cryptorchidism (undescended testicles) at birth.
• Low levels of the gonadotropins LH and FSH
• Hypogonadism due to low levels of testosterone in men or oestrogen / progesterone in females
• Infertility

Non-reproductive features.

• Total lack of sense of smell (anosmia) or markedly reduced sense of smell (hyposmia). This is the defining feature of Kallmann syndrome; it is not seen in other cases of HH. Approximately 50% of HH cases occur with anosmia and can be termed as Kallmann syndrome.
• Cleft palate, hare lip or other midline cranio-facial defects.
• Neural hearing impairment
• Absence of one of the kidneys (unilateral renal agenesis)
• Skeletal defects including split hand/foot (ectrodactyly), shortened middle finger (metacarpal) or scoliosis
• Manual synkinesis (mirror movements of hands)
• Missing teeth (hypodontia)
• Poor balance or coordination due to cerebral ataxia
• Eye movement abnormalities

The exact genetic nature of each particular case of KS / HH will determine which, if any, of the non-reproductive features will occur. The severity of the symptoms will also vary from case to case. Even family members will not show the same range or severity of symptoms.

KS / HH is most often present from birth but adult onset versions are found in both males and females. The hypothalamic-pituitary-gonadal axis (HPG axis) functions normally at birth and well into adult life giving normal puberty and normal reproductive function. The HPG axis then either fails totally or is reduced to a very low level of GnRH release, in adult life with no obvious cause such as a pituitary tumour. This will lead to a fall in testosterone or oestrogen levels and infertility.

Functional hypothalamic amenorrhoea is seen in females where the HPG axis is suppressed in response to physical or psychological stress or malnutrition. It is reversible with the removal of the stressor.

Some cases of KS / HH appear to reverse during adult life where the HPG axis resumes its normal function and GnRH, LH, and FSH levels return to normal levels. This occurs in an estimated 10 to 20% of cases, primarily normosmic CHH cases rather than KS cases and only found in patients who have undergone some form of testosterone replacement therapy. It is only normally discovered when testicular volume increases while on testosterone treatment alone and testosterone levels return to normal when treatment is stopped. This type of KS/CHH rarely occurs in cases where males have had a history of un-descended testes.

Affected individuals with KS and other forms of HH are almost invariably born with normal sexual differentiation; i.e., they are physically male or female. This is due to the human chorionic gonadotrophin (hCG) produced by placenta at approximately 12 to 20 weeks gestation (pregnancy) which is normally unaffected by having KS or CHH.

People with KS/CHH lack the surge of GnRH, LH, and FSH that normally occurs between birth and six months of age. This surge is particularly important in infant boys as it helps with testicular descent into the scrotum. The surge of GnRH/LH/FSH in non KS/HH children gives detectable levels of testosterone in boys and oestrogen & progesterone in girls. The lack of this surge can sometimes be used as a diagnostic tool if KS/CHH is suspected in a newborn boy, but is not normally distinct enough for diagnosis in girls.

References

Any suggestions or comments before I put this into the article would be appreciated. Thank you. Neilsmith38 (talk) 22:03, 12 December 2017 (UTC)

There is a bunch of content that is unsourced in the Non-reproductive features section. Each one of those paragraphs needs a source, as does the list.

The Quaynor ref is a primary source and is not OK to use as folks have told you several times. The NEJM ref is also a primary source. The Sidhoum ref is a primary source. The Quinton ref is a primary source (case study). Jytdog (talk) 20:10, 13 December 2017 (UTC)

....Is there a total ban on using primary sources under MEDRES ? Another editor stated earlier that primary sources can be used when writing about rare disorders such as Kallmann syndrome. I am using well respected medical journals in my references, is there any way some primary source material is allowed ? I do have four good quality (I think anyway) review articles that I am using already. There was a new review article published in July this year, I do not have the full version yet, only the abstract, so I will wait until I can read the full article before using that one as well.

Neilsmith38 (talk) 20:35, 13 December 2017 (UTC)

Per WP:MEDPRI, they aren't outright banned, but should be used cautiously, and some editors are staunchly anti-primary sources. Natureium (talk) 20:39, 13 December 2017 (UTC)

If you try to add them, I will remove them as will others, and if you try to force them in you will get blocked for edit warring. We do not use primary sources except rarely and with very good reason, which you have not even tried to offer. This is very serious. Please be aware that advocates of all kinds are pretty much the only ones who insist on primary sources and blow off our best practices. Pharma reps, people who really believe that magnetic bracelets cure cancer, people who want to cite their own papers, people with conditions, etc etc etc all behave exactly like this. MEDRS was actually created because our articles about autism were in a terrible state, with everybody from people selling snake oil to wildly worried parents adding all kinds of crap based on primary sources. MEDRS pulled us out of that morass, and it works so well because we apply it consistently. I get it that Kallman's important to you personally. In those situations you should hold yourself to our best practices to help manage your own advocacy. Editors who cannot self manage get topic banned after they exhaust our patience. I realize I am being harsh, but that is the deal here. If you want to play this "game" you have to play by its "rules". If you want to write whatever you want, there are blogs for that. Jytdog (talk) 20:55, 13 December 2017 (UTC)

agree, MEDRS is clear about this, they'll be reverted--Ozzie10aaaa (talk) 11:42, 14 December 2017 (UTC)

I am trying to do it correctly. I am editing on the Talk page, making suggestions and waiting for comments. I think I am being as careful as possible here and taking on board what you say. I am most certainly not trying to edit war and I am not making changes to the main article at the moment before discussing them here. I am just trying to produce as high a quality article as I can.

There is a very good comprehensive review article, but it is published on line only as part of the Rare Diseases website, would I be able to use that as a suitable reference ?

https://rarediseases.org/rare-diseases/kallmann-syndrome

I have already added a chapter from a Genes Review published on line into this section which I think is also suitable.

Neilsmith38 (talk) 21:11, 13 December 2017 (UTC)

Gene Reviews is good. The rarediseases.org ref is marginal; if anything is only there I wouldn't rely on it. Better to go with https://ghr.nlm.nih.gov/condition/kallmann-syndrome or https://rarediseases.info.nih.gov/diseases/10771/kallmann-syndrome Jytdog (talk) 21:20, 13 December 2017 (UTC)

Thank you. I have both those articles in my favourite links, they are good articles. I was just not too aware of how to use web pages as references when editing. The second link references the webpage from Rare Diseases.org and is authored by the same team of doctors from Boston. I think I will try to use those two references more. I will have a go at changing the references in the next couple of days.

Thank you.

Neilsmith38 (talk) 21:29, 13 December 2017 (UTC)

New introduction & first section on signs & symptoms.

Kallmann syndrome is a rare genetic disorder that prevents a person from starting or fully completing puberty. The condition affects both males and females but is more commonly diagnosed in males.

Kallmann syndrome (KS) is a form of a group of conditions termed hypogonadotropic hypogonadism. Kallmann syndrome has an additional symptom of a total lack of sense of smell (anosmia) or a reduced sense of sense of smell (hyposmia) which distinguishes it from other forms of hypogonadotropic hypogonadism.

The term hypogonadotropic hypogonadism describes both the symptoms and cause of the condition. Hypogonadism refers to low levels of the sex hormones; testosterone (men) or oestrogen and progesterone in women, normally produced by the testes or ovaries respectively. Hypogonadotropic refers to low levels of the gonadotropin hormones luteinizing hormone (LH) and follicle stimulating hormone (FSH), normally produced by the pituitary gland to control the production of the sex hormones and fertility. The correct release of the hormones LH and FSH is controlled by another hormone, gonadotropin releasing hormone (GnRH) produced by the hypothalamus. It is the failure in the production or correct activity of GnRH that is the root cause of the condition which has resulted in the alternative term, isolated GnRH deficiency (IGD) being used.

If left untreated people with Kallmann syndrome (KS) or other forms of hypogonadotropic hypogonadism (HH) will have poorly defined secondary sexual characteristics, show signs of hypogonadism, almost invariably be infertile and be at increased risk of developing osteoporosis. In addition there are a range of other symptoms that can occur affecting other parts of the body that occur in certain forms of KS and HH.

A 2011 study of the Finnish population produced an estimated incidence of 1 in 48,000 people overall, with 1 in 30,000 for males and 1 in 125,000 for females.

Kallmann syndrome was first described by name in a paper published in 1944 by Franz Josef Kallmann, a German-American geneticist. The link between anosmia and hypogonadism had already been noted however, in particular by the Spanish doctor Aureliano Maestre de San Juan in 1856.

Signs and Symptoms.

It is normally difficult to distinguish a case of KS / HH from a straightforward constitutional delay of puberty. However, if puberty has not started by either age 14 (girls) or 15 (boys) and one or more of the non-reproductie features mentioned belowe is present then a referral to reproductive endocrinologist might be advisable.

The features of Kallmann syndrome (KS) and other forms of hypogonadotropic hypogonadism (HH) can be split into two different categories; "reproductive" and "non reproductive".

Reproductive features.

• Failure to start or fully complete puberty in both men and women.
• Lack of testicle development in men (size < 4 ml, whereas the normal range is between 12 and 25 ml).
• Primary amenorrhoea (failure to start menstruation).
• Poorly defined secondary sexual characteristics in both men and women.
• Micropenis in 5-10% of male cases.
• Cryptorchidism (undescended testicles) at birth.
• Low levels of the gonadotropins LH and FSH.
• Hypogonadism due to low levels of testosterone in men or oestrogen / progesterone in females.
• Infertility.

Non-reproductive features.

• Total lack of sense of smell (anosmia) or markedly reduced sense of smell (hyposmia). This is the defining feature of Kallmann syndrome; it is not seen in other cases of HH. Approximately 50% of HH cases occur with anosmia and can be termed as Kallmann syndrome.
• Cleft palate, hare lip or other midline cranio-facial defects.
• Neural hearing impairment
• Absence of one of the kidneys (unilateral renal agenesis)
• Skeletal defects including split hand/foot (ectrodactyly), shortened middle finger (metacarpal) or scoliosis
• Manual synkinesis (mirror movements of hands)
• Missing teeth (hypodontia)
• Poor balance or coordination due to cerebral ataxia.
• Eye defects such as coloboma or ptosis.

The exact genetic nature of each particular case of KS / HH will determine which, if any, of the non-reproductive features will occur. The severity of the symptoms will also vary from case to case. Even family members will not show the same range or severity of symptoms.

KS / HH is most often present from birth but adult onset versions are found in both males and females. The hypothalamic-pituitary-gonadal axis (HPG axis) functions normally at birth and well into adult life giving normal puberty and normal reproductive function. The HPG axis then either fails totally or is reduced to a very low level of GnRH release, in adult life with no obvious cause such as a pituitary tumour. This will lead to a fall in testosterone or oestrogen levels and infertility.

Functional hypothalamic amenorrhoea is seen in females where the HPG axis is suppressed in response to physical or psychological stress or malnutrition. It is reversible with the removal of the stressor..

Some cases of KS / HH appear to reverse during adult life where the HPG axis resumes its normal function and GnRH, LH, and FSH levels return to normal levels. This occurs in an estimated 10 to 20% of cases, primarily normosmic CHH cases rather than KS cases and only found in patients who have undergone some form of testosterone replacement therapy. It is only normally discovered when testicular volume increases while on testosterone treatment alone and testosterone levels return to normal when treatment is stopped. This type of KS / HH rarely occurs in cases where males have had a history of un-descended testes.

Affected individuals with KS and other forms of HH are almost invariably born with normal sexual differentiation; i.e., they are physically male or female. This is due to the human chorionic gonadotrophin (hCG) produced by placenta at approximately 12 to 20 weeks gestation (pregnancy) which is normally unaffected by having KS or CHH.

People with KS / HH lack the surge of GnRH, LH, and FSH that normally occurs between birth and six months of age. This surge is particularly important in infant boys as it helps with testicular descent into the scrotum. The surge of GnRH/LH/FSH in non KS/HH children gives detectable levels of testosterone in boys and oestrogen & progesterone in girls. The lack of this surge can sometimes be used as a diagnostic tool if KS / HH is suspected in a newborn boy, but is not normally distinct enough for diagnosis in girls.

---

Need to double check the references and cite them in more of the paragraphs. I think the references are more appropriate now, there are a couple more reference articles I might add in later.

Neilsmith38 (talk) 22:16, 14 December 2017 (UTC)

References

New introduction & first section on signs & symptoms. Updated.

I have posted an update to the introduction and the signs and symptoms section.

I have used different references, mainly review articles and published reviews from NORD and NIH Genetics Home reference. I think they all are secondary sources. I have tried to ensure all the symptoms are linked to a reference.

I hope the updates are suitable.

Neilsmith38 (talk) 21:12, 26 December 2017 (UTC)

   I have updated the introduction again hopefully to comply with WP:LEAD to include all the key details within 4 paragraphs without repeating too much information that is already mentioned later in the article. There are references in the introduction which are suitable I think.

Neilsmith38 (talk) 20:02, 27 December 2017 (UTC)

Recent edits. - New genetics section.

I am in the process of updating the page to include more reviews and to keep it in line with MEDRES. I have completed the introduction and symptoms section. I am hoping the fact that this has not been reverted means that it is acceptable.

I am in the process of editing down the genetics section to make that table more readable and include the physical symptoms.

I will have a go at the remaining sections as I go along. A lot of content has been removed today. I hope to replace most of that once I can review it and assign better review references to it.

I am trying to make the article the best I can and to try to achieve as high a status as possible. This is a rare condition and it means a lot for me to be be able to produce accurate information while trying to comply with the Wikipedia regulations.

This is how I am thinking the genetics table should look as a suggestion.

The table comes from this review article:

OMIM	Name	Gene	Locus	Clinical features	Syndromes Associated	Inheritance pattern	Prevalence (%)
308700	KAL1 (ANOS1)	KAL1	Xp22.3	Bimanual synkinesia & renal agenesis.		x-linked	5
147950	KAL2	FGFR1	8p11.23	Cleft lip and / or cleft palate. Septo-optic dysplasia. Skeletal anomomalies. Bimanual synkinesia. Hand / foot malformation. Combined pituitary hormone deficiency.	Hartsfield syndrome	Autosomal dominant	10
146110	GNRHR	GNRHR	4q13.2			Autosomal recessive	6-16
612370	CHD7	CHD7	8q12.2	Congenital hearing loss. Semicircular canal hypoplasia.	CHARGE syndrome	Autosomal dominant (?)	6
610628	KAL4	PROK2	3p13			Autosomal recessive	3-6
244200	KAL3	PROKR2	20p12.3	Combined pituitary hormone deficiency.	Morning Glory syndrome	Autosomal recessive	3-6
615267	IL17RD	IL17RD	3p14.3	Congenital hearing loss.		Autosomal recessive	3
611584	SOX10	SOX10	22q13.1	Congenital hearing loss.	Waardenburg syndrome		2
614842	KISS1	KiSS-1	1q32.1			Autosomal recessive	2
614837	KISS1R (GPR54)	GPR54	19p13.3			Autosomal recessive	2
612702	FGF8	FGF8	10q24.32	Cleft lip and / or cleft palate. Skeletal anomomolies. Bimanual synkinesia. Combined pituitary hormone deficiency.		Autosomal dominant	<2
615270	FGF17	FGF17	8p21.3		Dandy-Walker syndrome	Autosomal dominant (?)	<2
164260	LEP	LEP	7q32.1	Early onset of morbid obesity.		Autosomal recessive	<2
601007	LEPR	LEPR	1p31.3	Early onset of morbid obesity.		Autosomal recessive	<2
162150	PCSK1	PCSK1	5q15	Early onset of morbid obesity.		Autosomal recessive	<2
616030	FEZF1	FEZF1	7q31.32			Autosomal recessive	Rare
616031	CCDC141	CCDC141	2q31.2			Autosomal recessive (?)	Rare
614897	SEMA3A	SEMA3A	7q21.11			Autosomal dominant	Rare
607961	SEMA7A	SEMA7A	15q24.1			Autosomal dominant	Rare
614880	HS6ST1	HS6ST1	2q14.3	Cleft lip and / or cleft palate. Skeletal anomalies.		Autosomal dominant (?)	Rare
614858	WDR11	WDR11	10q26.12	Combined pituitary hormone deficiency.		Autosomal dominant	Rare
614838	NELF (NSMF)	NELF	9q34.3			Autosomal dominant (?)	Rare
617351	IGSF10	IGSF10	3q24			Autosomal dominant	Rare
614841	GNRH1	GNRH1	8p21.2			Autosomal recessive	Rare
614839	TAC3	TAC3	12q3			Autosomal recessive	Rare
614840	TACR3	TACR3	4q24			Autosomal recessive	Rare
611744	OTUD4	OTUD4	4q31.21	Cerebellar ataxia.	Gordon Holmes syndrome	Autosomal recessive	Rare
609948	RNF216	RNF216	7p22.1	Cerebellar ataxia.	Gordon Holmes syndrome	Autosomal recessive	Rare
603197	PNPLA6	PNPLA6	19p13.2	Cerebellar ataxia.	Gordon Holmes syndrome	Autosomal recessive	Rare
109135	AXL	AXL	19q13.2			Autosomal dominant (?)	NR
615271	FLRT3	FLRT3	20p12.1	Encodes fibronectin-like domain-containing leucine rich transmembrane protein 3. Protein associated with the function of the KAL2 genes (FGFR1 and FGF8) which allows for the migration of both olfactory axons and GnRH releasing neurones during early embryonic development.
615269	DUSP6	DUSP6	12q21.33	Encodes dual specificity phosphate-6. Protein associated with the function of the KAL2 genes (FGFR1 and FGF8) which allows for the migration of both olfactory axons and GnRH releasing neurones during early embryonic development.
615266	SPRY4	SPRY4	5q31.3	Encodes sprouty, Drosphila, homolog of, 4. Protein associated with the function of the KAL2 genes (FGFR1 and FGF8) which allows for the migration of both olfactory axons and GnRH releasing neurones during early embryonic development.
300200	DAX1/NROB1	DAX1	Xp21.2	Encodes a nuclear receptor with no known ligand. Known to be a transcription inhibitor. Mutations in DAX1 are thought to cause X-linked recessive forms of CHH in both males and occasionally females. Known to cause pubertal delay in females.

Regarding layout, I think this is good but prevalence might be more interesting to the average reader than the OMIM index # (for example), so you might want to reconsider the column order. A table can be very helpful for summarizing, just make sure it's not original research - i.e. that it truly reflects the cited source(s). — soupvector (talk) 22:30, 13 January 2018 (UTC)

.....Thank you. At the moment the table is taken directly verbatim from a review article published last year mentioned at the top of the table, but summarised in another review article I will cite as well. Once the table is finished I will swap over the prevalence and OMIM columns, that sounds a very good idea. I like the idea of being able to clearly see the link between the physical symptoms and specific gene defect. Thank you for your suggestion. Neilsmith38 (talk) 22:36, 13 January 2018 (UTC)

I have updated the table. Still a few changes to be made though. Work in process.

Neilsmith38 (talk) 08:37, 14 January 2018 (UTC)

Updates

I have made some updates today. I have revised the genetics table, taking out a lot of references and replacing them with 2 more recent review articles. I have deleted some of the information to condense it down to linking genes to the physical symptoms, estimated prevalence and mode of inheritance.

I think this table is slightly easier to read and might be more informative.

I have kept a copy of the old table with reference which I can revert back if required.

Some of the genes in the table have been listed as rare or having been described in only one case. I have linked to the review article that mentioned them rather than the primary source. I hope this is acceptable in terms of references.

Neilsmith38 (talk) 19:17, 17 January 2018 (UTC)

Images on Kallmann syndrome

I have started to add a few images to the article to help illustrate certain points.

I was thinking of adding a Wiki Commons image of the Tanner stages of puberty in both males and females to the diagnosis section.

Does anybody have any suggestions of illustrations to use ? I would like a diagram, rather than a photo, showing the symptoms of delayed puberty / hypogonadism. I have seen a few diagrams that would be good but none available under free licence with Wiki Commons that I can see so far.

We used to have a couple of lines on notable patients with Kallmann syndrome (Brian Brett and Jimmy Scott), both of whom have Wiki articles. I was thinking of adding a mention of them into the "History" section of the article. These were deleted in the past by an editor but I think they warrant an inclusion.

Neilsmith38 (talk) 14:56, 18 January 2018 (UTC)

We don't do "notable patients" unless they are important to the history of the disease as described in reliable sources. They just become magnets for gossip. Jytdog (talk) 16:55, 18 January 2018 (UTC)

Genetics update.

I have removed the table of genes to its own page Genetics of GnRH deficiency conditions. After suggestions it was looking too technical for the main page I thought it would do better on a page of its own. I thought I would make a bold edit on this one.

There has been a recently published review article that now puts the number of genes up to 30.

I will update that information with the reference as soon as I can.

I am trying to improve the article and make it more readable for people not familiar with the condition, I would like to try to get the article to B standard class at least if I can.

Neilsmith38 (talk) 11:12, 25 February 2018 (UTC)

Colour blindness

I am not sure about the recent addition about colour blindness. The association between Kallmann syndrome and colour blindness has long been discredited and is not mentioned in any current review articles. One of the articles stated is a primary source and too old to be used as reference.

Septo-optic dysplasia is a known symptom and is already mentioned in the article.

I might revert the reference to colour blindness if a more recent review article is not found that mentions it.

Neilsmith38 (talk) 08:19, 1 March 2018 (UTC)