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Hypogonadotropic hypogonadism 4 with or without anosmia(HH4)

MedGen UID:
765257
Concept ID:
C3552343
Disease or Syndrome
Synonyms: HH4; HYPOGONADOTROPIC HYPOGONADISM 4 WITH ANOSMIA; KAL4; Kallmann syndrome 4
 
Gene (location): PROK2 (3p13)
 
Monarch Initiative: MONDO:0012528
OMIM®: 610628

Definition

Isolated gonadotropin-releasing hormone (GnRH) deficiency (IGD) is characterized by inappropriately low serum concentrations of the gonadotropins LH (luteinizing hormone) and FSH (follicle-stimulating hormone) in the presence of low circulating concentrations of sex steroids. IGD is associated with a normal sense of smell (normosmic IGD) in approximately 40% of affected individuals and an impaired sense of smell (Kallmann syndrome) in approximately 60%. IGD can first become apparent in infancy, adolescence, or adulthood. Infant boys with congenital IGD often have micropenis and cryptorchidism. Adolescents and adults with IGD have clinical evidence of hypogonadism and incomplete sexual maturation on physical examination. Adult males with IGD tend to have prepubertal testicular volume (i.e., <4 mL), absence of secondary sexual features (e.g., facial and axillary hair growth, deepening of the voice), decreased muscle mass, diminished libido, erectile dysfunction, and infertility. Adult females have little or no breast development and primary amenorrhea. Although skeletal maturation is delayed, the rate of linear growth is usually normal except for the absence of a distinct pubertal growth spurt. [from GeneReviews]

Clinical features

From HPO
Cryptorchidism
MedGen UID:
8192
Concept ID:
C0010417
Congenital Abnormality
Cryptorchidism, or failure of testicular descent, is a common human congenital abnormality with a multifactorial etiology that likely reflects the involvement of endocrine, environmental, and hereditary factors. Cryptorchidism can result in infertility and increases risk for testicular tumors. Testicular descent from abdomen to scrotum occurs in 2 distinct phases: the transabdominal phase and the inguinoscrotal phase (summary by Gorlov et al., 2002).
Primary amenorrhea
MedGen UID:
115918
Concept ID:
C0232939
Disease or Syndrome
Abnormally late or absent menarche in a female with normal secondary sexual characteristics.
Decreased testicular size
MedGen UID:
66027
Concept ID:
C0241355
Finding
Reduced volume of the testicle (the male gonad).
Micropenis
MedGen UID:
1633603
Concept ID:
C4551492
Congenital Abnormality
Abnormally small penis. At birth, the normal penis is about 3 cm (stretched length from pubic tubercle to tip of penis) with micropenis less than 2.0-2.5 cm.
Obesity
MedGen UID:
18127
Concept ID:
C0028754
Disease or Syndrome
Accumulation of substantial excess body fat.
Anosmia
MedGen UID:
1950
Concept ID:
C0003126
Finding
An inability to perceive odors. This is a general term describing inability to smell arising in any part of the process of smelling from absorption of odorants into the nasal mucous overlying the olfactory epithelium, diffusion to the cilia, binding to olfactory receptor sites, generation of action potentials in olfactory neurons, and perception of a smell.
Seizure
MedGen UID:
20693
Concept ID:
C0036572
Sign or Symptom
A seizure is an intermittent abnormality of nervous system physiology characterized by a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.
Bimanual synkinesia
MedGen UID:
473166
Concept ID:
C0454455
Disease or Syndrome
Involuntary movements of one hand that accompany and mirror intentional movements of the opposite hand.
Hyposmia
MedGen UID:
473584
Concept ID:
C2364082
Finding
A decreased sensitivity to odorants (that is, a decreased ability to perceive odors).
Aplasia of the olfactory bulb
MedGen UID:
1696661
Concept ID:
C5139362
Congenital Abnormality
Lack of formation (congenital absence) of the olfactory bulb.
Osteoporosis
MedGen UID:
14535
Concept ID:
C0029456
Disease or Syndrome
Osteoporosis is a systemic skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility. According to the WHO criteria, osteoporosis is defined as a BMD that lies 2.5 standard deviations or more below the average value for young healthy adults (a T-score below -2.5 SD).
Diabetes mellitus
MedGen UID:
8350
Concept ID:
C0011849
Disease or Syndrome
A group of abnormalities characterized by hyperglycemia and glucose intolerance.
Hypogonadotropic hypogonadism
MedGen UID:
82883
Concept ID:
C0271623
Disease or Syndrome
Hypogonadotropic hypogonadism is characterized by reduced function of the gonads (testes in males or ovaries in females) and results from the absence of the gonadal stimulating pituitary hormones
Absence of pubertal development
MedGen UID:
375841
Concept ID:
C1846228
Finding

Professional guidelines

PubMed

Tritos NA, Miller KK
JAMA 2023 Apr 25;329(16):1386-1398. doi: 10.1001/jama.2023.5444. PMID: 37097352
Jankovic J, Tan EK
J Neurol Neurosurg Psychiatry 2020 Aug;91(8):795-808. Epub 2020 Jun 23 doi: 10.1136/jnnp-2019-322338. PMID: 32576618
Butler MG, Miller JL, Forster JL
Curr Pediatr Rev 2019;15(4):207-244. doi: 10.2174/1573396315666190716120925. PMID: 31333129Free PMC Article

Recent clinical studies

Etiology

Snyder PJ, Bauer DC, Ellenberg SS, Cauley JA, Buhr KA, Bhasin S, Miller MG, Khan NS, Li X, Nissen SE
N Engl J Med 2024 Jan 18;390(3):203-211. doi: 10.1056/NEJMoa2308836. PMID: 38231621
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Burges Watson DL, Campbell M, Hopkins C, Smith B, Kelly C, Deary V
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Ascoli P, Cavagnini F
Pituitary 2006;9(4):335-42. doi: 10.1007/s11102-006-0416-5. PMID: 17077946

Diagnosis

Dong Y, Li Y, Liu K, Han X, Liu R, Ren Y, Cong L, Zhang Q, Hou T, Song L, Tang S, Shi L, Luo Y, Kalpouzos G, Laukka EJ, Winblad B, Wang Y, Du Y, Qiu C
Alzheimers Dement 2023 Feb;19(2):589-601. Epub 2022 Sep 15 doi: 10.1002/alz.12777. PMID: 36341691
Butowt R, von Bartheld CS
Neuroscientist 2021 Dec;27(6):582-603. Epub 2020 Sep 11 doi: 10.1177/1073858420956905. PMID: 32914699Free PMC Article
Ascoli P, Cavagnini F
Pituitary 2006;9(4):335-42. doi: 10.1007/s11102-006-0416-5. PMID: 17077946
Traggiai C, Stanhope R
Best Pract Res Clin Endocrinol Metab 2002 Mar;16(1):139-51. doi: 10.1053/beem.2001.0186. PMID: 11987904
Hayes FJ, Seminara SB, Crowley WF Jr
Endocrinol Metab Clin North Am 1998 Dec;27(4):739-63, vii. doi: 10.1016/s0889-8529(05)70039-6. PMID: 9922906

Therapy

Snyder PJ, Bauer DC, Ellenberg SS, Cauley JA, Buhr KA, Bhasin S, Miller MG, Khan NS, Li X, Nissen SE
N Engl J Med 2024 Jan 18;390(3):203-211. doi: 10.1056/NEJMoa2308836. PMID: 38231621
Yan CH, Jang SS, Lin HC, Ma Y, Khanwalkar AR, Thai A, Patel ZM
Int Forum Allergy Rhinol 2023 Jun;13(6):989-997. Epub 2022 Dec 21 doi: 10.1002/alr.23116. PMID: 36507615Free PMC Article
McCullough AR, Khan M
Urol Clin North Am 2022 Nov;49(4):679-693. doi: 10.1016/j.ucl.2022.07.010. PMID: 36309423
Corona G, Rastrelli G, Dicuio M, Concetti S, Minnetti M, Pivonello R, Isidori A, Sforza A, Maggi M
Minerva Endocrinol (Torino) 2021 Sep;46(3):252-261. Epub 2020 Sep 24 doi: 10.23736/S2724-6507.20.03208-3. PMID: 32969626
Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, Montori VM; Task Force, Endocrine Society
J Clin Endocrinol Metab 2010 Jun;95(6):2536-59. doi: 10.1210/jc.2009-2354. PMID: 20525905

Prognosis

Mohanraj S, Prasad HK
Indian J Pediatr 2023 Jun;90(6):590-597. Epub 2023 May 2 doi: 10.1007/s12098-023-04577-x. PMID: 37127825
Papazian EJ, Pinto JM
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Front Horm Res 2018;49:131-155. Epub 2018 May 24 doi: 10.1159/000485999. PMID: 29895018
Muraleedharan V, Jones TH
Clin Endocrinol (Oxf) 2014 Oct;81(4):477-87. Epub 2014 Jul 7 doi: 10.1111/cen.12503. PMID: 25041142

Clinical prediction guides

Yan CH, Jang SS, Lin HC, Ma Y, Khanwalkar AR, Thai A, Patel ZM
Int Forum Allergy Rhinol 2023 Jun;13(6):989-997. Epub 2022 Dec 21 doi: 10.1002/alr.23116. PMID: 36507615Free PMC Article
Corona G, Rastrelli G, Vignozzi L, Maggi M
Best Pract Res Clin Endocrinol Metab 2022 Jul;36(4):101615. Epub 2022 Jan 20 doi: 10.1016/j.beem.2022.101615. PMID: 35153145
Papazian EJ, Pinto JM
Chem Senses 2021 Jan 1;46 doi: 10.1093/chemse/bjab045. PMID: 34673938
Yassin A, AlRumaihi K, Alzubaidi R, Alkadhi S, Al Ansari A
Aging Male 2019 Dec;22(4):219-227. Epub 2019 Jan 7 doi: 10.1080/13685538.2018.1524456. PMID: 30614347
Howard SR, Dunkel L
Best Pract Res Clin Endocrinol Metab 2018 Aug;32(4):355-372. Epub 2018 Jun 6 doi: 10.1016/j.beem.2018.05.011. PMID: 30086863

Recent systematic reviews

Esposito M, Salerno M, Calvano G, Agliozzo R, Ficarra V, Sessa F, Favilla V, Cimino S, Pomara C
Panminerva Med 2023 Mar;65(1):43-50. Epub 2022 Feb 11 doi: 10.23736/S0031-0808.22.04677-8. PMID: 35146992
Lopez-Leon S, Wegman-Ostrosky T, Ayuzo Del Valle NC, Perelman C, Sepulveda R, Rebolledo PA, Cuapio A, Villapol S
Sci Rep 2022 Jun 23;12(1):9950. doi: 10.1038/s41598-022-13495-5. PMID: 35739136Free PMC Article
Malik P, Patel K, Pinto C, Jaiswal R, Tirupathi R, Pillai S, Patel U
J Med Virol 2022 Jan;94(1):253-262. Epub 2021 Sep 7 doi: 10.1002/jmv.27309. PMID: 34463956Free PMC Article
Gómez-Ochoa SA, Franco OH, Rojas LZ, Raguindin PF, Roa-Díaz ZM, Wyssmann BM, Guevara SLR, Echeverría LE, Glisic M, Muka T
Am J Epidemiol 2021 Jan 4;190(1):161-175. doi: 10.1093/aje/kwaa191. PMID: 32870978Free PMC Article
Christou MA, Christou PA, Markozannes G, Tsatsoulis A, Mastorakos G, Tigas S
Sports Med 2017 Sep;47(9):1869-1883. doi: 10.1007/s40279-017-0709-z. PMID: 28258581

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