Physiologic induction of puberty in Turner syndrome with very low-dose estradiol

Many hormone preparations are available for the induction of puberty. We present arguments and evidence that favor the use of physiologic hormone replacement regimens with estradiol and progesterone that mimic the normal changes in production of these natural hormones across puberty. Delaying estrogen therapy until 15 years of age to optimize height potential, as previously recommended, seems unwarranted. This emphasis on stature tends to undervalue the psychosocial importance of age-appropriate pubertal maturation and may be deleterious to bone and other aspects of the child's health. It is now clear that puberty induction can be initiated as early as 12 years of age with very low-dose estradiol (starting doses of one-tenth to one-eighth of the adult dose) without compromising enhancement of growth potential by growth hormone (GH). We give suggestions and recommendations for the induction of puberty in Turner syndrome on the basis of existing data from prospective clinical trials. However, such data are sparse, and there are unanswered questions about optimal treatment schedules for stature, feminization, and uterine and bone development since estradiol percutaneous preparations have only recently become available by prescription in sufficiently low dosages to initiate puberty.