How do You initiate Oestrogen Therapy in a Girl Who has Not Undergone Puberty?

Peter C. Hindmarsh


Clin Endocrinol. 2009;71(1):7-10. 

In This Article

Normal Puberty

The appearances and progression of the secondary sexual characteristics arise as a result of pulsatile gonadotrophin release from the anterior pituitary. It is important to realize that the appearance of pubic hair in females is dependent in part on adrenal androgen secretion. Both observational and interventional[4,5] studies demonstrate that the first stages of pubertal development arise from nocturnal pulsatile gonadotrophin secretion leading to oestradiol production in low concentrations limited initially to the overnight period. Progression through puberty requires secretion day and night with a further refinement of the LH surge to promote ovulation. The activity of the hypothalamo–pituitary–ovarian axis increases from a nadir at 6–8 years of age[6] but it is not until 10–11 years that the secondary sexual characteristics appear[1] (Fig. 1).

Figure 1.

Changes in pubertal appearances in girls. Girls: breast development: Stage 1: Preadolescent. Elevation of the papilla only; Stage 2: Breast bud stage. Elevation of the breast and papilla as a small mound. Enlargement of the areola diameter; Stage 3: Further enlargement and elevation of the breast and areola, with no separation of their contours; Stage 4: Projection of the areola and papilla above the level of the breast; Stage 5: Mature stage, projection of the papilla alone due to recession of the areola. Girls: pubic hair: Stage 1: Preadolescent. No pubic hair; Stage 2: Sparse growth of slightly pigmented downy hair chiefly along the labia; Stage 3: Hair darker, coarser and more curled, spreading sparsely over the junction of the pubes; Stage 4: Hair adult in type, but covering a considerably smaller area than in the adult. No spread to the medial surface of the thighs; Stage 5: Adult quantity and type with distribution of a horizontal pattern and spread to the medial surface of the thighs. In about 10% of women, after adolescence is complete pubic hair spreads up the linea alba and is rated Stage 6.


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