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

Peter C. Hindmarsh

Clin Endocrinol. 2009;71(1):7-10.

Conclusions and Areas of Uncertainty

The physiology of puberty needs to be taken into consideration in the induction of puberty. Puberty is a relatively slow process and the replacement therapy in the induction process should mimic this. Long-term maintenance requires careful monitoring and long-term assessment of risk-benefit. This has not been appreciably defined in the adolescent population. Options for fertility need careful consideration and may depend on the adequacy of pubertal induction in terms of uterine development.

There remain a number of areas of uncertainty. Despite the widespread use of pubertal induction programmes, there are very few carefully constructed randomized control studies that can inform the clinician on aspects of efficacy and safety. In particular, there are no superiority studies to advance the case for one particular therapeutic modality over another in terms of clinical outcome and biochemical changes. Dosing schedules for the induction process are reasonably well defined, but those required for long-term bone health are not. Studies assessing 'trade-offs' between growth and uterine development and bone mineralization and cardiovascular risk factors are needed.

Future studies need to consider these issues and whether there are cardiovascular risk factor advantages to certain preparations. The long-term risks of breast and gynaecological malignancy remain uncertain. Long-term cohort studies are required to address these issues.

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Correspondence
Prof. Peter C. Hindmarsh, Developmental Endocrinology Research Group, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK. Tel: +44 (0) 207 905 2840; Fax: +44 (0) 207 905 2838; E-mail: p.hindmarsh@ucl.ac.uk

Cite this: How do You initiate Oestrogen Therapy in a Girl Who has Not Undergone Puberty? - Medscape - Jul 01, 2009.

Abstract and Introduction
Normal Puberty
Aims of Pubertal Induction
Process of Pubertal Induction
Pubertal Induction in Special Situations
Conclusions and Areas of Uncertainty
References

Table 1. Pubertal induction programme
Using ethinyloestradiol
Start ethinyloestradiol	2 μg per day for 6 months
Ethinyloestradiol	4 μg per day for 6 months
Ethinyloestradiol	6 μg per day for 6 months
Ethinyloestradiol	10 μg per day for 6 months
Ethinyloestradiol	15 μg per day for 6 months
At this point introduce progestagen to cycle
Finally use either oral or transdermal hormone replacement depending upon patient preference and titration of dose against symptoms, uterine growth and bone mineral density
Using oestragel (Divigel; Orion Pharma, Newbury, UK)^[9]
0·1 mg for the first year
0·2 mg for the second year
0·5 mg for the third year
1·0 mg for the fourth year
1·5 mg for the fifth year
Monitoring of progress
6 monthly
Height velocity
Pubertal staging
Blood pressure
12 monthly
Bone age
Pelvic ultrasound to assess uterine growth
Lipid profile
Bone mineral density (perhaps more reserved for later stages of pubertal induction when rapid growth is completed)
Routine annual review for girls with Turner syndrome

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