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Management of Turner syndrome in children and adolescents

Management of Turner syndrome in children and adolescents
Author:
Philippe Backeljauw, MD
Section Editors:
Peter J Snyder, MD
Mitchell E Geffner, MD
Deputy Editors:
Jessica Kremen, MD
Kathryn A Martin, MD
Literature review current through: Apr 2025. | This topic last updated: Nov 27, 2024.

INTRODUCTION — 

Turner syndrome (TS) is an important cause of short stature in females and of primary or secondary amenorrhea in adolescents. It is diagnosed based on characteristic clinical features and a blood karyotype demonstrating loss of part or all of one of the X chromosomes [1].

This topic will review the management of children and adolescents with this condition. Treatment varies with the age of the patient and includes therapy for short stature and estradiol deficiency as well as identifying and managing the associated congenital anomalies and related comorbidities or complications (table 1) [2].

The clinical manifestations and diagnosis of TS and management in adults are reviewed separately. (See "Turner syndrome: Clinical manifestations and diagnosis" and "Management of Turner syndrome in adults".)

PRENATAL MANAGEMENT — 

The diagnosis of TS may be suspected after noninvasive prenatal testing (of cell-free deoxyribonucleic acid [DNA]), an abnormal combined first-trimester screen, or abnormal fetal ultrasound. The diagnosis may be confirmed by chorionic villous sampling, amniocentesis, or cordocentesis. (See "Prenatal screening for common fetal aneuploidies: Cell-free DNA test" and "Turner syndrome: Clinical manifestations and diagnosis", section on 'Diagnosis of Turner syndrome'.)

Genetic counseling should be provided before and after prenatal testing. If possible, the counseling should be provided by health care professionals with direct experience caring for patients with TS throughout childhood and adolescence (eg, pediatric endocrinologists). Such clinicians are best suited to answer questions about available treatments and prognoses of comorbidities. Genetic counseling may be challenging because of the difficulty of predicting the specific phenotype for an individual diagnosed with TS prenatally [3]. However, retrospective case series suggest that 45,X/46,XX mosaicism may be associated with a milder phenotype [4,5]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Most common features'.)

DISCUSSION OF THE DIAGNOSIS — 

We counsel parents and other caregivers about how to discuss the TS diagnosis and related health information with children in a timely, caring, and developmentally appropriate manner.

Many patients report that their TS diagnosis or other important information was inappropriately withheld from them. In a study conducted in the United States, approximately one-third of patients with TS reported that their families or health care providers had withheld all or part of the diagnosis [6]. Several patients were not informed that they might be infertile, which caused significant distress. A guide to disclosure prepared by the Turner Syndrome Foundation is available online.

MONITORING AND MANAGING COMORBIDITIES — 

A comprehensive initial evaluation and subsequent monitoring are recommended for each of the following issues, as outlined in the table (table 2) [7,8]. Whenever possible, patients should be cared for in a multidisciplinary clinic dedicated to TS or at least by a team of specialists with experience in the care of youth with TS.

Neonates

●Confirm diagnosis – For patients in whom prenatal testing is suggestive of TS, we perform diagnostic postnatal chromosomal testing to confirm the diagnosis. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Confirmatory diagnostic testing'.)

●Evaluate for comorbidities – We also evaluate for comorbidities that may cause health concerns in the neonatal period:

•Blood glucose monitoring – Because of the link between TS and hyperinsulinemic hypoglycemia [9] (likely caused by haploinsufficiency of the KDM6A gene, which is located on Xp11.3), we typically perform prefeeding blood glucose monitoring in all newborns with known or highly suspected TS throughout the first 48 hours of life.

•Cardiovascular assessment – We conduct a thorough cardiac examination and echocardiogram to identify congenital heart defects such as coarctation of the aorta. (See 'Initial evaluation' below.)

•Kidney ultrasound – We perform an ultrasound to identify congenital abnormalities of the kidney and urinary tract. (See 'Kidney anomalies and urinary tract infections' below.)

Infants, children, and adolescents

Cardiovascular anomalies — Congenital heart defects are the most frequent cause of early mortality in this population. The incidence of such defects is higher in patients with a 45,X karyotype compared with those who have X chromosome mosaicism or structural X chromosome defects. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Cardiovascular abnormalities'.)

An approach to screening for cardiovascular anomalies is shown in the table (table 2).

Initial evaluation — At the time of diagnosis, all infants, children, and adolescents with TS should have a comprehensive cardiovascular evaluation by a pediatric cardiologist, which should include the following [7,8,10]:

●Blood pressure – In both the upper and lower extremities to screen for coarctation of the aorta.

●Electrocardiogram (ECG) – To screen for congenital heart disease, arrhythmia, or conduction abnormality.

●Echocardiogram – To evaluate for structural abnormalities, such as coarctation of the aorta, bicuspid aortic valve, and hypoplastic left heart syndrome.

●Cardiac magnetic resonance (CMR) – When the patient is old enough to tolerate the procedure without general anesthesia (typically around 12 years of age) [8]. CMR is valuable for both screening and surveillance, especially to detect abnormalities such as a dilated ascending aorta, an elongated transverse aortic arch (as well as other aortic phenotypes with milder aortic arch hypoplasia), and partial anomalous pulmonary venous return. Other cardiovascular anomalies in TS are outlined in the table and reviewed separately (table 1) [7,8,11]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Cardiovascular abnormalities'.)

Monitoring with cardiac imaging — All patients with TS, especially those with identified cardiac anomalies, should have ongoing follow-up care with a cardiologist—preferably one who has expertise in congenital heart disease. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Cardiovascular abnormalities'.)

Repeat imaging with echocardiography and/or CMR imaging is suggested periodically throughout life to monitor for the development and/or progression of ascending aortic dilatation. Aortic dissection or rupture is an important cause of death in women with TS, and the risk is predicted by measuring the ascending aortic diameter. Because patients with TS are typically smaller than their general population peers, the measured aortic diameter should be indexed according to body size [8].

Patients with known aortic dilatation and those with risk factors for dissection (eg, hypertension, coarctation of the aorta, and/or bicuspid aortic valve) should undergo more frequent monitoring [8]. However, routine surveillance is suggested for all patients with TS since aortic dissection can occur even in the absence of these risk factors. Despite increased efforts, it appears that more than one-half of individuals with TS are not adequately informed about the need for ongoing monitoring, even in the absence of cardiovascular symptomatology [12]. The protocol for patients 15 years and older and those considering pregnancy is discussed separately. (See "Management of Turner syndrome in adults", section on 'Cardiovascular health'.)

Management of specific cardiovascular abnormalities — Specific management issues include:

●Aortic dilatation – If aortic dilatation is identified, prophylactic intervention should be considered, especially if hypertension is present [10,13]. Maintaining normal blood pressure may lower the risk of acute aortic events [14-16]. Management may include beta blockers, exercise restriction, and/or more aggressive blood pressure control.

Prophylactic antihypertensive therapy may be started early in the course because aortic dissection may also occur earlier (at smaller aortic dimensions) in TS than in patients with aortic dilatation in the general population [8,17]. Elective surgical repair may be an option for some patients, particularly if aortic diameter is rapidly expanding (ie, an increase of >+1 in TS-specific Z-scores or an absolute increase of >+0.5 cm in one year). The techniques and perioperative care are similar in patients with TS and all other patients with aortic dilatation or dissection. (See 'Hypertension' below and "Management of thoracic aortic aneurysm in adults".)

Any complaint of chest pain should be evaluated urgently by a specialist because it may be a symptom of early dissection. (See "Clinical features and diagnosis of acute aortic dissection".)

●Coarctation of the aorta – Patients with coarctation of the aorta usually require corrective surgery. Management of coarctation of the aorta is discussed in detail separately. (See "Management of coarctation of the aorta".)

●Bicuspid aortic valve – Antimicrobial prophylaxis is not required for most patients with TS and heart valve disease, including those with bicuspid aortic valve. This is based on the 2007 American Heart Association guidelines on the prevention of bacterial endocarditis, which recommend that only patients with the highest risk for the development of endocarditis should receive antimicrobial prophylaxis [18].

Although prolonged QT interval was previously thought to be more common in TS, a crossover study measuring the corrected QT (QTc) interval in more than 300 pediatric and adult patients with TS demonstrated no increased prevalence of QTc abnormalities [19]. Therefore, we do not counsel patients with TS and normal ECG to take special precautions (eg, avoidance of QT-prolonging medications) [8].

Hypertension — Hypertension is common in TS. Blood pressure should be monitored at every clinical visit. It is important to measure blood pressure manually because automatic blood pressure monitoring often results in falsely high readings. Please refer to the European Journal of Endocrinology's 2024 TS clinical practice guidelines for additional information on management of hypertension.

●Diagnosis – Elevated blood pressure (prehypertension) and hypertension are diagnosed and evaluated using the same criteria in patients with TS as in pediatric patients without TS. Hypertension is defined as blood pressure >130/80 mmHg for adults and children >13 years or >95th percentile for younger children (table 3) [20,21]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Elevated blood pressure and hypertension' and "Hypertension in children and adolescents: Evaluation" and "Hypertension in children and adolescents: Evaluation", section on 'Initial evaluation'.)

●Treatment – If hypertension develops, it should be treated immediately with lifestyle modification and weight management. Medication is indicated in some patients. Early recognition of and treatment for systemic hypertension are particularly important for patients with TS because of their increased risk for aortic dilatation and other cardiovascular events. Patients should also be carefully evaluated for causes of hypertension that are part of the TS phenotype such as kidney disease, obstructive uropathy, and coarctation of the aorta.

Treatment of hypertension for patients with TS without a dilated aorta is the same as in pediatric patients without TS. Most experts suggest starting medical therapy for high blood pressure when measurements are in the hypertensive range on multiple measurements, ideally over multiple days [14,20-24]. The goal is to achieve a low-normal blood pressure. (See "Hypertension in children and adolescents: Nonemergency treatment", section on 'Details on specific antihypertensive drugs'.)

Patients with TS who are found to have aortic dilatation should be managed intensively by cardiologists. (See 'Management of specific cardiovascular abnormalities' above and "Management of Turner syndrome in adults", section on 'Aortic dilatation'.)

Cognitive function and learning disabilities — Neuropsychology and allied behavioral health services should be integrated into the care for all patients with TS [8]. This includes annual developmental and behavioral screenings until adulthood, with referrals as needed. Simple screening tools are also available for anxiety, a common mood disorder in TS, and can even be applied easily by nonmental health care providers more frequently [25].

In addition, neuropsychologic assessments should be performed at key transitional stages in schooling, such as entry into elementary, middle, and high school. Any learning or performance issues identified should be addressed with appropriate academic and occupational adjustments. Educational needs should be reevaluated periodically, depending on initial results and school performance (see "Specific learning disorders in children: Educational management"). A review of the many neurocognitive features observed in individuals with TS provides practical recommendations for the treatment of psychological and behavioral difficulties as well as specific considerations for educational support for the school-aged child with TS [26].

Most individuals with TS have normal intelligence. However, patients with a small ring X chromosome may have a higher risk for significant intellectual disability. This occurs if the ring X missing the X-inactivation site XIST at Xq13.2. The result is functional disomy of certain Xp loci that should normally be inactivated but instead leads to an atypical TS phenotype [27]. Many patients with TS have attention hyperactivity deficit disorder (ADHD) and difficulties with visual-spatial processing, executive function, social cognition, and nonverbal problem-solving tasks such as mathematics. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Neuropsychological concerns'.)

Tympanometry and audiology — Regular monitoring of hearing, including serial audiology evaluations, is recommended throughout life, with an audiology evaluation every three years in children and every five years in adults [8].

Children with TS have high rates of conductive hearing problems due to recurrent otitis media and middle ear effusions resulting from abnormalities of the Eustachian tubes and cranial base [28]. Progressive sensorineural hearing loss develops by adulthood in more than 50 percent of patients. (See "Management of Turner syndrome in adults", section on 'Audiology testing' and "Turner syndrome: Clinical manifestations and diagnosis", section on 'Hearing and ear abnormalities'.)

Scoliosis and kyphosis — Surveillance for scoliosis and kyphosis is important throughout childhood and especially during adolescence [7,8]. At a minimum, surveillance should include a physical examination for scoliosis (visual inspection and bend-forward test) annually and every six months during growth hormone therapy, with a consideration for additional radiographic assessment around school entry (five to six years of age) and during midpuberty (12 to 14 years of age) or when concerns arise. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Scoliosis examination'.)

Scoliosis may progress or first appear during growth hormone therapy. The presence of scoliosis or kyphosis does not preclude growth hormone therapy but warrants close monitoring during therapy, sometimes with the assistance of orthopedic specialists [7,8]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Short stature' and "Adolescent idiopathic scoliosis: Management and prognosis", section on 'Indications for referral'.)

Kidney anomalies and urinary tract infections — Patients should undergo kidney ultrasonography at diagnosis to identify congenital malformations of the kidney/urinary collecting system. If structural abnormalities are identified, patients should be evaluated by a nephrologist or urologist and may require ongoing monitoring for urinary tract infections. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Anatomical findings'.)

Ophthalmologic concerns — We perform (if feasible) a detailed ophthalmologic examination between 6 and 12 months of age or at diagnosis if older than 12 months [8]. Follow-up eye examination is required if abnormalities are present or new problems occur [7,8]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Anatomical findings'.)

Edema — Edema in TS is usually due to lymphatic hypoplasia. Lymphedema of the hands and feet at birth usually remits substantially but not always completely. Anecdotal reports describe worsening of some of the edema coinciding with the institution of either growth hormone therapy or estrogen supplementation. When present in the lower extremities in children or adults, it can be controlled in most cases with support stockings, lymphatic drainage massage therapy, and physical therapy. Some patients may benefit from referral to a lymphedema treatment center. Vascular surgery aimed at the correction of the lymphedema is rarely indicated. Use of diuretics does not improve edema and is not warranted [8].

Gonadoblastoma risk — We screen for Y chromosome mosaicism in any patient with TS who has marker chromosome elements (sex chromosome material of uncertain origin) detected on the karyotype or who presents with/develops virilization. This is because Y chromosome mosaicism can be associated with an increased risk for gonadoblastoma with or without malignant transformation. Routine molecular search for Y chromosome-derived DNA is not necessary in TS patients without marker chromosome elements or virilization [29]. (See "Turner syndrome: Clinical manifestations and diagnosis".)

If Y chromosome material is detected, we engage in collaborative decision-making discussions with the patient (if possible) and their parents/caregivers to determine whether the patient will be monitored clinically or undergo prophylactic removal of the gonads (oophorectomy or salpingo-oophorectomy). The first approach is recommended in TS clinical practice guidelines, though prophylactic gonadectomy was recommended previously [8,17,29]. Hysterectomy is not recommended to preserve the possibility of pregnancy using donor oocytes [30]. Streak gonads do not need to be explored or removed in patients without Y chromosome mosaicism.

Laboratory monitoring in children and adolescents — Routine laboratory monitoring for some TS- associated comorbidities is recommended, as outlined in the table (table 2) [8].

Celiac disease — Screen for celiac disease by measuring tissue transglutaminase immunoglobulin A antibodies (tTG-IgA; usually combined with total IgA) beginning in early childhood (around two years of age); repeat screening every two to five years throughout childhood and with new symptoms [7,8]. During early adulthood, screening should be repeated if symptoms suggestive of celiac disease arise. The risk of celiac disease is modestly increased in TS, with approximately 3 to 7 percent of patients affected. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Comorbidities'.)

Autoimmune thyroiditis — Screen for autoimmune thyroiditis by measuring thyroid-stimulating hormone annually beginning around two years of age [7,8]. The prevalence of autoimmune thyroid disorders increases with advancing age. Hypothyroidism develops in approximately 15 percent of adolescents and 25 to 30 percent of adults, while up to 50 percent of adults have thyroid autoantibodies [31]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Comorbidities'.)

Liver disease — Screen for liver disease by measuring alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGTP), and alkaline phosphatase once in childhood and around peripuberty and every one to two years thereafter. Abnormalities in these measures are common in patients with TS, perhaps due to metabolic syndrome, obesity, and/or autoimmunity. Patients with persistent aminotransferase elevations (eg, greater than twice the upper limit of normal) should be further evaluated for other causes of liver disease and/or referred to a hepatologist. Although liver enzymes may remain elevated throughout childhood and in the adolescent years, they may improve or resolve with estrogen replacement therapy [8]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Comorbidities'.)

Metabolic syndrome — Because youth with TS have reduced insulin secretion and/or sensitivity, screening for hyperglycemia by measuring hemoglobin A1c (with or without fasting glucose) should begin around 10 years of age [32]. Screening every one to two years and with new symptoms is appropriate thereafter. Screen for dyslipidemia by measuring a lipid panel annually if at least one cardiovascular disease risk factor is present (per local recommendations) and during transition [8]. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Comorbidities'.)

Vitamin D deficiency — We screen for vitamin D deficiency by measuring serum 25-hydroxyvitamin D between 9 and 11 years of age and every two to three years thereafter [8]. Alternatively, universal vitamin D supplementation may be advised rather than laboratory assessment.

Maintaining recommended serum concentrations of 25-hydroxyvitamin D is important because individuals with TS have an increased risk of fracture even if they have normal bone mineral density. In a nationwide survey, there was no difference in fracture prevalence in younger patients with TS compared with controls [33]. On the other hand, the location of their fractures differed, and, after controlling for age, impaired balance was associated with an increased fracture risk. This may be an underrecognized risk factor for fracture in this population. Patients should be counseled to ingest the recommended amount of calcium in the diet or by taking supplements. Bone mineral density assessment is not needed during the childhood years; such assessment should begin when patients reach adult estradiol replacement doses (late adolescence or early adulthood). (See "Vitamin D insufficiency and deficiency in children and adolescents" and "Turner syndrome: Clinical manifestations and diagnosis", section on 'Comorbidities'.)

MANAGEMENT OF SHORT STATURE

Monitoring growth — Short stature is the most common clinical feature of TS. To monitor growth, measurements should be plotted on TS-specific growth charts. These growth curves show height percentiles for patients with TS not treated with growth hormone and height percentiles for the general female population (figure 1) [34,35].

We do not perform growth hormone stimulation testing because patients with TS do not have growth hormone deficiency despite their short stature. Nonetheless, growth hormone therapy in pharmacologic doses improves growth.

Growth hormone therapy — Our practice is to offer growth hormone therapy to most patients with TS and short stature to maximize adult height and improve body composition.

●Indications and timing – We initiate recombinant human growth hormone therapy as soon as the height of a patient with TS falls below the 5th percentile for age on the growth chart for girls in the general population. This usually occurs between two and five years of age [7,8,36].

Younger patients with particularly poor height velocity may benefit from starting growth hormone even earlier (ie, before the height falls below the 5th percentile). We monitor how the patient's growth compares with the expected growth based on the midparental (target) height and expected target height growth curve. Significant deviation from the expected growth curve is always reason for concern and should prompt assessment of superimposed secondary causes of growth failure and/or earlier intervention. We continue growth hormone therapy until growth is complete or nearly complete (eg, bone age exceeds 13.5 to 14 years and growth slows to less than 2.5 cm per year). (See "Treatment of growth hormone deficiency in children".)

●Dosing – In the United States, a typical initial dose of recombinant growth hormone is approximately 45 to 50 mcg/kg/day (0.35 to 0.375 mg/kg/week) given once daily by subcutaneous injection. Patients with TS are typically treated with higher doses of growth hormone than patients with growth hormone deficiency.

In other countries, slightly lower doses are used. In Europe, a typical dose is 1.3 to 1.4 mg/m2/day (approximately 40 to 50 mcg/kg/day or 4.0 to 4.3 international units/m2/day), and in Australasia, 4.5 to 9.5 mg/m2/week administered in divided doses seven days per week.

Growth hormone doses >50 mcg/kg/day are not routinely recommended but may be considered in patients with very poor height prognosis if the dose is below the product-specific maximum dose and only after a careful discussion of potential risks and benefits.

Because this dosing scheme is based on body weight, the growth hormone dose may be excessive if the child is overweight. To avoid this problem, we suggest measuring serum concentrations of insulin-like growth factor-1 (IGF-1) at least annually [8]. The growth hormone dose can then be adjusted as needed to maintain IGF-1 concentrations below +2 standard deviations (SD) above the mean for age and/or Tanner stage of pubertal development but ideally above the mean (approximately +1 SD). This is because a prolonged elevation of IGF-1 (eg, >+3 SD) may be associated with toxicity, while a low IGF-1 suggests that the dose of growth hormone may be insufficient and may not achieve an optimal growth response. IGF-1-based dose titration of growth hormone therapy is extrapolated from the management of children with other growth disorders, such as idiopathic short stature or growth hormone deficiency, although the efficacy of this approach for TS has not been established. (See "Treatment of growth hormone deficiency in children", section on 'Dose adjustment based on IGF-1 response'.)

Alternatively, growth hormone dosing in TS patients can be calculated based on body surface area (using 1.33 mg/m2/day as a starting point). This approach may be most appropriate for patients older than 9 to 10 years of age (when patients are more likely to be overweight); therefore, body weight-based dose calculations are more likely to lead to larger doses than are required for treatment [37].

●Formulations – Daily growth hormone is well studied in patients with TS and therefore remains the preferred formulation for treatment in this population [8]. Although long-acting growth-hormone preparations are approved for treatment of growth-hormone deficiency in the general population, data from randomized controlled trials of these agents in individuals with TS are not available. One retrospective study found that outcomes in patients with TS treated with long-acting growth hormone were comparable to those in patients with TS treated with daily growth hormone, with respect to safety and efficacy [38].

●Effect on height – Initiation of recombinant human growth hormone at a young age (four to six years) often permits attainment of normal adult height. This has been illustrated in several studies:

The impact of growth hormone dose on growth in this population was evaluated in a trial of 68 children (mean age six to seven years) with TS who were randomly assigned to three different regimens of growth hormone (figure 2). The starting dose was approximately 45 mcg/kg/day, with some patients escalating to doses as high as approximately 90 mcg/kg/day during the first few years of therapy [39]. In long-term follow-up of 60 participants, 83 percent reached a normal adult height (ie, >-2 SD) [40]. Escalating the growth hormone dose over time to approximately 67.5 mcg/kg/day achieved a mean additional height gain of 5.3 cm (figure 3). These height outcomes were achieved after an average treatment duration of 8.6 years. Similar results were reported from an observational registry of 344 patients with TS treated with growth hormone [41].

Effects of very early initiation of growth hormone were evaluated in a prospective, randomized, open-label clinical trial in 88 children with TS aged nine months to four years of age [28]. The patients were treated with growth hormone (50 mcg/kg/day; n = 45) or were not treated (n = 43) for two years. The between-group difference at the end of the study was 1.6±0.6 SD (p<0.0001). This study confirmed that early growth hormone treatment can correct growth failure and normalize height in infants and toddlers with TS. Long-term follow-up of these patients showed that although the earlier-treated children were taller throughout childhood, their near-adult height outcome was not significantly different from those in whom treatment was initiated later (ie, the initial control group) [42].

Together, the findings from these studies demonstrate that early initiation of growth hormone therapy is important to achieve clinically significant increments in height. In select patients, higher doses (eg, above 45 mcg/kg/day) may yield additional benefits [43].

●Effect on body composition – In addition to its effect on longitudinal bone growth, growth hormone therapy may have beneficial effects on body composition. In a cross-sectional study of youth with TS, growth hormone therapy increased lean body mass and decreased body fat [44]. These changes were independent of estrogen exposure. Growth hormone therapy does not appear to have a deleterious effect on blood pressure, left ventricular function, or aortic diameter [45-47]. Adverse effects of growth hormone therapy, including benign intracranial hypertension and slipped capital femoral epiphysis, are uncommon but perhaps slightly more prevalent than in children who are treated with growth hormone for indications other than TS [48]. (See "Treatment of growth hormone deficiency in children", section on 'Adverse effects of growth hormone therapy'.)

●Effect on health-related quality of life – It is unclear whether the benefits of growth hormone therapy on adult height affect the overall health-related quality of life (HRQoL). Improved height is often the basis of the parents'/caregivers' decision to initiate growth hormone therapy and is also endorsed as important by most adolescents with TS. However, in one study of adults with TS, growth hormone treatment was not associated with improved HRQoL despite a mean 5.7 cm gain in adult height [49]. This finding does not preclude an effect of growth hormone on HRQoL because many girls experience significant improvement in adult height with growth hormone therapy compared with their untreated height projections, and HRQoL is compromised by the effects of multiple other comorbidities of TS. Studies with novel therapeutic approaches (eg, C-natriuretic peptide analogs) may further benefit the outcome of growth-promoting therapies in TS.

Strategies no longer advocated — In children and adolescents with severe short stature (ie, unlikely to reach the 5th percentile for the adult general female population), we do not use adjunctive growth-promoting approaches such as delaying pubertal induction and/or therapy with oxandrolone.

Updated TS clinical practice guidelines advise against the following:

●Use of the nonaromatizable anabolic steroid oxandrolone as an adjunctive treatment for short stature in patients with TS [8]. Prior guidance suggested use of oxandrolone in addition to growth hormone for patients with TS and severe short stature, based on evidence of positive height gain for treated patients in randomized trials [50,51]. However, the US Food and Drug Administration (FDA) withdrew regulatory approval for oxandrolone in 2023 because of reported adverse effects such as liver failure and liver cell tumors in adult patients without TS treated with oxandrolone for indications such as relief of osteoporosis-associated bone pain [52]. Oxandrolone remains unavailable in most countries.

●Delaying pubertal induction (waiting until approximately age 14 to allow for a longer period of growth before physeal fusion) [8]. This approach appears to provide, at best, a modest additional benefit to adult height. This was shown in a trial in which delaying pubertal induction from age 12 to 14 years was associated with an extra 2.7 cm increase in adult height, which was not statistically significant (95% CI -0.8 to 6.1 cm; n = 56) [50,53].

MANAGEMENT OF DELAYED OR ABSENT PUBERTY — 

Primary hypogonadism is one of the most common features of TS. Approximately 90 percent of individuals with TS have absent pubertal development and primary amenorrhea or pubertal arrest with secondary amenorrhea. (See "Turner syndrome: Clinical manifestations and diagnosis", section on 'Gonadal insufficiency'.)

Monitoring pubertal development — Pubertal development should be assessed through physical examination and measurement of serum follicle-stimulating hormone (FSH). We also measure anti-müllerian hormone (AMH) to guide decisions about fertility preservation.

●Physical examination – We monitor patients with yearly physical examinations for Tanner staging beginning around nine years of age. Prior to performing the pubertal staging examination, we take several measures to ensure patients understand and assent to an examination. We provide a clear explanation of the purpose of the examination and how it will be conducted. We offer patients the opportunity to have a chaperone present during the examination (usually a clinical staff member). (See "The pediatric physical examination: The perineum", section on 'Preparation for examination' and "Normal puberty", section on 'Pubertal changes'.)

●FSH – We measure serum FSH at approximately eight or nine years of age as it may provide information on ovarian function [54]. In most individuals with ovarian insufficiency older than 10 years, FSH will be markedly elevated [55]. However, FSH alone is inadequate to diagnose ovarian insufficiency. Although prepubertal patients with TS tend to have higher FSH values than prepubertal females without TS, there is considerable overlap, especially because FSH varies with age in healthy children [56] (see "Clinical manifestations and diagnosis of primary ovarian insufficiency (premature ovarian failure)"). We do not routinely use inhibin B in clinical practice for monitoring of puberty [55,56].

●AMH – We consider measurement of serum AMH prepubertally but offer it annually from approximately 9 to 10 years of age if primary ovarian insufficiency (POI) has not already been established. AMH has some utility as a predictor of the likelihood of spontaneous puberty [54] and the presence of functional oocytes [57]. In one retrospective study of adolescents and adults with TS, those with detectable serum AMH were more likely to experience spontaneous puberty (odds ratio [OR] 19.3) and menarche (OR 47.6) [58]. However, there is variability in AMH assays. A single detectable AMH value is rarely useful for predicting the timing or course of puberty for an individual and does not replace long-term monitoring for pubertal development.

Estradiol therapy — Most patients with TS will require hormone replacement therapy to treat hypogonadism. This includes the 15 to 20 percent of individuals with TS who experience spontaneous puberty, which may persist for a variable amount of time before premature ovarian failure occurs [59]. The objective of estradiol replacement is to mimic the normal progression of puberty while maximizing growth potential with minimal risk. Later, cyclic progestins are added to the regimen to induce cyclic uterine bleeding and prevent endometrial hyperplasia.

When to initiate — In most patients 11 to 12 years of age with absent, delayed, or stalled puberty and elevated gonadotropins, we initiate low-dose estradiol replacement. This approach allows puberty to begin at an age-appropriate time without compromising adult height [60]. We do not initiate estradiol replacement in patients younger than this age (even at a low dose) as evidence is insufficient to support this approach [61,62].

Growth hormone and estradiol may be given together until epiphysial fusion occurs, after which we stop growth hormone.

Transdermal 17β-estradiol for most patients — We suggest transdermal rather than oral estradiol (E2) and 17βE2 rather than ethinyl E2 or conjugated estrogens when possible, given the benefits of 17βE2 for bone density (see 'Dose' below). These practices are in agreement with the TS clinical practice guidelines [8].

●Rationale – Small trials suggest advantages of transdermal 17β-estradiol, including more physiologic estrogen kinetics, though data are limited.

A small randomized trial comparing oral to transdermal forms of 17β-estradiol in patients with TS demonstrated more physiologic estrogen concentrations in patients treated with the transdermal form [63,64]. Other studies suggest that metabolic parameters (eg, blood pressure and blood glucose) are similar in patients treated with transdermal and oral 17β-estradiol [63,65,66].

Transdermal 17β-estradiol is also associated with a lower risk of venous thromboembolism when compared to oral estrogens. (See "Menopausal hormone therapy: Benefits and risks", section on 'Venous thromboembolism'.)

The benefits of transdermal estradiol preparations should be balanced against the potential for poorer treatment adherence compared with oral estrogens [60] and limits of transdermal patches in patients with dermatologic disease (eg, eczema, psoriasis).

●Use of combined oral contraceptives – Many adult patients with TS prefer combined oral contraceptives (COCs) for hormone replacement. For some patients, the added convenience may improve treatment adherence. However, COCs may be associated with an increased risk of some cardiovascular complications. In a retrospective cohort of more than 500 youths and adults with TS, patients using combined COCs were more likely to have hypertension than those managed with other estrogen formulations [67]. We avoid COCs in individuals with uncontrolled hypertension or risk factors for venous thromboembolism.

Dose — Transdermal estradiol is administered via a patch. For patients with no previous pubertal development, we use initial doses ranging from 3.125 to 6.25 mcg daily (approximately one-tenth to one-eighth of the adult replacement dose). Because transdermal estradiol patches are not supplied in these low doses, patches must be cut to achieve the desired dose. Only matrix estradiol patches may be cut. Reservoir patches cannot be cut as this would make the entire dose available at once.

Some clinicians advise patients to apply the patch only overnight. This approach delivers lower estrogen doses and simulates the early-morning estrogen peaks observed in early puberty [8,68].

The dose is increased incrementally at approximately 6- to 12-month intervals to simulate normal pubertal progression until adult dosing is reached over a two- to three-year period (table 4) [8,60]. Timing of dose increases may vary based on the patient's clinical response. (See 'When to initiate' above.)

A typical adult dose is a transdermal estradiol patch (100 mcg/day) applied weekly or twice weekly. This dose is also roughly equivalent to 2 mg of oral micronized estradiol, or approximately 10 mcg of oral ethinyl estradiol [7]. Some clinicians choose to measure serum estradiol concentrations and adjust the dose to a normal range for the patient's age, but the utility of this approach has not been demonstrated.

The rationale for the gradual increase in estradiol dose is to mimic normal puberty and breast development. Although there are no available clinical data, many clinicians feel that this approach results in more normal breast development than when high doses are initiated.

Progestogen therapy

Timing — In all patients being treated with estradiol for pubertal induction, we add cyclic progesterone therapy when breakthrough bleeding occurs to minimize the risk of endometrial hyperplasia. Breakthrough bleeding typically occurs 18 to 24 months after estrogen initiation, although it may start later in patients on lower doses of estrogen [7,8]. (See "Menopausal hormone therapy: Benefits and risks".)

Oral micronized progesterone for most — We use oral micronized progesterone for most patients undergoing pubertal induction to simulate the typical duration of the luteal phase. The selection of micronized progesterone is largely based on data in postmenopausal adults, in whom treatment with micronized progesterone has been associated with lower risk of cardiovascular disease and thrombosis than medroxyprogesterone acetate. However, limited data in youth with TS have not demonstrated a difference between these agents. As an example, in a retrospective cohort study of patients with TS treated with medroxyprogesterone acetate, levonorgestrel, or micronized progesterone, no differences were noted in blood pressure, lipid profile, fasting blood glucose, or kidney function. The study population was too small to provide information on thrombosis risk [69].

Dose — After breakthrough bleeding occurs in patients maintained on estrogen, we initiate micronized progesterone at a dose of 200 mg daily for 12 days (eg, days 1 to 12 of each calendar month).

A sample regimen is as follows:

●Estradiol – Change patch weekly or twice weekly. Estradiol therapy is used continuously with no interruption; plus

●Micronized progesterone – Initiate on the first day of the month. Take daily for 12 days. Continue even if bleeding begins, discontinue on the 13th day of the month. Withdrawal bleeding is expected within one week of discontinuing progesterone.

The benefit of cyclic administration of progesterone is more predictable bleeding. However, some patients prefer continuous daily combined regimens with 100 mg micronized progesterone daily for ease of adherence [8].

Benefits of hormonal therapy — Estradiol therapy effectively induces and maintains pubertal development (eg, breast development and uterine growth). In addition, estrogen therapy positively impacts growth and height outcomes when combined with growth hormone therapy (figure 3) [40,61,70] and improves bone mineralization and peak bone mass [71,72]. Early and consistent estradiol replacement may also have benefits for cardiovascular health, as indicated by improvements in the lipid profile and reduced aortic stiffness [73,74]; it may also improve liver enzyme abnormalities [75].

Estrogen replacement appears to have some benefits on cognitive function in preadolescent patients, but its effects in older individuals are unclear [76]. In a study of patients ages seven to nine years with TS, low doses of ethinyl estradiol (25 ng/kg/day) improved verbal and nonverbal memory when compared with placebo [77]. No effect on other verbal abilities or attention was seen. A similar report in slightly older patients suggested that estrogen replacement improved nonverbal processing speed and motor function [78].

Adverse effects — Abnormal uterine bleeding occurs in approximately one-third of patients during pubertal induction with transdermal estradiol preparations, including prolonged, heavy, or intermenstrual bleeding [79]. Abnormal uterine bleeding is more likely if progestogen therapy is started later (after >18 months of unopposed estrogen), given as micronized progesterone in doses <200 mg, given less often than on a monthly basis, or if patients are not adherent to treatment.

FERTILITY PRESERVATION — 

We provide counseling about options for fertility preservation and family building to all patients with TS (table 2). Please refer to the European Journal of Endocrinology's 2024 TS clinical practice guidelines for additional information on fertility preservation.

We begin counseling during peripuberty or (in some cases) earlier, even if patients are not likely to be candidates for fertility preservation procedures. The primary option for fertility preservation in youth with TS is oocyte cryopreservation, which is used routinely in the clinical care of adolescent females without TS undergoing treatment with gonadotoxic agents [80-83]. (See "Overview of cancer survivorship in adolescents and young adults" and "Overview of cancer survivorship in adolescents and young adults", section on 'Fertility'.)

Ovarian tissue cryopreservation is not routinely used for patients with TS; it is available in selected centers only on an investigational basis [84]. Generally, fertility preservation for adolescents with TS should be undertaken only by centers with expertise in caring for youth and ideally in the context of a multidisciplinary team including physicians and mental health providers who can support a collaborative decision-making process.

Oocyte cryopreservation — Our practice is to offer oocyte cryopreservation through controlled ovarian stimulation to patients with TS who are postmenarchal and of appropriate psychological maturity; they are therefore able to participate in decision-making about fertility preservation [8].

We measure anti-müllerian hormone (AMH) prior to referral for fertility preservation and use this value to set general expectations regarding the likelihood of success of oocyte retrieval [54].

In retrospective cohort studies of patients with TS undergoing oocyte retrieval, a higher percentage of 46,XX cells [85], a higher AMH, and a lower FSH [86,87] were positively associated with number of oocytes retrieved [8,88-90]. Patients with a nonmosaic 45,X karyotype may be eligible for oocyte cryopreservation; small case series of adults with TS have documented successful cryopreservation of oocytes after controlled ovarian stimulation in those with 45, X karyotype without mosaicism [91].

The first live birth using cryopreserved oocytes in an adult with mosaic TS has been reported [92]. More data are needed to understand the long-term outcomes and risks of this approach, particularly given the increased risk of aortic dissection associated with pregnancy for adults with TS. (See "Fertility preservation: Cryopreservation options", section on 'Cryopreservation' and "Management of Turner syndrome in adults", section on 'Management of fertility and pregnancy'.)

Ovarian tissue cryopreservation — Cryopreservation of cortical ovarian tissue is an experimental technique that has been used to preserve primordial follicles in ovarian tissue from adults without TS, and a case report describes its use in a prepubertal patient without TS [93]. Clinical practice guidelines recommend that this procedure be conducted only in the context of a research protocol [88]. (See "Female infertility: Evaluation", section on 'Assessment of ovarian reserve' and "Fertility and reproductive hormone preservation: Overview of care prior to gonadotoxic therapy or surgery", section on 'Fertility preservation'.)

Counseling — Consultation with a fertility expert (eg, reproductive endocrinology and infertility physician) may be beneficial to discuss prognosis and fertility options for many patients with TS and their families [94,95]. Counseling about fertility preservation should address both benefits and risks. Patients should be included in the discussion whenever possible [8]. Early referral (eg, during childhood) may be considered for those considering ovarian tissue cryopreservation as part of a research protocol, though challenges related to effective counseling about the implications and significant medical burden of fertility preservation procedures must be considered [8].

Physicians offering fertility preservation should communicate the excess risk of mortality during pregnancy due to aortic complications such as dilatation and dissection. Therefore, if the cryopreservation procedure is successful, future pregnancy may not be advisable. The use of a gestational carrier and other options for family building should also be included in counseling. (See "Management of Turner syndrome in adults", section on 'Management of fertility and pregnancy'.)

Although available guidelines recommend counseling regarding infertility, fertility preservation, and pregnancy risks in patients with TS [96], this counseling is not always occurring. In a medical record review of over 460 young women with TS who received care at academic medical centers, documentation of fertility counseling was noted for 67 percent of families but in only 27 percent of individual patients. Only 10 percent of TS patients were referred to a reproductive specialist to discuss fertility preservation. Spontaneous menarche occurred in 58 patients (17 percent) aged nine years and older, but only 24 (41 percent) of these patients were referred to a fertility specialist [97]. Patients receiving care at a multidisciplinary clinic were more likely to receive fertility and/or pregnancy counseling.

TRANSITION TO ADULT CARE — 

The transition period is a crucial window for the health care management of patients with TS. Loss to follow-up is common, leading to insufficient monitoring of comorbidities and lack of estrogen therapy or other interventions [98,99]. Providers must take this opportunity to address the many medical and nonmedical aspects of health, including a comprehensive health evaluation [8,100]. The communication and counseling should be tailored to the patient's maturity level and is ideally achieved by a multidisciplinary team (table 2).

A toolkit to assist with the transition to adult care was developed by the Endocrine Society in 2016 and includes forms for assessing patient readiness, knowledge and skills, general recommendations to the adult-care provider, and a summary of screening recommendations [101]. Please refer to the European Journal of Endocrinology's 2024 TS clinical practice guidelines for additional information on approach to health care transition in adolescents and young adults with TS.

Important issues to discuss with the patient during the transition period include:

●Potential long-term complications of TS (especially cardiovascular disease and hearing loss) and need for ongoing monitoring.

●Reproductive issues, including fertility options and potential risks of pregnancy. (See "Management of Turner syndrome in adults", section on 'Management of fertility and pregnancy'.)

●Strategies and resources for managing learning difficulties, which, if present, continue into adult life. These resources may include educational consulting and support as well as vocational counseling [26]. (See 'Cognitive function and learning disabilities' above.)

●Resources for psychosocial support. The team should specifically encourage the patient to engage with TS support groups for emotional support and to help empower the patient to stay engaged with their health maintenance [8]. (See 'Resources and information' below.)

MORTALITY — 

Overall mortality rates in patients with TS are increased approximately threefold when compared with the general population, with the greatest excess mortality in older adulthood [102]. Noncongenital cardiovascular disease accounts for approximately 40 percent of deaths. These observations highlight the importance of preventive measures and careful monitoring for complications in both children and adults with TS. (See "Management of Turner syndrome in adults", section on 'Mortality'.)

RESOURCES AND INFORMATION — 

Information and support for patients and their families can be obtained from:

●TS Society of the United States – 1-800-365-9944

●TS Foundation – 1-800-594-4585

●TS Society of Canada – 1-800-465-6744

●TS Support Society (United Kingdom) – +44-0141-952-8006

A patient/family version of the TS clinical practice guideline is available at the TS Society website [103].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Turner syndrome".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Turner syndrome (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Initial evaluation – In all patients with Turner syndrome (TS), we perform a cardiac evaluation and kidney ultrasound to detect structural malformations shortly after diagnosis. In neonates, we also monitor for hypoglycemia in the first 48 hours of life using prefeeding blood glucose testing. (See 'Neonates' above.)

●Cardiovascular disease

•Evaluation and monitoring – All infants and children with TS should have a comprehensive cardiovascular evaluation by a pediatric cardiologist, including measurements of blood pressure in both the upper and lower extremities, electrocardiography (ECG), and echocardiography. We suggest cardiac magnetic resonance (CMR) imaging in adolescents and adults, mainly to monitor for dilatation of the ascending aorta. (See 'Cardiovascular anomalies' above.)

Repeat echocardiogram should be performed approximately every five years during childhood and adolescence and more often if aortic dilatation or other risk factors for aortic dissection (eg, hypertension, coarctation, and/or bicuspid aortic valve) are detected (table 2). (See 'Cardiovascular anomalies' above.)

Management of patients with aortic dilatation may include beta blockers, exercise restriction, and aggressive blood pressure control. However, all patients with TS should have routine blood pressure monitoring and treatment. (See 'Monitoring with cardiac imaging' above and "Management of Turner syndrome in adults", section on 'Aortic dilatation'.)

●Short stature

•Prevalence – Short stature is the most common clinical feature of TS. (See 'Management of short stature' above.)

•Growth hormone therapy – We recommend starting recombinant human growth hormone therapy as soon as the height of a patient with TS falls below the 5th percentile for age, which usually occurs between two and five years of age, rather than later initiation of growth hormone therapy (Grade 1B). The dose of growth hormone used in TS is typically higher than is used for growth hormone deficiency but must be individualized to the patient. (See 'Growth hormone therapy' above.)

●Hypogonadism

•Prevalence – Most individuals with TS have primary hypogonadism (ovarian insufficiency), as demonstrated by lack of pubertal development, primary amenorrhea, and/or pubertal arrest. All patients should be provided counseling regarding infertility, fertility preservation, and pregnancy risks. (See 'Oocyte cryopreservation' above.)

•Estradiol therapy – For most patients, we suggest starting low-dose estradiol therapy at approximately age 11 to 12 years to permit timing and pace of puberty comparable to peers, without compromising adult height (Grade 2C). (See 'When to initiate' above.)

We suggest transdermal 17β-estradiol rather than ethinyl estradiol or conjugated estrogens (Grade 2C). Oral 17β-estradiol is a reasonable alternative. This suggestion is based on the safety profile of 17β-estradiol. In addition, transdermal 17β-estradiol offers better flexibility for titration at low doses. We increase the dose gradually over two to four years (table 4). We add micronized progesterone at least 12 days per month starting when breakthrough bleeding occurs, which is typically two years after puberty starts. (See 'Transdermal 17β-estradiol for most patients' above and 'Management of delayed or absent puberty' above and 'Progestogen therapy' above.)

●Other comorbidities – Monitoring for other important health issues is outlined in the table (table 2). During childhood, monitoring focuses on learning disabilities, conductive and sensorineural hearing loss, scoliosis, and autoimmune disease (thyroiditis and celiac disease). (See 'Monitoring and managing comorbidities' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Paul Saenger, MD, MACE, who contributed to an earlier version of this topic review.

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  76. Ross JL, Reiss A, Freund L, et al. Estrogen effects on cognition and social function in Turner syndrome. In: Basic and Clinical Approach to Turner Syndrome, Hibi I, Takano K (Eds), Excerpta Medica, 1993. p.215.
  77. Ross JL, Roeltgen D, Feuillan P, et al. Use of estrogen in young girls with Turner syndrome: effects on memory. Neurology 2000; 54:164.
  78. Ross JL, Roeltgen D, Feuillan P, et al. Effects of estrogen on nonverbal processing speed and motor function in girls with Turner's syndrome. J Clin Endocrinol Metab 1998; 83:3198.
  79. Shim S, Streich-Tilles T, Gutmark-Little I, et al. Abnormal Uterine Bleeding during Pubertal Induction with Transdermal Estrogen in Individuals with Turner Syndrome. J Pediatr Adolesc Gynecol 2023; 36:358.
  80. Poirot C, Brugieres L, Yakouben K, et al. Ovarian tissue cryopreservation for fertility preservation in 418 girls and adolescents up to 15 years of age facing highly gonadotoxic treatment. Twenty years of experience at a single center. Acta Obstet Gynecol Scand 2019; 98:630.
  81. Gillipelli SR, Pio L, Losty PD, Abdelhafeez AH. Female Fertility Cryopreservation Outcomes in Childhood Cancer: A Systematic Review. J Pediatr Surg 2024; 59:1564.
  82. Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013; 31:2500.
  83. Gayete-Lafuente S, Turan V, Oktay KH. Oocyte cryopreservation with in vitro maturation for fertility preservation in girls at risk for ovarian insufficiency. J Assist Reprod Genet 2023; 40:2777.
  84. Oktay K, Bedoschi G. Oocyte cryopreservation for fertility preservation in postpubertal female children at risk for premature ovarian failure due to accelerated follicle loss in Turner syndrome or cancer treatments. J Pediatr Adolesc Gynecol 2014; 27:342.
  85. Wang R, Zhang L, Liao J, et al. In vitro fertilization and pregnancy outcomes of women with X chromosome abnormality: A case series. Birth Defects Res 2024; 116:e2349.
  86. Nadesapillai S, Mol F, Broer SL, et al. Reproductive Outcomes of Women with Turner Syndrome Undergoing Oocyte Vitrification: A Retrospective Multicenter Cohort Study. J Clin Med 2023; 12.
  87. Brouillet S, Ranisavljevic N, Sonigo C, et al. Should we perform oocyte accumulation to preserve fertility in women with Turner syndrome? A multicenter study and systematic review of the literature. Hum Reprod 2023; 38:1733.
  88. Oktay K, Bedoschi G, Berkowitz K, et al. Fertility Preservation in Women with Turner Syndrome: A Comprehensive Review and Practical Guidelines. J Pediatr Adolesc Gynecol 2016; 29:409.
  89. Acet F, Sahin G, Ucar AAO, et al. In vitro fertilization and preimplantation genetic diagnosis outcomes in mosaic Turner's syndrome: A retrospective cohort study from a single referral center experience. J Gynecol Obstet Hum Reprod 2022; 51:102405.
  90. Liao J, Luo K, Cheng D, et al. Reproductive outcomes after preimplantation genetic testing in mosaic Turner syndrome: a retrospective cohort study of 100 cycles. J Assist Reprod Genet 2021; 38:1247.
  91. Vergier J, Bottin P, Saias J, et al. Fertility preservation in Turner syndrome: Karyotype does not predict ovarian response to stimulation. Clin Endocrinol (Oxf) 2019; 91:646.
  92. Strypstein L, Van Moer E, Nekkebroeck J, et al. First live birth after fertility preservation using vitrification of oocytes in a woman with mosaic Turner syndrome. J Assist Reprod Genet 2022; 39:543.
  93. Demeestere I, Simon P, Dedeken L, et al. Live birth after autograft of ovarian tissue cryopreserved during childhood. Hum Reprod 2015; 30:2107.
  94. Schleedoorn MJ, Mulder BH, Braat DDM, et al. International consensus: ovarian tissue cryopreservation in young Turner syndrome patients: outcomes of an ethical Delphi study including 55 experts from 16 different countries. Hum Reprod 2020; 35:1061.
  95. Nadesapillai S, van der Coelen S, Goebel L, et al. Deciding on future fertility: considerations of girls with Turner syndrome and their parents to opt for or against ovarian tissue cryopreservation. Reprod Biomed Online 2023; 46:1017.
  96. Nahata L, Quinn GP, Tishelman AC, SECTION ON ENDOCRINOLOGY. Counseling in Pediatric Populations at Risk for Infertility and/or Sexual Function Concerns. Pediatrics 2018; 142.
  97. Morgan TL, Kapa HM, Crerand CE, et al. Fertility counseling and preservation discussions for females with Turner syndrome in pediatric centers: practice patterns and predictors. Fertil Steril 2019; 112:740.
  98. Devernay M, Ecosse E, Coste J, Carel JC. Determinants of medical care for young women with Turner syndrome. J Clin Endocrinol Metab 2009; 94:3408.
  99. Gawlik A, Kaczor B, Kaminska H, et al. Quality of medical follow-up of young women with Turner syndrome treated in one clinical center. Horm Res Paediatr 2012; 77:222.
  100. Lucaccioni L, Wong SC, Smyth A, et al. Turner syndrome--issues to consider for transition to adulthood. Br Med Bull 2015; 113:45.
  101. Endocrine Society. Transitions of Care for Turner syndrome. Available at: http://www.endocrinetransitions.org/turner-syndrome/ (Accessed on August 29, 2016).
  102. Schoemaker MJ, Swerdlow AJ, Higgins CD, et al. Mortality in women with turner syndrome in Great Britain: a national cohort study. J Clin Endocrinol Metab 2008; 93:4735.
  103. Turner Syndrome Society. Patient/Family version of the Clinical Practice Guidelines. Available at: https://www.turnersyndrome.org/guidelines-and-checklists (Accessed on April 19, 2018).
Topic 7386 Version 43.0

References

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41 : Early initiation of growth hormone treatment allows age-appropriate estrogen use in Turner's syndrome.

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43 : Growth-promoting strategies in Turner's syndrome.

44 : The effects of growth hormone treatment on bone mineral density and body composition in girls with turner syndrome.

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47 : Growth hormone treatment and left ventricular dimensions in Turner syndrome.

48 : Long-term safety of recombinant human growth hormone in turner syndrome.

49 : Health-Related Quality of Life in Turner Syndrome and the Influence of Growth Hormone Therapy: A 20-Year Follow-Up.

50 : Effect of oxandrolone and timing of pubertal induction on final height in Turner syndrome: final analysis of the UK randomised placebo-controlled trial.

51 : Oxandrolone for growth hormone-treated girls aged up to 18 years with Turner syndrome.

52 : Oxandrolone for growth hormone-treated girls aged up to 18 years with Turner syndrome.

53 : Growth in girls with Turner syndrome.

54 : AMH as Predictor of Premature Ovarian Insufficiency: A Longitudinal Study of 120 Turner Syndrome Patients.

55 : Differences in follicle-stimulating hormone secretion between 45,X monosomy Turner syndrome and 45,X/46,XX mosaicism are evident at an early age.

56 : FSH, LH, inhibin B and estradiol levels in Turner syndrome depend on age and karyotype: longitudinal study of 70 Turner girls with or without spontaneous puberty.

57 : Anti-Müllerian hormone levels in patients with turner syndrome: Relation to karyotype, spontaneous puberty, and replacement therapy.

58 : Anti-Müllerian hormone levels in girls and adolescents with Turner syndrome are related to karyotype, pubertal development and growth hormone treatment.

59 : Spontaneous pubertal development in Turner's syndrome. Italian Study Group for Turner's Syndrome.

60 : Estrogen Replacement in Turner Syndrome: Literature Review and Practical Considerations.

61 : Growth hormone plus childhood low-dose estrogen in Turner's syndrome.

62 : Effects of low-dose estrogen replacement during childhood on pubertal development and gonadotropin concentrations in patients with Turner syndrome: results of a randomized, double-blind, placebo-controlled clinical trial.

63 : Metabolic effects of oral versus transdermal 17β-estradiol (E₂): a randomized clinical trial in girls with Turner syndrome.

64 : Pharmacokinetics and pharmacodynamics of oral and transdermal 17βestradiol in girls with Turner syndrome.

65 : Estrogen therapy in Turner syndrome: does the type, dose and mode of delivery matter?

66 : A randomized trial of transdermal and oral estrogen therapy in adolescent girls with hypogonadism.

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68 : Sex hormone replacement therapy for individuals with Turner syndrome.

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70 : Near Adult Height in Girls with Turner Syndrome Treated with Growth Hormone Following Either Induced or Spontaneous Puberty.

71 : Turner syndrome adolescents receiving growth hormone are not osteopenic.

72 : Turner syndrome adolescents receiving growth hormone are not osteopenic.

73 : Vasculopathy in Turner syndrome: arterial dilatation and intimal thickening without endothelial dysfunction.

74 : Glucose metabolism, lipid metabolism, and cardiovascular risk factors in adult Turner's syndrome. The impact of sex hormone replacement.

75 : Hormone replacement therapy may improve hepatic function in women with Turner's syndrome.

76 : Hormone replacement therapy may improve hepatic function in women with Turner's syndrome.

77 : Use of estrogen in young girls with Turner syndrome: effects on memory.

78 : Effects of estrogen on nonverbal processing speed and motor function in girls with Turner's syndrome.

79 : Abnormal Uterine Bleeding during Pubertal Induction with Transdermal Estrogen in Individuals with Turner Syndrome.

80 : Ovarian tissue cryopreservation for fertility preservation in 418 girls and adolescents up to 15 years of age facing highly gonadotoxic treatment. Twenty years of experience at a single center.

81 : Female Fertility Cryopreservation Outcomes in Childhood Cancer: A Systematic Review.

82 : Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update.

83 : Oocyte cryopreservation with in vitro maturation for fertility preservation in girls at risk for ovarian insufficiency.

84 : Oocyte cryopreservation for fertility preservation in postpubertal female children at risk for premature ovarian failure due to accelerated follicle loss in Turner syndrome or cancer treatments.

85 : In vitro fertilization and pregnancy outcomes of women with X chromosome abnormality: A case series.

86 : Reproductive Outcomes of Women with Turner Syndrome Undergoing Oocyte Vitrification: A Retrospective Multicenter Cohort Study.

87 : Should we perform oocyte accumulation to preserve fertility in women with Turner syndrome? A multicenter study and systematic review of the literature.

88 : Fertility Preservation in Women with Turner Syndrome: A Comprehensive Review and Practical Guidelines.

89 : In vitro fertilization and preimplantation genetic diagnosis outcomes in mosaic Turner's syndrome: A retrospective cohort study from a single referral center experience.

90 : Reproductive outcomes after preimplantation genetic testing in mosaic Turner syndrome: a retrospective cohort study of 100 cycles.

91 : Fertility preservation in Turner syndrome: Karyotype does not predict ovarian response to stimulation.

92 : First live birth after fertility preservation using vitrification of oocytes in a woman with mosaic Turner syndrome.

93 : Live birth after autograft of ovarian tissue cryopreserved during childhood.

94 : International consensus: ovarian tissue cryopreservation in young Turner syndrome patients: outcomes of an ethical Delphi study including 55 experts from 16 different countries.

95 : Deciding on future fertility: considerations of girls with Turner syndrome and their parents to opt for or against ovarian tissue cryopreservation.

96 : Counseling in Pediatric Populations at Risk for Infertility and/or Sexual Function Concerns.

97 : Fertility counseling and preservation discussions for females with Turner syndrome in pediatric centers: practice patterns and predictors.

98 : Determinants of medical care for young women with Turner syndrome.

99 : Quality of medical follow-up of young women with Turner syndrome treated in one clinical center.

100 : Turner syndrome--issues to consider for transition to adulthood.

101 : Turner syndrome--issues to consider for transition to adulthood.

102 : Mortality in women with turner syndrome in Great Britain: a national cohort study.