Pubertal induction and maintenance therapy for individuals with Turner syndrome, using transdermal estrogens: Approach for the first 18 to 24 months
This protocol is but one of many that can be used. This specific protocol is used in the author's clinic and is individualized depending on patient circumstances and desires. For example, older girls may prefer to start at 25 mcg of estrogen. The estrogen-progestin replacement should be continued until approximately age 50 years, the average age of menopause, to mimic the hormonal patterns of women with functioning ovaries.
Alternatives to the transdermal estrogen patch include:
- Oral micronized E2, starting at 0.25 mg daily and gradually advancing to the usual adult dose of 2 mg daily.
- Oral ethinyl estradiol, starting at 2 mcg daily and gradually advancing to the adult dose of 10 mcg daily.
- Transdermal estradiol gel (eg, Divigel), starting at 0.25 mg daily and gradually advancing to 1 mg daily[1]. The appropriate dose for a gel preparation is substantially higher than for a transdermal patch due to differences in absorption.
Neither ethinyl estradiol nor topical estradiol gels are optimal choices for pubertal induction. Ethinyl estradiol is a potent synthetic estrogen used in most combined oral contraceptives. It has a greater effect on hepatic protein synthesis than other estrogens and is the most thrombogenic
[2]. Estradiol gels are not preferred, because of the potential for transfer of estrogens to other children.