A 12-year-old girl with Turner syndrome (45,X) is being evaluated for pubertal induction. Her height is 132 cm and she has been on growth hormone therapy since age 6. Bone age is 11 years. Which of the following is the most appropriate approach to induce puberty?

• A Start high-dose estrogen immediately to maximize height potential
• B Wait for spontaneous puberty as some Turner patients undergo natural pubertal development
• C Start combined oral contraceptive pills at age 12
• D Begin low-dose estrogen at age 11-12 years or when growth potential is limited, then add progesterone after 1-2 years or at breakthrough bleeding ✓

Explanation

In Turner syndrome, pubertal induction uses low-dose estrogen started at age 11-12 or when growth potential is limited, with gradual dose escalation over 2-3 years. Progesterone is added after 1-2 years of estrogen or at breakthrough bleeding to induce regular withdrawal bleeds. High-dose estrogen prematurely and would compromise final height. Combined oral contraceptives are not used for induction. Spontaneous puberty occurs in only 5-10% of 45,X patients, so waiting is inappropriate.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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