Growth hormone plus childhood low-dose estrogen in Turner's syndrome
Open accessAbstract
BACKGROUND: Short stature and ovarian failure are characteristic features of Turner's syndrome. Although recombinant human growth hormone is commonly used to treat the short stature associated with this syndrome, a randomized, placebo-controlled trial is needed to document whether such treatment increases adult height. Furthermore, it is not known whether childhood estrogen replacement combined with growth hormone therapy provides additional benefit. We examined the independent and combined effects of growth hormone and early, ultra-low-dose estrogen on adult height in girls with Turner's syndrome. METHODS: In this double-blind, placebo-controlled trial, we randomly assigned 149 girls, 5.0 to 12.5 years of age, to four groups: double placebo (placebo injection plus childhood oral placebo, 39 patients), estrogen alone (placebo injection plus childhood oral low-dose estrogen, 40), growth hormone alone (growth hormone injection plus childhood oral placebo, 35), and growth hormone-estrogen (growth hormone injection plus childhood oral low-dose estrogen, 35). The dose of growth hormone was 0.1 mg per kilogram of body weight three times per week. The doses of ethinyl estradiol (or placebo) were adjusted for chronologic age and pubertal status. At the first visit after the age of 12.0 years, patients in all treatment groups received escalating doses of ethinyl estradiol. Growth hormone injections were terminated when adult height was reached. RESULTS: The mean standard-deviation scores for adult height, attained at an average age of 17.0±1.0 years, after an average study period of 7.2±2.5 years were -2.81±0.85, -3.39±0.74, -2.29±1.10, and -2.10±1.02 for the double-placebo, estrogen-alone, growth hormone-alone, and growth hormone-estrogen groups, respectively (P<0.001). The overall effect of growth hormone treatment (vs. placebo) on adult height was a 0.78±0.13 increase in the height standard-deviation score (5.0 cm) (P<0.001); adult height was greater in the growth hormone-estrogen group than in the growth hormone-alone group, by 0.32±0.17 standard-deviation score (2.1 cm) (P=0.059), suggesting a modest synergy between childhood low-dose ethinyl estradiol and growth hormone. CONCLUSIONS: Our study shows that growth hormone treatment increases adult height in patients with Turner's syndrome. In addition, the data suggest that combining childhood ultra-low-dose estrogen with growth hormone may improve growth and provide other potential benefits associated with early initiation of estrogen replacement. (Funded by the National Institute of Child Health and Human Development and Eli Lilly; ClinicalTrials.gov number, NCT00001221.).
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Only six RCTs have compared GH treatment with concurrent non-treatment or placebo control for at least one year.
“Despite numerous studies of GH treatment in TS, only six randomized, controlled trials (RCTs) have compared GH treatment with a concurrent non-treatment or placebo control for at least one year157-162”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
Only two of these trials have followed non-GH-treated participants to adult height.
“and only two of these trials have followed non-GH-treated participants to adult height.158,160”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
A meta-analysis reported mean adult height gain of 7.2 cm.
“A subsequent meta-analysis concluded a similar effect of GH therapy, reporting mean adult height gain of 7.2 cm,168 based on data from the two RCTs that followed non-GH-treated subjects to adult height.158,160”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
Two studies demonstrated no increased risk of developing or worsening scoliosis with GH therapy in TS.
“but two studies demonstrated no increased risk of developing scoliosis or worsening existing scoliosis with GH therapy160,215 in TS.”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
In two clinical trials, adult height was within normal range for 40-50% of treated vs 4-16% of non-GH treated individuals.
“In the two clinical trials that maintained long-term untreated/placebo controls, adult height was within the normal range for 40%-50% of treated individuals vs. 4%-16% percent of non-GH treated individuals.158,160”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
One double-blind placebo-controlled trial demonstrated a modest synergistic increase in adult height, normalization of the timing of thelarche for about one-quarter of girls, and modest improvements in cognition and memory.
“One double-blind, placebo-controlled trial using ultra-low-dose oral ethinyl estradiol as a growth-promoting agent during the prepubertal period combined with GH, followed by a standardized incremental pubertal induction regimen, demonstrated a modest synergistic increase in adult height, normalization of the timing of thelarche for about one-quarter of the girls, and modest improvements in cogni”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
Even ethinyl estradiol, generally not recommended for puberty induction but used in ultra-low doses and gradually increased, resulted in favorable adult height.
“Even ethinyl estradiol, generally not recommended for puberty induction, but used in ultra-low doses and gradually increased, resulted in favorable adult height.”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [160]
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- Authors
- Ross, J. L., Quigley, C. A., Cao, D., Feuillan, P., Kowal, K., Chipman, J. J., & Cutler, G. B.
- Affiliations
- Alfred I. duPont Hospital for Children (US)
- Eli Lilly (United States) (US)
- National Institutes of Health (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2011-03-31
- Volume
- 364
- Issue
- 13
- Pages
- 1230-1242
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC3083123
- OpenAlex
- W2050210944
- Cited by
- 212
- References
- 45
- Citations by year
- 2026: 5 · 2025: 5 · 2024: 15 · 2023: 12 · 2022: 14 · 2021: 13 · 2020: 10 · 2019: 18 · 2018: 12 · 2017: 16 · 2016: 14 · 2015: 18 · 2014: 14 · 2013: 13 · 2012: 18
- FWCI
- 15.72
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Neurological Disorders and Stroke (R01NS029857)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Growth Hormone and Insulin-like Growth Factors
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genetic and Clinical Aspects of Sex Determination and Chromosomal Abnormalities
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Sexual Differentiation and Disorders
- Keywords
- recombinant human growth hormone, ethinyl estradiol, adult height, short stature, ovarian failure, pubertal stage, girls, puberty timing, growth rate, insulin-like growth factor I, bone mineral density
- MeSH terms
- Adolescent, Adult, Analysis of Variance, Body Height, Child, Child, Preschool, Double-Blind Method, Drug Therapy, Combination, Ethinyl Estradiol, Female, Growth, Growth Disorders, Humans, Turner Syndrome, Estrogen Replacement Therapy, Human Growth Hormone, Intention to Treat Analysis
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