A 17-year 3-month-old male presents with concern for short stature. Patient is short, appears well-nourished, has no dysmorphic features, is normotensive, and noted to be prepubertal. Past medical history: Patient has been well and has not had any chronic illnesses nor has he been on any chronic medications. Parents report that he has always been among the shorter children at school. Birth history: Patient was born at full term by normal vaginal delivery. His birth weight was 2.5 kg and his birth length is not available. Developmental history: Parents report normal developmental milestones. No history of delayed dentition. Diet history: Patient consumes about 1800 kcal/day. Family history: Patient lives with his parents and younger brother. No reported medical or hormonal disorders in the immediate or extended family. Social history: Patient is studying in twelfth grade and reported good grades. Physical examination: Patient is noted to be 147 cm tall (–3.5 SD below mean) and 40 kg (–1.88 SD below mean). No evidence of goiter. Patient is noted to be tanner 1 for pubic hair with tanner 1 prepubertal testicles. Other systemic exam is within normal limits. Labs • Normal CBC, electrolytes, S. calcium and phosphorus, renal function, liver function and urinalysis • AM cortisol noted to be 4.6 mg/dL, stimulated cortisol level 15 mg/dL • FSH 0.51 mIU/mL, LH 0.10 mIU/mL, Testosterone <2.5 ng/dL • Prolactin 11.44 ng/mL • TSH 0.019 mcIU/L (0.6–5.5), fT4 0.6 ng/dL (0.8–1.7) • Testosterone primed GH stimulation testing with clonidine noting peak GH level below 3 ng/mL.
What are some suggested hormone replacement regimens in girls?
Medicine
• Hormonal replacement therapy is usually begun around 11–12 years of age.
• Ethinyl estradiol 5 μg (or lower) by mouth or conjugated estrogen 0.3 mg (or less) by mouth daily for 4–6 months or transdermal estradiol, 0.1 μg/kg/day patch is usually started, with gradual increase in doses over two years to adult replacement doses of 20 μg/day ethinyl estradiol or 1.25 mg/day conjugated estrogen or 100 μg/day transdermal estradiol.
• After about 2 years of estrogen or when patient develops breakthrough bleeding, progestin is added. Hormones are given cyclically with estrogen for the first 21 days of the month and 200–300 mg micronized oral progesterone or 5 mg oral medroxyprogesterone for about 12 days a month from day 10 to day 21. A 7-day pill free period leads to monthly menstrual bleeding.
• Once patient has attained adult replacement doses and is having regular cycles, she may be switched to oral contraceptive preparations containing combination of estrogen and progesterone.
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