What is the daily estrogen patch dosage in mcg/day for a woman with Turner's syndrome?

Estradiol Patch Dosing for Women with Turner's Syndrome

The recommended adult dose of transdermal estradiol for women with Turner's syndrome is 100-200 μg/day, which is typically achieved with a full patch applied weekly. 1

Age-Based Dosing Protocol

• For adolescents with Turner's syndrome, initiate estrogen therapy at age 12-13 years with a starting dose of 6.25 μg/day if no spontaneous development and FSH is elevated 1
• Transdermal estradiol should be gradually increased over 2-3 years to reach the adult dose, following this progression 1:
  • 0-6 months: 6.25 μg/day (1/8 of a patch weekly or 1/4 patch for 3-4 days/week)
  • 6-12 months: 12.5 μg/day (1/4 patch weekly)
  • 12-18 months: 25-37.5 μg/day (1/2 patch for 3-4 days, then 1/4 patch for remaining days)
  • 18-24 months: 50 μg/day (1/2 patch weekly)

  • 24 months: 100-200 μg/day (full patch weekly - adult dose)

Route of Administration

• Transdermal estradiol is strongly preferred over oral formulations for women with Turner's syndrome due to 1:
  • Better uterine development parameters
  • Avoidance of first-pass liver metabolism
  • More favorable bone mass accrual and cardiovascular risk profiles 2

Progestin Addition

• Begin cyclic progestogen after at least 2 years of estrogen therapy or when breakthrough bleeding occurs (typically age 14-16) 1
• Options include:
  • Oral micronized progesterone 100-200 mg/day for 12-14 days of the month 1
  • Dydrogesterone 5-10 mg/day for 12-14 days of the month 1
• Progestin must be added to estrogen therapy for women with an intact uterus to reduce endometrial cancer risk 2

Monitoring and Dose Adjustments

• Evaluate treatment effect with 1:
  • Clinical assessment of secondary sexual characteristics
  • Ultrasonographic evaluation of uterine volume
• Make dose adjustments based on clinical response at 6-month intervals 1
• Conduct annual clinical reviews once established on therapy, paying particular attention to compliance 1

Special Considerations

• For patients receiving growth hormone therapy, estradiol dose increases might be relatively slower to achieve optimal adult height 1
• Uterine development is often suboptimal in women with Turner syndrome, with only 37% developing a uterus >65 mm in length 3
• The daily estrogen dose correlates with both uterine length and Tanner breast stage, with earlier artificial menarche associated with better uterine development 3

Practical Implementation Challenges

• The lowest commercially available estradiol patches deliver 25 or 50 μg/day; dose fractionation (cutting patches) is often necessary to achieve the recommended starting doses 1
• Avoid ethinylestradiol for pubertal induction as it may lead to suboptimal uterine development 1
• Studies comparing low-dose oral conjugated estrogen (0.625 mg) with higher-dose ethinyl estradiol (30 μg) found that ethinyl estradiol was more effective at normalizing FSH levels and suppressing bone turnover markers 4

Long-Term Considerations

• Hormone replacement therapy should be continued until the average age of spontaneous menopause (45-55 years) 2
• After menopause age, continuation decisions should be based on individual risks, family history, and symptom severity 2
• Gradually increasing estrogen therapy from ultra-low doses may produce good final height but not ideal bone mineral density in Turner syndrome patients 5