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Turner Syndrome

(Monosomy X; Gonadal Dysgenesis)

By Nina N. Powell-Hamilton, MD, FAAP, FACMG, Alfred I. duPont Hospital for Children ;Thomas Jefferson University Medical College

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In Turner syndrome, girls are born with one of their two X chromosomes partly or completely missing. Diagnosis is based on clinical findings and is confirmed by karyotype analysis. Treatment depends on manifestations and may include surgery for cardiac anomalies and often growth hormone therapy for short stature and estrogen replacement for pubertal failure.

Turner syndrome occurs in about 1/2500 live female births worldwide. However, 99% of 45,X conceptions abort spontaneously.

About 50% of affected girls have a 45,X karyotype; about 80% have lost the paternal X. Most of the other 50% are mosaics (eg, 45,X/46,XX or 45,X/47,XXX). Among mosaic girls, phenotype may vary from that of typical Turner syndrome to normal. Occasionally, affected girls have one normal X and one X that has formed a ring chromosome. Some affected girls have one normal X and one long-arm isochromosome formed by the loss of short arms and development of a chromosome consisting of two long arms of the X chromosome. These girls tend to have many of the phenotypic features of Turner syndrome; thus, deletion of the X chromosome’s short arm seems to play an important role in producing the phenotype.

Pathophysiology

Common cardiac anomalies include coarctation of the aorta and bicuspid aortic valve. Hypertension frequently occurs with aging, even without coarctation. Renal anomalies and hemangiomas are frequent. Occasionally, telangiectasia occurs in the GI tract, with resultant GI bleeding or protein loss. Hearing loss occurs; strabismus and hyperopia (farsightedness) are common and increase the risk of amblyopia. Thyroiditis, diabetes mellitus, and celiac disease are more common than among the general population.

Infants are at a higher risk of developmental dysplasia of the hip. Of adolescents, 10% have scoliosis. Osteoporosis and fractures are fairly common among women with Turner syndrome. Gonadal dysgenesis (ovaries replaced by bilateral streaks of fibrous stroma and devoid of developing ova) occurs in 90% of females. Between 15% and 40% of adolescents with Turner syndrome undergo spontaneous puberty, but only 2 to 10% undergo spontaneous menarche.

Intellectual disability is rare, but many girls have nonverbal learning disability, attention-deficit/hyperactivity disorder, or both and thus score poorly on performance tests and in mathematics, even though they score average or above in the verbal components of intelligence tests.

Symptoms and Signs

Many neonates are very mildly affected; however, some present with marked dorsal lymphedema of the hands and feet and with lymphedema or loose folds of skin over the back of the neck. Other frequent anomalies include a webbed neck and a broad chest with widely spaced and inverted nipples. Affected girls have short stature compared with family members.

Less common findings include a low hairline on the back of the neck, ptosis, multiple pigmented nevi, short 4th metacarpals and metatarsals, prominent finger pads with whorls in the dermatoglyphics on the ends of the fingers, and hypoplasia of the nails. Increased carrying angle at the elbow occurs.

Symptoms of cardiac anomalies depend on severity. Coarctation of the aorta can cause high BP in the upper extremities, diminished femoral pulses, and low or absent BP in the lower extremities. Gonadal dysgenesis results in the inability to undergo puberty, develop breast tissue, or begin menses. Other medical problems that are associated with Turner syndrome develop with aging and may not be evident without screening.

Diagnosis

  • Clinical appearance

  • Cytogenetic testing by karyotyping, FISH analysis and/or chromosomal microarray analysis

  • Testing for associated conditions

In neonates, the diagnosis of Turner syndrome may be suspected based on the presence of lymphedema or a webbed neck. In the absence of these findings, some children are diagnosed later, based on short stature, lack of pubertal development, and amenorrhea.

Diagnosis is confirmed by cytogenetic analysis (karyotyping, fluorescent in situ hybridization [FISH] analysis, and chromosomal microarray analysis [CMA]).

Echocardiography or MRI is indicated to detect cardiac anomalies.

Cytogenetic analysis and Y-specific probe studies are done for all people with gonadal dysgenesis to rule out mosaicism with a Y-bearing cell line (eg, 45,X/46,XY). These people are usually phenotypic females who have variable features of Turner syndrome. They are at an increased risk of gonadal cancer, especially gonadoblastoma, and, although controversial, it is often recommended that the gonads be removed prophylactically.

Concomitant medical conditions

Certain routine evaluations help identify problems that may be associated with Turner syndrome:

  • Cardiovascular evaluation by a specialist; MRI and echocardiography at time of diagnosis to rule out coarctation and bicuspid aortic valve and every 3 to 5 yr thereafter to evaluate aortic root diameter

  • Renal ultrasonography at time of diagnosis, annual urinalysis, BUN, and creatinine for patients with renal system anomalies

  • Hearing evaluation by an audiologist and audiogram every 3 to 5 yr

  • Evaluation for scoliosis/kyphosis annually during childhood and adolescence

  • Evaluation for hip dislocation

  • Eye examination by pediatric ophthalmologist

  • Thyroid function tests at diagnosis and every 1 to 2 yr thereafter

  • Celiac screen (eg, endomysial antibody levels)

  • Glucose tolerance test may be abnormal; fasting blood sugar and lipid profile annually during adulthood (started earlier if indicated)

Treatment

  • Management of comorbid conditions

  • Possible surgical repair of cardiac abnormalities

There is no specific treatment for the underlying genetic condition and management is based on an individual's findings.

Coarctation of the aorta is usually repaired surgically. Other cardiac anomalies are monitored and repaired as needed.

Lymphedema can usually be controlled with support hosiery and other techniques such as massage.

Treatment with growth hormone can stimulate growth. Estrogen replacement is usually needed to initiate puberty and is typically given at age 12 to 13 yr. Thereafter, birth control pills with a progestin are given to maintain secondary sexual characteristics. Growth hormone can be given with estrogen replacement until epiphyses are fused, at which time growth hormone is stopped. Continuation of estrogen replacement helps establish optimal bone density and skeletal development.

Key Points

  • Girls are missing all or part of one of their two X chromosomes.

  • Manifestations vary, but short stature, webbed neck, broad chest, gonadal dysgenesis, and cardiac anomalies (commonly coarctation of the aorta and bicuspid aortic valve) are common; intellectual disability is rare.

  • Risk of gonadal cancer is increased; it is often recommended to remove the gonads prophylactically, although this is controversial.

  • Do routine age-specific screening to detect associated medical conditions (eg, cardiac and renal anomalies).

  • Give estrogen to initiate puberty, followed by use of birth control pills with progestin to maintain secondary sexual characteristics.

  • Treat specific manifestations, and provide social and educational support and genetic counseling.

Resources In This Article

* This is the Professional Version. *