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JOURNAL OF
THE ANATOMICAL SOCIETY OF INDIA

Vol. 49, No. 2, December, 2000


In this issue :

Editorial
Dr. Patnaik V.V.Gopichand

Gross Anatomy of the Caudate Lobe of the Liver
Sahni, D., Jit, I., Sodhi L. Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Branching Pattern of Axillary Artery - A Morphological Study
*Patnaik V.V.G., Kalsey, G; Singla Rajan, K. Department of Anatomy, Government Medical College, Amritsar, *Patiala. INDIA

The Course, Relations and The Branching Pattern Of The Middle Meningeal Artery In South Indians
Manjunath, K.Y. & Thomas, I.M. Department of Anatomy, St. John�fs Medical College, Bangalore-560 034 INDIA

Morphometry of the Human Inferior Olivary Nucleus
Dhall, U; Chhabra, S. & Rathi, S.K. Department of Anatomy, Pt. B.D. Sharma P.G.I.M.S., Rohtak. INDIA

Management of Turner Syndrome in India Using Anthropometric Assessment of Response to Hormone Replacement Therapy.
Sehgal R. and Singh A. Department of Anatomy, Maulana Azad Medical College and Associated Lok Nayak, G.B. Pant & G.N.E.C. Hospitals, New Delhi ? 110 002 INDIA.

Insertion Of Umbilical Cord On The Placenta In Hypertensive Mother
Rath* G, Garg** K, and Sood*** M. *Department of Anatomy, ***Department of Obstetrics & Gynaecology, Lady Hardinge Medical College, New Delhi-110001 **Department of Anatomy, Santosh Medical College, Gaziabad. INDIA

Utility Of Finger Prints in Myocardial Infarction Patients
Dhall, U; Rathee, S.K; *Dhall, A; Department of Anatomy & *Medicine, Pt. B.D. Sharma, PGIMS, Rohtak. INDIA

The Prenatal Parotid Gland
Fouzia Nayeem, Sagaff S., *Krishna G., **Rao S. Department of Anatomy, K.A.A.U. Jeddah. Department of *Pediatrics & **Surgery, Osmania Medical College, Hyderabad. INDIA

Possibility of Cell Death Induced Skeletal Malformations Of The Upper Limb
Sinha, D.N. Department of Anatomy, B.R.D. Medical College, Gorakhpur?273013 INDIA,

Efficacy of Manual Bladder Expression in Relieving Urine Retention After Traumatic Paraplegia In Experimental Animals.
Preeths, T.S., Sankar, V. Muthusamy, R. Department of Anatomy, Dr. A. Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai 600 113, India.

Stress And Serum Cholesterol Levels-An Experimental Study
Jain, S.K. *Pandey, S.N. *Srivastava, R.K. Ghosh, S.K. Department of Anatomy, D.R.P.G. Medical College, Kangra at Tanda. * Department of Anatomy, G.S.V. Medical College, Kanpur.

Effect of Ibuprofen On White Cell Series of Bone Marrow Of Albino Rats
* Bhargava, R., Chandra, N., Naresh, M., *Sakhuja S. * Department of Anatomy, M.L.N. Medical College, Allahabad * Lady Hardinge Medical College, N. Delhi, India.

JB4 An Embedding Medium For Flourescent Tracer Technique
*Gupta, M; **Mishra, S., ***Sengupta P. Department of Anatomy, *PGI, Chandigarh; **AIIMS, N. Delhi; ***UCMS, New Delhi. INDIA

Comparative Anatomy of Cardiac Veins in Mammals
Kumar Keshaw Department of Anatomy, Institute of Medical Sciences B.H.U., Varanasi?5. INDIA

Aplasia Cutis Type 9 With Trisomy-13 Syndrome ? A Rare Association
Adhisivam, B, Narayanan, P, Vishnu Bhat, B, *Ramachandra Rao. R*, *Rao. S*, Kusre, G.* Department Pediatrics & *Anatomy, JIPMER, Pondicherry - 605 006

Absence of Musculocutaneous Nerve And The Innervation of Coracobrachialis, Biceps Brachii And Brachialis From The Median Nerve
Sud, M.; Sharma A. Department of Anatomy, Christian Medical College, Ludhiana. Punjab INDIA.

A Rare Pseudo Ansa Cervicalis: A Case Report
Indrasingh I. and Vettivel S. Department of Anatomy, Christian Medical College, Vellore, India

A Rare Variation In The Relation Of Omohyoid Muscle: A Case Report
Vettivel, S. Korula, A. and Koshy S. Department of Anatomy, Christian Medical College, Vellore, India

Surgical Incisions ? Their Anatomical Basis Part II - Upper Limb
1Patnaik V.V.G., 2Singla Rajan. K., 3 Gupta P.N. Department of Anatomy, Government Medical College, Patiala1, Amritsar2, 3Department of Orthopedics, Government Medical College, Chandigarh. INDIA

Anatomy Of Temporomandibular Joint?A Review
1Patnaik V.V.G., 3Bala Sanju; 2Singla Rajan K. Department of Anatomy, Govt. Medical College, 1Patiala, 2Amritsar, 3Department of Oral & Maxillofacial Surgery, Pb. Govt. Dental College, Amritsar


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J Anat. Soc. India 49(2) 142-148 (2000)
Management of Turner Syndrome in India Using Anthropometric Assessment of Response to Hormone Replacement Therapy.

Sehgal R. and Singh A. Department of Anatomy, Maulana Azad Medical College and Associated Lok Nayak, G.B. Pant & G.N.E.C. Hospitals, New Delhi ? 110 002 INDIA.

Abstract : Physical maturity and growth have a great bearing on the self-esteem of a young woman, especially in the overly critical social milieu that still exists in many parts of India. For a victim of Turner syndrome, hormone replacement therapy (HRT) with estrogen and progesterone offers hope of a relatively normal life. The present study was aimed at assessing the value of clinical anthropometry and Tanner criteria for monitoring response to HRT in Indian women with Turner syndrome. Fifty patients presenting in Gynaecology OPD with features of Turner syndrome underwent clinical and diagnostic work-up. Anthropometric parameters and Tanner stages were recorded prior to and at three-monthly intervals after beginning HRT. The data was classified according to duration of treatment and analyzed using the Student�fs paired t-test. Statistical analysis revealed highly significant changes in girth measurements of trunk, bithelion breadth, Tanner stages of breast and pubic hair development and weight, in a duration dependent manner. Regular measurement of the gradual changes in body proportions was found to enhance the patients�f eagarness to continue the treatment. Anthropometry and Tanner staging thus constitute a simple, inexpensive and useful methodology for assessing the therapeutic effect of HRT on the sexually infantile phenotype in Turner syndrome.

Keywords : Turner syndrome, hormone replacement therapy, anthropometry, Tanner criteria.

Introduction

Turner syndrome (TS) is a frequent cause of impaired physical development, amenorrhea and infertility, as a consequence of total or partial loss of one of the two X chromosomes in some or all cells (Sylven, Hagenfeldt, Brondum-Nielsen and von Schoultz, 1991). Early oocyte destruction, absent folliculogenesis and a resultant deficiency of ovarian sex- steroid hormones characterize the pathophysiology in TS (Wilson and Foster, 1992). Management is therefore targeted at compensating these deficits through hormone replacement therapy (HRT) with estrogen and progesterone (Emery and Rimoin, 1983), after the patients have achieved a chronological age of 14 years (Ranke and Grauer, 1994). The role of HRT in promoting a positive self-concept for social functioning and appropriate gender identity (Emery and Rimoin, 1983; Ross, Mc Cauley and Roeltgen et al, 1996) is well-documented, as also are its long-term benefits in preventing osteoporosis (Asch and Studd, 1993; Rubin, 1998) and cardiovascular diseases (Ginsburg, 1989; Asch and studd, 1993). Review of literature throws light on the paucity of information relating to the prevalence rates, common presentations and prognosis of this multi-system disorder in Indian populations. Sizeable lacunae exist in our knowledge of the short and long-term consequences of hormone treatment in Indian women with TS. There is thus a need for a reasonably accurate method of assessing response to HRT, but involving minimum investments in terms of money, technology, equipment and medical personnel.

The authors were involved in conducting a biweekly Infertility Clinic associated with the Genetics laboratory at the Anatomy department. We decided to test the feasibility of clinical anthropometry and Tanner staging as means for assessing the therapeutic value of HRT. The present study was planned with the long-term goal of making it possible for a young woman of TS, to lead a relatively normal life in a developing country with limited access to advanced medical technology.

Materials and Methods

Patients :

Fifty ethnic Indian patients presenting in Gynaecology OPD with features of TS, underwent clinical evaluation followed by laboratory and radiological investigations at the Lok Nayak Hospital. Diagnosis was established in each case through : (1) gonadotropin assay (LH, FSH, prolactin) conducted at the Department of Nuclear Medicine; (2) pelvic ultrasound at the Department of Obstetrics & Gynaecology; (3) sex-chromatin analysis at the Department of Anatomy using giemsa- stained slides of buccal and peripheral smears. The free-of-cost availability of these investigations in government-run Lok Nayak Hospital was an important factor in their choice- karyotype is not a cost-effective proposition in most cases. Forty-six patients were of ages ranging from 14 to 32 years (41 were aged 17 years or above) at the time of seeking medical counsel for the first time, only four presenting in the pediatric age- group. The latter were referred to Pediatric Endocrinology for assessment, while the former participated in the study consequent upon informed consent. Twenty-seven women were married at first consultation, over half of them citing primary infertility as their chief presenting complaint despite presence of amenorrhea. Primary amenorrhea and sexual infantilism emerged as significant factors motivating the unmarried girls for consulting the doctor, often just weeks before marriage. As a group, the educational and economic status of the patients was not high-13 had studied only upto primary school level and another 10 were completely illiterate; 30 women were housewives, 15 were school-going girls and only one was professionally employed. None of the patients of the study-group had received growth hormone/oxandrolone or estrogen-progesterone therapy prior to the time of the study. They showed less than 15% chromatin positive nuclei on sex-chromatin analysis (Hafez and Peluso, 1976; Yunis, 1977) and elevated levels of serum LH and FSH i.e. luteinizing and follicle stimulating hormones (Asch and Studd, 1993). Their hypoestrogenic status was confirmed by progestogen challenge test (Asch and Studd, 1993)- oral medroxyprogesterone acetate given in a dose of 5 mg per day for 5 days failed to induce a withdrawal bleed. Ultrasonography (Mazzanti, Cacciari and Bergamaschi et al, 1997) revealed defects ranging from unilaterally or bilaterally absent gonads to hypoechoic small ovaries with absent follicles and associated hypoplastic uterus or vaginal atresia.

Anthropometry and Tanner staging :

Standing height and sitting height were measured as vertical distances from the highest point on the head to the floor and the sitting surface respectively, with the head of the patient positioned in the eye-ear (Frankfurt) plane. For measuring armspan, the patient was asked to stand with her back against a vertical blank wall, both upper limbs stretched parallel to the floor with their flexor surfaces facing anteriorly. Marks were made corresponding to the tips of the middle finger on both sides and the distance between the two points was recorded with a measuring tape. The weight was estimated using an accurate weighing scale (Ramon Surgical Co., Polo Road, Delhi, India). The next set of measurements were made using palpable landmarks as described by Williams, Bannister and Berry et al in Gray�fs Anatomy (1995). For midarm circumference, the tape measure was placed around the bare upper arm at the midpoint between acromial angle and lateral epicondyle of the humerus. Girth measurements were estimated with the tape measure placed horizontally at the level of nipples (chest girth), umbilicus (waist girth) and around the widest part of hips (hip grith). Bithelion breadth was recorded as the straight distance between the right and left nipple (thelion). Limb lengths were measured on both sides by holding the tape measure taut between palpable bony landmarks : acromial angle and styloid process of the radius (upper limb length without hand); styloid process of the radius and tip of middle finger (hand length); anterior superior spine of the ilium and medial malleolus of the tibia (lower limb length without foot); medial malleouls of the tibia and tip of second toe (foot length.) Mean values were calculated for bilateral body measurements. The staging and maturity rating of secondary sexual characters was done through clinical examination of breast and pubic hair development using Tanner criteria (Speroff, Glass and Kase, 1994).

The parameters outlined above were recorded in a structured case-sheet format for each patient of the study-group, along with their individual particulars, findings on history and examination, and results of diagnostic tests. The case-sheet included a questionnaire relating to the psychological state of the patient : (1) how do you feel about yourself ? (2) how do you view yourself in the context of others - sibling/schoolmates/playmates, spouse/ in-laws ? (3) do you like participating in group activities or do you prefer being alone ? (4) do studies/ work interest you ? (5) how do you look at your future ? This exercise as well as the record of parameters was done once before administering HRT and subsequently every three months.

Hormone replacement therapy :

Oral ethinyl estradiol was prescribed in a dose of 0.025 mg per day for 21 days. Intake was started on the first day of the month and it was combined two weeks later with oral medroxyprogesterone acetate (Yen and Jaffe, 1991; Breckwoldt, keck and karck, 1995). in a dose of 5 mg per day for a period of 10 days (i.e. from the 15th to the 24th day of the month). The treatment was repeated from the first day of the next month and so on.

Statistical analysis :

The data was classified according to the duration of intake of HRT. Calculations were made to obtain the mean and standard deviation (SD) of the change (d) in each parameter after hormone intake for a specific time period. The t- value of this change (d) was deduced for each parameter, using the Student�fs paired t-test :

Comparison of this calculated t-value with the table value at (n-1) degrees of freedom facilitated classification of the change (d) as : (1) not significant (NS) if t-value was found less than the table value at P = 0.05 level of significance; (2) significance (S) if t-value exceeded the table value at P = 0.05; (3) highly significant (HS) if t-value exceeded the table value at P=0.01. Thus the level of significance of the change in various parameters in response to HRT was deduced for different durations of hormone intake.

Observations and Results :

The patients were under hormore therapy for variable lengths of time, depending on when they sought first consultation during the study period of 24 months (Table 1).

Table I. Classification of cases according to duration of hormone intake.

Duration of HRT (months) n (number of cases)
3-6
6-9
9-12
>12
No treatment*
Total
3
5
9
29
4
50

The data was classified into four groups (Table II), the cases included in each group not being mutually exclusive. The number of cases (n) in each group was determined by the frequency of follow-up visits ? some patients returned regularly every three months while others came only once or twice.

Table II. Classification of data for statistical analysis.
Group code Duration of HRT (Months) n
A
B
C
D
>12
9
6
3
29
12
17
10

* No treatment was given to four patients of ages less than 14 years.

Analysis of data (Table III) revealed highly significant increase in the girth measurements, Tanner stages of secondary sexual development, mean midarm circumference and weight in response to HRT for a period of 12 months and above (Group-A). A highly significant decrease in value was noted for bithelion breadth in the same duration. Patients assessed nine months (Group-B) and six months (Group-C) after commencement of HRT showed similar changes in chest girth, Tanner stages, bithelion breadth and weight. However in three months (Group-D), the patients just begin to respond to treatment signifying the duration dependent nature of therapeutic response to HRT (Table IV). Only rhythmic menstrual bleeding began immediately after the first cycle of HRT.

Feelings of inferiority, disinterest in academic and professional activity, social withdrawal and a pervasive sense of hopelessness were found to characterize the psyche of most patients prior to HRT. Twenty-three women stated that they felt depressed all the time. One married woman seeking medical aid for infertility, confessed to having made several suicidal attempts due to fear of abandonment. A gradual improvement in body-image and self-esteem was observed as secondary sexual development and menstruation commenced under the influence of hormones. An increased desire to interact socially with peers was a direct result of increased social acceptance and self-confidence. As feeling of inadequacy lessened, an improvement in academic performance was noted among the school-going girls. Many older women became receptive to the idea of economic independence through gainful employment to cope with abandonment by spouse and family, and some began considering adoption. Medical supervision through three monthly follow-up was reassuring for the patients on hormone therapy. Regular measurement of the gradual physical changes induced by HRT, had a very positive impact on patients�f willingness towards compliance and continuation of treatment.

Discussion

A significant observation of this study was that Indian patients with TS unlike their western counterparts (Kleczkowska, Kubien, Fryans and van den Berghe, 1990; Gluck, Attanasio, Speer, Butenandt, Tietze and Scherbaum, 1992), seek medical intervention at a later age and often after marriage due to social constraints. Scant attention is paid to growth and nutrition of girls during childhood and concerted attempts are made by patients and their families towards concealment of puberty-related problems for as long as possible. In a country like India where early marriages are the norm and motherhood is equated to womanhood, Turner patients are either concerned about being ostracized because of sexual infantilism and amenorrhea, or anxious about being abandoned because of infertility. There is general agreement that infertility and sexual infantilism, not short stature, primarily concerns adult women with TS (Holl, Kunze, Etzrodt, Teller and Heinze, 1994). But the patient profile in the west differs markedly from that in India, specifically with reference to age at

Table III. Statistical analysis of data.

S. No. Parameters Group - A Group - B Group - C Group - D
mean + SD t-value Si of (d) of (d) of (d) mean + SD t-value Si of (d) of (d) of (d) mean + SD t-value Si of (d) of (d) of (d) mean + SD t-value Si of (d) of (d) of (d)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Height (cm)
Sitting height (cm)
Weight (kg)
Mean mid-arm circumference (cm)
Chest girth (cm)
Girth at waist (cm)
Girth at hips (cm)
Bithelion breadth (cm)
Arm span (cm)
Mean upper limb length (cm)
Mean hand length (cm)
Mean lower limb length (cm)
Mean foot length (cm)
Tanner's grade: breast development
Tanner's grade : pubic hair

0.29  0.85  1.87  NS
0.07  0.22  1.71  NS
1.78 0.94 10.15  HS
0.21  0.30  3.86  HS
6.41 2.00 17.24  HS
0.41  0.43  5.22  HS
0.80  1.01  4.23  HS
-0.78 0.36 -11.5  HS
0.21  0.57  1.97  NS
0.08  0.19  2.12  S
0.02  0.08  1.39  NS
0.23  0.68  1.85  NS
0.03  0.13  1.47  NS
2.24 0.77 15.62  HS
2.10 0.84 13.41  HS

0.04  0.14  1.04  NS
0.00  0.00    -      NS
1.37  0.45  10.6  HS
0.02  0.06  1.04  NS
4.77  1.76  9.37  HS
0.13  0.30  1.46  NS
0.29  0.38  2.66  S
-0.68 0.34 -7.04 HS
0.04  0.14  1.04  NS
0.01  0.03  1.04  NS
0.00  0.00      -    NS
0.04  0.14  1.04  NS
0.03  0.08  1.04  NS
1.67  0.62  9.26  HS
1.67  0.75  7.75  HS

0.216 0.67 1.64 NS
0.06  0.16  1.51 NS
1.10  0.71  6.39 HS
0.13  0.27  1.96 NS
3.15 1.04 12.49 HS
0.10  0.20  2.03 NS
0.34  0.52  2.69 S
-0.51 0.30 -6.93 HS
0.03  0.12  1.03  NS
0.04  0.12  1.37  NS
0.01  0.05  1.03  NS
0.19  0.48  1.68  NS
0.00  0.00      -    NS
1.12  0.47  9.79  HS
1.00  0.47  6.01  HS

0.00   0.00   -       NS
0.00    0.00   -      NS
0.65 0.23 8.80     HS
0.10  0.20  1.58   NS
1.61  1.16  4.40   HS
0.09  0.18  1.57   NS
0.15  0.23  2.07   NS
-0.34  0.23  -4.70 HS
0.00    0.00    -     NS
0.00     0.00    -    NS
0.00     0.00     -   NS
0.05  0.15  1.05    NS
0.00     0.00    -     NS
0.50   0.50  3.16    S
0.20   0.40    1.58  NS

(d) : difference between post-treatment table-values table values table values table values
and pre-treatment value; Si : level of - At P = 0.05 : 2.048 - At P = 0.05 : 2.201 - At P = 0.05 : 2.120 - At P = 0.05 : 2.262
Significance. - At P = 0.01 : 2.763 - At P = 0.01 : 3.106 - At P = 0.01 : 2.921 - At P = 0.01 : 3.250

Table IV. Correlation of change in 15 parameters with duration of hormone intake.

S.No. Parameters Change 3mths 6mths 9mths > 12mths

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Height (cm)
Sitting height (cm)
Weight (kg)
Mean mid-arm circumference (cm)
Chest girth (cm)
Girth at waist (cm)
Girth at hips (cm)
Bithelion breadth (cm)
Arm span (cm)
Mean upper limb length without hand (cm)
Mean hand length (cm)
Mean lower limb length without foot (cm)
Mean foot length (cm)
Tanner's grade : breast development
Tanner's grade : pubic hair















NS
NS
HS
NS
HS
NS
NS
HS
NS
NS
NS
NS
NS
S
NS

NS
NS
HS
NS
HS
NS
S
HS
NS
NS
NS
NS
NS
HS
HS

NS
NS
HS
NS
HS
NS
S
HS
NS
NS
NS
NS
NS
HS
HS

NS
NS
HS
HS
HS
HS
HS
HS
NS
S
NS
NS
NS
HS
HS

: increase; ↓ : decrease.

presentation, marital status, education and economic self-reliance (Sylven et al, 1991; Holl et al, 1994).

In this scenario, the results of the present study suggest a possible role of clinical anthropometry and Tanner criteria for evaluation of spontaneous growth of Turner cases and the maturation changes induced by hormone replacement. Research supports our observation of secondary sexual development and menstrual bleeding following HRT in Turner patients (Emery and Rimoin, 1983, Yen and Jaffe, 1991). A satisfactory rate of breast development may be inferred from the highly significant increase in chest girth and Tanner stage. The decreasing bithelion breadth indicates a shift from the Turner phenotype of �e�eshield chest�f�f with widely spaced nipples (Emery and Rimoin, 1983) towards a more mature state of development. The differential increase in the three girths recorded during our study, lead us to conclude that administration of hormones promotes the typical female distribution of fat in Turner patients. This would also explain the increase in midarm circumference and weight observed among patients of the study group. It is inappropriate to draw any conclusions about the effect of HRT on linear growth in TS from the present study, since many cases first sought medical advice only after achieving final adult height and limb growth ? 41 patients were aged 17 years or above at first consultation.

Anthropometric surveys provide norms regarding the average physique of national populations, establish regional and ethnic standards for growth, and provide guidelines for implementation of medical and public health programmes. Short stature being the most constant finding in TS (Ranke and Grauer, 1994; Juul, Bernasconi and Chatelain et al, 1999), a great deal of investigative research has concentrated on establishing standards for a single growth parameter ? height (Haeusler and Frisch, 1994; Kaplowitz and Webb, 1994; Ranke, 1996) while ignoring other anthropometric and phenotypic parameters that are equally relevant determinants of patient satisfaction. For girls in India, living upto their physical potential takes second place to fulfilling the social role ordained for them. Although the findings relating to the psychological state of patients assessed in our study are similar to the observations of other workers (Rickert, Hassed, Hendon and Conniff, 1996), the level of ostracism faced by an infertile woman in India adds another dimension to the problem. Management of Indian patients with TS must therefore take into account the unique psychosocial consequences of their aberrant genetic heritage. Normalization of menstrual cycle and external appearance induced by HRT, go a long way towards the emotional empowerment and social rehabilitation of the largely marginalized Turner woman in India. Anthropometry and Tanner criteria are simple and effective ways for monitoring the dramatic changes affected by estrogen and progesterone on the sexually infantile phenotype in TS. The methodology adopted in this study can be easily standardized and the instruments used are easily available or improvisable and inexpensive. Regular follow-up was found to mitigate the anxiety experienced by Turner patients about an uncertain future, and helped them to face their tomorrows with determination and hope.

Acknowledgements :

The authors gratefully acknowledge the contribution of the following gynaecologists for motivating their patients to participate in this study and for supervising their treatment: Dr. Kamla Sharma and Dr. S Batra (Department of Obstetrics & Gynaecology, Lok Nayak Hospital, New Delhi); Dr. Shanti Yadav (Deptt. of Obstetrics & Gynaecology, Smt, Sucheta Kriplani Hospital, New Delhi). This paper has been abridged and updated from thesis for M.S. (Anatomy) accepted by the University of Delhi in 1998.

References :

1. Asch, R.H. and Studd, J.W.W. : Annual Progress In Reproductive Medicine, In : Can bone density be increased with estrogen therapy ; Sex steroids, lipids and cardiovascular risk & Amenorrea ? causes and consequences. The Parthenon Publishing Group, USA, pp 283-290, 247-260 & 205-234 respectively (1993).
2. Brekwoldt, M., Keck, C. and Karck U. (1995) : Benefits and Risks of Hormone Replacement Therapy (HRT). Journal of Steroid Biochemistry and Molecular Biology, 53 (1-6) : 205-208.
3. Emery, A.E.M. and Rimoin, D.L. : Principles and Practice of Medical Genetics. In : Sex chromosome abnormalities Vol. 1, Churchill Livingstone, London. pp 193-215. (1983).
4. Ginsburg, J. : The Circulation in the Female. In : Effects of ovarian steroids on the cardiovascular system. Parthenon Publishing, Camforth. pp 117-141. (1989).
5. Gluck, M; Attanasio, A; Speer, U; Butenandt, O; Tietze, H.U. & Scherbanm, W.A. (1992): Prevalence of auto antibodies to Endocrine organs in Girls with Turner Syndrome aged 5-14 years. Hormone Research 38: 114-119
6. Haesuler, G. and Frisch, H. (1994) : Methods for evaluation of growth in Turner�fs syndome : critical approach and review of the literature. Acta Paediatrica, 83 : 309-314.
7. Hafez, E.S.E. and Peluso, J.J. : Sexual Maturity ? Physiological and Clinical Parameters (Perspectives in Human Reproduction). In : Hormonal therapy in delayed adolescence. Vol. 3, Ann Arbor, Michigan. pp 245-278. (1976).
8. Holl, R.W., Kunze, D., Etzrodt, H., Teller, W. and Heinze, E. (1994) : Turner syndrome : final height, glucose tolerance, bone density and psychosocial status in 25 adult patients European Journal of Pediatrics, 153 : 11-16.
9. Juul, A., Bernasconi, S. and Chatelain, P. et al (1999) : Diagnosis and Growth Hormone (GH) Deficiency and the Use of GH in Children with Growth Disorders. Hormone Research, 51 : 284-299
10. Kaplowtiz, P. and Webb, J. (1994) : Diagnostic Evaluation of Short children with Height 3 SD or More Below the Mean. Clinical Pediatrics, 33(9) : 530-535.
11. Kleczkowska, A., Kubein, E., Fryns, J.P. and van den Berghe, H. (1990) : Turner syndrome : the Leuven experience (1965-1989) in 478 patients. I. Patients age at the time of diagnosis in relation to chromosomal findings. Genetic Counsel, 1(3-4) : 235-240.
12. Mazzanti, L., Cacciari, E. and Bergamaschi, R. et al (1997) : Pelvic ultrasonography in patients with Turner syndrome : age related findings in different karyotypes. Journal of Pediatrics, 131(1) : 135-140.
13. Ranke, M.B. and Grauer, M.L. (1994) : Adult Height in Turner syndrome : Results of a Multinational Survey 1993. Hormone Research, 42 : 90-94.
14. Ranke, M.B. (1996) : Disease-specific Standards in Congenital Syndromes. Hormone Research, 45 (suppl. 2) : 35-41.
15. Rickert, V.I., Hassed, S.J., Hendon, A.E. and Conniff C. (1996) : The effects of peer ridicule on depression and self-image among adolscent females with Turner syndrome. Journal of Adolscent Health, 19(1) : 34-38.
15. Ross, J.L., McCauley, E. and Roeltgen, D. et al (1996) : Self -concept and behaviour in adolscent girls with Turner syndrome : potential estrogen effects. Journal of Clinical Endocrinology and Metabolism, 81(3) : 926-931.
17. Rubin, K. (1998) : Turner syndrome and osteoporosis : mechanisms and prognosis. Pediatrics, 102(2pt3) : 481-485.
18. Speroff, L., Glass, R.H. and Kase, N.G.: Clinical Gynaecologic Endocrinology and Infertility. In : Abnormal Puberty and Growth Problems. 5th Edn., Williams & Wilkins, Baltimore. pp 361-399. (1994).
19. Sylven, L., Hagenfeldt, K., Brondum-Nielsen, K. and von Schoultz, B. (1991) : Middleaged women with Turner�fs syndrome. Medical status, hormonal treatment and social life. Acta Endocrinologica (Copenhagen), 125 : 359-365.
20. Williams, P.L., Bannister, L.H. and Berry, M.M. et al : Gray�fs Anatomy. In : Surface anatomy. 38th Edn., Churchill Livingstone, Edinburgh, pp 1909-1935. (1995).
21. Wilson, J.D. and Foster, D.W. : Williams Textbook of Endocrinology. In : Disorders of sexual differentiation. 8th Edn., W.B. Saunders, Philadelphia. pp 853-952. (1992).
22. Yen, S.C. and Jaffe, R.B. : Reproductive Endocrinology ? Physiology, Pathophysiology and Clinical Management. In : Disorders of sexual development. 3rd Edn., W.B. Saunders, Philadelphia. pp 480-510. (1991).
23. Yunis, J.J. : New Chromosomal Syndromes (Chromosomes in Biology and Medicine). In : Classical Chromosome Disorders. Academic Press, New York. pp 60-118. (1977).



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