doi:10.1111/j.1440-1754.2008.01428.

ORIGINAL ARTICLE

Referrals for tall stature in children: A 25-year

personal experience
Michael J Thomsett
Department of Endocrinology, Mater Children’s Hospital, South Brisbane, Queensland, Australia

Aim: Extreme tall stature may lead to a variety of concerns in tall children and their parents, leading to requests for treatment to reduce final
height in some children. This study reviews referrals for tall stature to a single pediatric endocrinologist and results of treatment over 25 years
from 1980 to 2004.
Methods: Diagnoses, heights, target heights and estimated final heights at presentation, and final heights and complications in treated
patients, were examined by retrospective chart review.
Results: Of 345 referrals, 244 (71%) were girls and 101 (29%) were boys. Of the 68 (19.7%) treated, 53 (78%) were girls and 15 (22%) were boys.
Most children had familial tall stature. Treated children were tall for their already tall families. Treatment reduced final heights compared with
estimated final heights by (mean +/- standard error of the mean) 4.2 +/- 0.5 cm (P = 0.001) in girls and 5.1 +/- 0.8 cm (P < 0.001) in boys. Minor
complications occurred in 27 (51%) girls, including 5 (9.4%) who stopped treatment because of weight gain, and 5 (33%) of boys. In more recent
years, girls (but not boys) presented less frequently, were taller at presentation and opted for treatment less often, and at taller estimated final
heights than in the earlier years.
Conclusions: Any benefits of high-dose sex steroid treatment of tall children in terms of reduced final height and improved self-image are at
the expense of complications in many. Fewer tall girls being referred and treated probably reflects altered attitudes to tallness in society. Such
treatment should seldom – if ever – be used in the future.
Key words: attitudes; final height; tall stature; temporal changes; treatment.

Introduction during adolescence being a factor.1 Such concerns have led to

Concerns reported by tall children and their parents have
included social unattractiveness, feeling different, being teased,
withdrawing socially, and perceived or predicted difficulties in
finding partners and in purchasing clothes. Women who were as
tall as adolescents have a higher prevalence of major depression
than the general population with self-reported difficulties
Key Points
1 High-dose sex steroid treatment significantly reduces final
height in tall children.
2 Changes over the 25 years of this study in referral numbers,
heights at which referrals were made, and estimated final
heights on which the families opted for treatment indicate pro-
found alterations in attitudes to tall stature over that interval,
particularly in girls.
3 Any benefits in terms of reduced final height and improved
self-image are at the expense of short- and long-term complica-
tions in many. Such treatment should seldom, if ever, be used in
the future.
Correspondence: Dr Michael Thomsett, Department of Endocrinology,
Mater Children’s Hospital, Stanley Street, South Brisbane, QLD 4101,
Australia. Fax: +61 73163 1744; email: mthomsett@bigpond.com
Accepted for publication 12 July 2008.
attempts to limit final height (FH) by high-dose sex steroid
treatment.
Of the many reports of treatment for tall stature since the first
in 1956,2 few have documented the experience of a single
clinician. Such individual experience allows for consistency in
clinical approach to the problem and in the advice given to the
family and the patient. This consistency ensures that any
changes in treatment patterns over time are not because of
conflicting advice from different clinic members. Reported here
are the results of 345 referrals for tall stature to the private
paediatric endocrinology practice of the author in Brisbane,
Australia over 25 years, and the results of treatment of 68
(19.5%) of the children.
Materials and Methods
Between January 1980 and December 2004, the author con-
ducted paediatric endocrinology clinics in the two teaching
children’s hospitals in Brisbane, Australia and in a private prac-
tice, geographically separate from the hospitals. Only patients
referred by their family physicians or by other pediatricians
were seen. From 1996–1997, other paediatric endocrinologists
also attended the hospital clinics, potentially leading to the
inconsistency of clinical approach and advice to families and
patients. Therefore, only patients referred to the private practice
are reported here.

58 Journal of Paediatrics and Child Health 45 (2009) 58–63

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MJ Thomsett Referrals for tall stature in children

All interviews, measurements, examinations, bone-age read- Results

ings and estimations of FH (EFH; by the Bayley–Pinneau
method), diagnoses and discussions were performed by the
author. Consistent information was given to families and
patients regarding the diagnosis, limitations of the EFH, details
of treatment protocols, and potential advantages and disadvan-
tages of high-dose sex steroid treatment for non-disease (i.e. tall
stature) based on information available at the time. Frequently,
this was done on several visits. They were then advised to make
a considered decision on whether to treat or not, and to convey
that decision to the author at a later date. If the family opted for
intervention, all treatments were prescribed and supervised by
the author. Children not being treated were not followed up.
Treated children had a bone-age and EFH estimation repeated
every 6 months. Girls were treated with oral ethinyl oestradiol
200 mg per day, increasing to 300 mg per day if six monthly EFH
estimations were not reducing. From 1998, when ethinyl
oestradiol was taken off the market, conjugated equine oestro-
gen was prescribed at doses of 1.25–3.75 mg. Norethisterone
2.5 or 5 mg per day for 10 days a month was also prescribed.
Boys were treated with intramuscular (IM) testosterone esters
250 mg every 3 weeks, increasing to 250 mg every 2 weeks if
six monthly EFH estimations were not reducing.
Patients were asked to return after 3 months until FH was
reached (defined as no gain in height over 9 months or a gain in
height of <1 cm over 12 months) or until the family decided to
cease treatment. All patients were asked to return in a further
12 months. Not all families adhered to this advice for various
reasons and FH data was not available on those children.
National Center for Health Statistics (NCHS) standards were
used for height, weight and body mass index (BMI).3 Data on
referrals were obtained from a patient database maintained by
the author. Data on treated patients were obtained from patient
files. Pre- and post-treatment data were analysed by unpaired or
paired t-test and trends across time periods by analysis of vari-
ance. Statistical significance was defined as a P-value of <0.05.
Patients referred
Over the 25 years, 345 children were referred for tall stature,
including 244 (70%) girls and 101 (30%) boys. Diagnoses made
were familial tall stature (FTS) (85%), Marfan syndrome (4%),
constitutional advance in growth (3%), precocious puberty
(2%), and Sotos syndrome, Klinefelter syndrome and non-
classical congenital adrenal hyperplasia (1% each).
Patients treated
Families opted for treatment in 68 of the 348 patients (19.5%). Of
those treated, 53 (78%) were girls and 15 (22%) boys. The
percentage of children referred who were eventually treated was
similar in girls (22%) and boys (15%). Marfan syndrome was
present in 5 girls and 1 boy, and Klinefelter syndrome in 1 boy.
The rest of the treated children (90%) had FTS. Final height data
was available in 37 (70%) girls and 11 (73%) boys. There was no
difference in age, height standard deviation score (SDS) and EFH
between those with FH data and those without, both for girls and
boys; thus, pretreatment data for the entire group is combined.
Details of pretreatment age, height, body mass index (BMI)
and EFH, target height (TH), duration of treatment and last
available BMI in all patients and FH, where available, are shown
in Table 1. Girls and boys presented with a similar height (mean
+/- standard error of the mean) SDS (2.7 +/- 0.1 and 2.7 +/- 0.2,
respectively) but girls opted to start treatment with a lower mean
EFH SDS (3.1 +/- 0.7) than boys (3.6 +/- 0.9) (P = 0.03).
As shown in Figure 1 and Table 1, the treated children were
from tall families (EFH SDS range 0–2.9 in girls and 0.70–2.8
in boys) but the children were taller, even allowing for their
parents’ heights (height SDS range 1.0–4.7 in girls and 1.6–3.5
in boys; P < 0.001).
The mean apparent reductions in FH of 4.2 +/- 0.5 cm in girls
and 5.1 +/- 0.8 cm in boys were both significant (P < 0.001).

Table 1 Patient characteristics and duration and results of treatment

Girls SEM (Range) Boys SEM (Range)

Pre-treatment n = 53 n = 15
Age (year) 12.5 0.4 (8.7–15.4) 14.2 0.5 (11.1–17.3)
Height SDS 2.7 0.1 (1.0–4.7) 2.7 0.2 (1.6–3.5)
BMI SDS 0.1^ 0.2 (-1.8–4.4) -0.3^^ 0.2 (-1.8–1.5)
EFH (cm) 182.5* 0.6 (174.0–190.3) 200.5** 1.6 (192.8–212.1)
EFH SDS 3.1*** 0.7 (1.4–4.4) 3.6*** 0.7 (2.4–5.3)
Target height SDS 1.5 0.1 (0–2.9) 1.6 0.2 (0.7–2.8)
Post-treatment n = 37 n = 11
Treatment duration (mo) 21 1.3 (4–36) 18.5 3.0 (6–37)
FH (cm) 178.2* 0.7 (170.0–187.0) 195.4** 1.4 (188.0–202.0)
EFH–FH (cm) 4.2 0.5 (-2.3–13.4) 5.1^^ 0.8 (2.0–9.4)
BMI SDS -0.2^ 0.2 (-1.8–1.9) 0.1 0.2 (-1.5–1.2)

Pre and post-treatment comparisons: *P < 0.001; **P < 0.001; ^ and ^^ not significant. Comparisons between girls and boys: ***P = 0.03. Age, pre-
treatment height SDS and EFH were similar in FH and no FH groups in both girls and boys so all were included in pre-treatment data.
BMI, body mass index; EFH, estimated final height; FH, final height; SDS, standard deviation score; SEM, standard error of the mean.

Journal of Paediatrics and Child Health 45 (2009) 58–63 59

© 2008 The Author
Journal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Referrals for tall stature in children
Girls without FH data had a higher (P < 0.01) pretreatment
BMI SDS and post-treatment BMI SDS (0.7 +/- 0.3 and 1.1
+/- 0.3, respectively) than girls with FH data (-0.3 +/- 0.2
and -0.2 +/- 0.2, respectively). No such BMI SDS differences
were evident between boys with and without FH data.
Temporal trends
Temporal trends in gender differences are shown in Figures 2–4
and Table 2. Figure 2 shows that referrals declined in later years
so that referrals for 2000–2004 were only 28% of those in
Fig. 1 Comparison of presenting height and target height in treated girls
and boys.
Mean presenting height standard deviation score (SDS) was significantly
taller than mean target height SDS (P < 0.001) indicating that the treated
children were tall for their already tall families.
60
Journal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
MJ Thomsett
1985–1989. This fall in referrals over time was more marked
in girls than boys (P = 0.001). Figure 3 shows a similar rise in
treated cases initially, followed by an even greater decline over
recent years. No girls have started treatment since 1999 and no
boys since 2002. The falls over time in both the percentage of
referrals who were girls and the percentage of girls who were
treated are significant (P = 0.001 in each), as shown in Table 2.
Such changes over time in boys were not significant. In girls, the
mean height SDS at presentation rose (P = 0.02) and the mean
EFH SDS also rose (P < 0.001) over the study period (Fig. 4).
Thus, over time, fewer girls were seen, the mean presenting
height of girls was taller, girls were less likely to want treatment
and the EFH which led to treatment was taller – differences
were not seen in boys.
Complications
Minor complications during treatment were reported in 27 girls
(51%; often headaches, weight gain, nausea, dysmenorrhoea
and hirsutism) and 5 boys (33%; acne and oedema). However,
the only complication leading to cessation of treatment was
unacceptable weight gain in five girls (9.4%) who ceased treat-
ment after 6–13 months.
Discussion
The report details the experience of one clinician over 25 years
in seeing 345 and treating 68 children with tall stature. The
author was personally responsible for all aspects of the clinical
experience of the children, with a consistent approach to the
problem throughout. This involved providing as much informa-
tion as possible to the families and patients and insisting that
they make the decision to treat or not to treat themselves.
Eighty-five percent of the referred children and 90% of those
treated had FTS. The treated children were from tall families and
had EFHs >97 percentile. Of interest is that they were unusually
tall even for their tall parents. Reasons for this are not clear but
studies looking at whether they have inherited multiple copies
of genes coding for tallness would be interesting.
Fig. 2 Referrals for tall stature over time.
Total = 345; girls = 244 (71); Boys = 101 (29%).
Journal of Paediatrics and Child Health 45 (2009) 58–63
© 2008 The Author
MJ Thomsett
Fig. 3 Children referred and children treated
divided into 5-year intervals. The falls over time in
both referrals and children treated was signifi-
cant in girls (P = 0.001) but not boys.
Fig. 4 Changes over time in girls’ pretreatment and estimated final height
SDS divided into 5-year intervals. Changes in both were significant (P = 0.02
and <0.001, respectively).
Unfortunately, FH data was not available in 39% of girls and
27% of boys. It is important to remember that this was not a
clinical trial but treatment in a busy clinical setting. Attempts to
retrieve data from patients not returning as requested were
often not successful.
It is possible that the difference between EFH and FH (4.2
+/- 0.5 cm in girls and 5.1 +/- 0.8 cm in boys) would have been
smaller with more complete FH data. Results vary considerably
in different published reports. These differences may be due to
different treatment regimens and inaccuracies in EFH prediction
which appears to be more accurate in girls than in boys.4 The
mean reduction in FH compared with EFH has been reported as
2.4 cm,5 3.0 cm,6 and 5.2 cm7 in girls and 5.4 cm8 and 9.0 cm9 in
boys. Others report far less encouraging results.10
The results reported here suggest a profound change in atti-
tudes to tall stature since around 1990, particularly in girls. Over
recent years, compared with previous years, not only fewer girls
are being referred, but those being referred are taller. They are
less likely to want treatment and the estimated final heights
Journal of Paediatrics and Child Health 45 (2009) 58–63
© 2008 The Author
Journal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Referrals for tall stature in children
regarded as so unsatisfactory that treatment is requested are
taller. Reasons for these changes in attitudes are conjectural.
What is regarded as ‘too tall’ has changed over recent decades.
The EFH in the last group of girls treated in the current report
ranged from 184.4 to 189.3 cm, whereas in Wettenhall’s 1975
Australian report,11 treatment was considered if the EFH was
>177 cm. Such differences have been developing earlier in other
countries.12 In a 1978 American report, the height regarded by
girls as too tall was 173 cm in the mid-1960s, rising to 183 cm in
the mid 1970s.13
Complications during treatment in this report have been
frequent but mild, consistent with other reports,4,7 although
9.4% of treated girls ceased therapy because of excessive weight
gain. Girls without FH data had higher BMI SDS before and
after treatment than those with FH data. Their failure to return
for follow-up could indicate dissatisfaction with a treatment,
making a weight problem worse. Formal data on patient satis-
faction with treatment and long-term complications are not
available in the present study.
However, a major Australian study on 1243 women who had
been assessed for tall stature between 1959 and 1993 provides
important information on these issues. This examined the rela-
tionship between concern about tall stature in adolescence and
depression in later life,1 satisfaction in later years with the deci-
sion to treat or not to treat14 and long-term effects on fertility.15
Forty-two percent of the treated women expressed dissatis-
faction with the decision to treat, whereas 99.1% of untreated
women were satisfied with the decision not to treat, regardless
of their FH. Reasons for dissatisfaction included not having a say
in the decision-making, negative experiences in the assessment
and treatment procedures, side-effects during treatment and
problems encountered in later life that the participants attrib-
uted to their treatment.14
This study also reported that treatment was followed by
long-term effects on fertility.15 The treated group had greater
difficulty in conceiving than those untreated, although the
proportion of women in each group who had ever been preg-
nant was similar.
Similar long-term concerns apply in boys. In one study, men
who had been treated for tall stature as boys had a lower sperm
61
Referrals for tall stature in children MJ Thomsett

Table 2 Temporal trends in referrals, patients treated, pretreatment height SDS and estimated final heights

80–84 85–89 90–94 95–99 00–04

Referrals
Total 50 114 87 65 32
Girls 39 91 55 44 15
Boys 11 23 32 21 14
% Girls 78 80 63 68 46
% Boys 22 20 37 32 44
Treated
Total 18 24 16 9 1
Girls 13 19 11 9 0
Boys 3 5 5 1 1
% Girls 38 21 20 18 0
% Boys 27 22 16 5 7
Height SDS (mean (SD))
Girls 2.3 (0.9) 2.5 (0.7) 3.1 (0.7) 3.1 (0.5) P = 0.02
Boys 2.1 (0.5) 2.8 (0.8) 2.6 (0.8) ns
EFH cm (mean (SD))
Girls 180.0 (3.7) 181.8 (4.1) 183.6 (4.8) 186.9 (1.9) P = 0.001
Boys 199.3 (6.6) 199.7 (6.9) 201.9 (7.7) ns

EFH, estimated final height; ns, non-significant; SD, standard deviation; SDS, standard deviation score.

count, lower sperm motility and reduced normal sperm mor-
phology, together with a lower testosterone level than untreated
controls.16
The Australian study1 found that the prevalence of major
depression in both treated and untreated women was high,
compared with the findings of population-based studies, and
highlighted the importance of attending to the mental health of
adolescents with self-concept and body image concerns.
These findings, although of concern, may not necessarily
apply to the patients presented here. Many patients in this
study1 received much higher doses of oestrogen than those used
in the patients discussed in the current report. In addition, the
apparent recent changes in societal attitudes mentioned above
could well contribute to a lower prevalence of major depression
in tall women as of the present. Data on psychiatric disease in
patients reported here are not available.
In summary, a large personal experience in seeing and treat-
ing tall children over 25 years is reported. Major changes in
attitudes to tallness have led to a substantial reduction in the
number of tall girls presenting and treated but not in boys. These
changes, and the emerging evidence of interference with both
female and male adult fertility by this treatment, are likely to
lead to even fewer treatment episodes in the future. The falling
numbers of referrals of girls with FTS suggests that the percent-
age of referrals with an organic cause for tall stature is likely to
increase. Therefore, clinicians should be thorough in excluding
such causes. Treatment in extreme cases may still be warranted,
provided the patient and parents are fully aware of the difficul-
ties of accurate predictions of FH and effectiveness of treatment
in an individual, and of recent follow-up data concerning poten-
tial long-term side-effects. Psychological evaluation and coun-
selling of the patient may be beneficial. The patient should be
involved as much as possible in the decision on whether to treat
or not. In general, high-dose sex steroid treatment of tall chil-
dren should not be undertaken in the future.
Acknowledgements
I thank Drs Andrew Cotterill, Mark Harris and Gary Leong for
reviewing drafts of the manuscript.
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