full 45,x0 karyotype. serious complications of the kidney anomalies associated with turner syndrome are rare, although there is some risk of issues such as obstructive uropathy, where the flow of urine from the kidneys is blocked. women with turner syndrome are more likely than average to have high blood pressure; as many as 60% of women with the condition are hypertensive. isolated diastolic hypertension often precedes systolic hypertension in the condition and may develop at a young age. treatments for hypertension in turner syndrome are as in the general population. approximately 25%–80% of women with turner syndrome have some level of insulin resistance, and a minority develop type 2 diabetes. the risk of diabetes in turner syndrome varies by karyotype and appears to be raised by specific deletions of the short arm of the x chromosome (xp). one study found that while a relatively low 9% of women with xq (long arm) deletions had type 2 diabetes, 18% of those with full 45,x0 karyotypes did, as well as 23% with xp deletions. 43% of women with isochromosome xq, who both lacked the short arm and had an additional copy of the long arm, developed type 2 diabetes. though part of the diabetes risk in turner syndrome is a function of weight control, some is independent; age- and weight-matched women with non-turner's ovarian failure have a lower diabetes risk than in turner syndrome. growth hormone treatment plays an unclear role in diabetes risk, as does estrogen supplementation. the association between turner syndrome and other diseases, such as cancer, is unclear. overall, women with turner syndrome do not appear more likely to develop cancer than women with 46,xx karyotypes, but the specific pattern of what cancers are highest risk seems to differ. the risk of breast cancer appears lower in turner's than in control women, perhaps due to decreased levels of estrogen. neuroblastoma, a cancer of infancy and early childhood, has been reported in girls with turner syndrome. tumours of the nervous system, both the central nervous system and the peripheral nervous system, are overrepresented amongst cancers in turner syndrome. furthermore, about 5.5% of turner syndrome individuals have an extra, abnormal small supernumerary marker chromosome (ssmc) which consists of part of a y chromosome. this partial y chromosome-bearing ssmc may include the sry gene located on the p arm of the y chromosome at band 11.2 (notated as yp11.2). this gene encodes the testis-determining factor protein (also known as sex-determining region y protein). turner syndrome individuals with this sry gene-containing ssmc have a very real increased risk of developing gonadal tissue neoplasms such as gonadoblastomas and in situ seminomas (also termed dysgerminomas to indicate that this tumor has the pathology of the testicular tumor, seminoma, but develops in ovaries). in one study, 34 turner syndrome girls without overt evidence of these tumors were found at preventative surgery to have a gonadoblastoma (7 cases), dysgerminoma (1 case), or non-specific in situ gonadal neoplasm (1 case). turner syndrome girls with this ssmc otherwise have typical features of the turner syndrome except for a minority who also have hirsutism and/or clitoral enlargement. surgical removal of the gonads has been recommended to remove the threat of developing these ssmc-associated neoplasms. tuner syndrome individuals with an ssmc that lacks the sry gene are not at an increased risk of developing these cancers. sensory hearing loss is common in turner syndrome. though at birth hearing is generally normal, chronic middle ear problems are frequent throughout childhood, which can cause permanent conductive hearing loss. in adulthood, sensorineural hearing loss occurs more often than in 46,xx women and at younger ages; though differing thresholds of hearing loss make it difficult to compare between studies, younger adult women with turner syndrome are routinely found to have disproportionate rates of hearing issues, with sometimes up to half of women in their 20s and 30s having poor hearing. this hearing loss is progressive; at the age of 40, women with turner syndrome have equivalent hearing loss to 46,xx women aged 60, on average. cohort studies imply hearing loss may be more common in women who also have metabolic syndrome. the high prevalence of sensorineural hearing loss in turner syndrome appears to be related to shox deficiency. ocular and visual disorders are also increased in prevalence in turner syndrome. more than half of individuals with turner syndrome have some form of eye disorder. this may be a consequence of shared genes on the x chromosome in both eye and ovary development. nearly half of cases have hyperopia or myopia, usually mild. strabismus, or misalignment of the eye, occurs in around one-fifth to one-third of girls with turner syndrome. as with strabismus outside the turner's context, it may be treated with glasses, patching, or surgical correction. esotropia, where the eye turns inwards, is more common than exotropia, where it turns outwards. ptosis, or a drooping eyelid, is a common facial manifestation of turner syndrome; it usually has no appreciable impact on vision, but severe cases may limit visual range and require surgical correction. the rate of red-green colourblindness in turner syndrome is 8%, the same as in men. this is due to red-green colourblindness being an x-linked recessive condition; in people with a single x chromosome, whether normal males or turner females, only a single mutated x is necessary for symptoms. red-green colourblindness may be underdiagnosed in the turner context, as the rarity of the condition in females reduces the likelihood of screening, and practitioners may not connect that the karyotype of turner syndrome increases the risk from the female baseline. autoimmune women with turner syndrome are two to three times as likely to develop autoimmune disorders as the general population. specific autoimmune disorders linked to turner syndrome include hashimoto's disease, vitiligo, psoriasis and psoriatic arthritis, alopecia, and celiac disease. inflammatory bowel disease is also common, while the prevalence of type 1 diabetes is unclear, though appears increased. thyroid disease is common in turner syndrome. hypothyroidism is prevalent; 30%–50% of women with turner syndrome have hashimoto's disease, where the thyroid gland is slowly destroyed by an autoimmune reaction. by age 50, half of women with turner syndrome have subclinical or clinical hypothyroidism. hyperthyroidism and graves' disease are also increased in prevalence, though more modestly. the turner's presentation of hyperthyroidism is as in the general population, while the presentation of hypothyroidism is often atypical, with a mild early presentation yet a more severe progression. women with isochromosome xq are more likely to develop autoimmune thyroid disease than women with other forms of turner syndrome. the risk of irritable bowel syndrome is increased around fivefold in turner syndrome, and that of ulcerative colitis around fourfold. celiac disease is also increased in prevalence, with around 4%–8% of turner's patients having comorbid celiac disease compared to 0.5%–1% of the general population. diagnosis of such conditions is difficult due to their nonspecific early symptoms. in the turner's context, diagnosis may in particular be missed due to growth delay; such conditions cause growth delay and failure to thrive when they onset in childhood, but as girls with turner syndrome already have such delay, symptoms may be overlooked and ascribed to the original condition. alopecia areata, or recurrent patchy hair loss, is three times as common in turner syndrome as the general population. alopecia in the turner syndrome context is frequently treatment-resistant, also seen in other chromosome aneuploidies such as down syndrome. psoriasis is common in turner syndrome, although the precise prevalence is unclear. turner's psoriasis may be related to growth hormone treatment, as psoriasis as a side effect of such therapies has been reported in patients without the karyotype. psoriasis may progress to psoriatic arthritis, and this progression may be more common in turner syndrome. vitiligo has been reported in conjunction with turner syndrome, but the risk is unclear and may be a side effect of increased clinical attention to autoimmune disease in this population. puberty histopathology of ovarian tissue in mosaic (a and b) and full (c) turner syndrome puberty is delayed or absent in turner syndrome. a 2019 literature review found that 13% of women with a 45,x0 karyotype could expect to experience spontaneous thelarche (breast development), while 9% would undergo spontaneous menarche (beginning of menstruation). these numbers were higher in women with mosaic turner's; 63% with 45,x0/46,xx karyotypes experienced spontaneous thelarche and 39% spontaneous menarche, while 88% with 45,x0/47,xxx (the presence of a trisomy x cell line) experienced spontaneous thelarche and 66% spontaneous menarche. unexpectedly, women with y-chromosome cells also had increased rates of thelarche and menarche compared to the 45,x0 baseline, at 41% and 19%. however, few women with trisomy x or y-chromosome cell lines were covered in the review, impeding extrapolation from these results. 6% of women with turner syndrome have regular menstrual cycles; the rest experience primary or secondary amenorrhea or other menstrual dysfunction.: 84 in girls with turner syndrome who do not experience spontaneous puberty, exogenous estrogen is used to induce and maintain feminization. estrogen replacement is recommended to begin at around age 11–12, although some parents prefer to delay the induction of puberty in girls with lower social and emotional preparedness. the dose of estrogen in induced puberty begins at 10% of adult estrogen levels and is steadily increased at six-month intervals, with a full adult dose attained two to three years after the beginning of treatment. estrogen replacement may interfere with growth hormone therapy, due to the closing effects of estrogen on growth plates; individuals must weigh up their preferences for taller height versus greater feminization.: 97–103 fertility women with turner syndrome are at extremely high risk for primary ovarian insufficiency (poi) and infertility. although about 70–80% have no spontaneous pubertal development and 90% experience primary amenorrhea, the remainder may possess a small residual of ovarian follicles at birth or early childhood. early in gestation, fetuses with turner syndrome have a normal number of gametes in their developing ovaries, but this starts decreasing rapidly as early as 18 weeks of pregnancy; by birth, girls with the condition have markedly reduced follicular counts. women with turner syndrome who wish to raise families but are incapable of conception with their own oocytes have the options of adoption or of pregnancy with donor eggs; the latter has a comparable success rate to donor pregnancy in women with 46,xx karyotypes. pregnancy in turner syndrome is inherently high-risk; the maternal death rate is 2%. usually, estrogen replacement therapy is used to spur the growth of secondary sexual characteristics at the time when puberty should onset. while very few women with turner syndrome menstruate spontaneously, estrogen therapy requires a regular shedding of the uterine lining ("withdrawal bleeding") to prevent its overgrowth. withdrawal bleeding can be induced monthly, like menstruation, or less often, usually every three months, if the patient desires. estrogen therapy does not make a woman with nonfunctional ovaries fertile, but it plays an important role in assisted reproduction; the health of the uterus must be maintained with estrogen if an eligible woman with turner syndrome wishes to use ivf (using donated oocytes). especially in mosaic cases of turner syndrome that contains y-chromosome (e.g. 45,x/46,xy) due to the risk of development of ovarian malignancy (most common is gonadoblastoma) gonadectomy is recommended. turner syndrome is characterized by primary amenorrhoea, premature ovarian failure (hypergonadotropic hypogonadism), streak gonads and infertility (however, technology (especially oocyte donation) provides the opportunity of pregnancy in these patients). failure to develop secondary sex characteristics (sexual infantilism) is typical. neurodevelopmental individuals with turner syndrome have normal intelligence. verbal iq is usually higher than performance iq; one review of thirteen studies found an average verbal iq of 101 compared to an average performance iq of 89. people with turner syndrome have normal intelligence, and demonstrate relative strengths in verbal skills, but may exhibit weaker nonverbal skills – particularly in arithmetic, select visuospatial skills, and processing speed. turner syndrome does not typically cause intellectual disability or impair cognition. however, learning difficulties are common among women with turner syndrome, particularly a specific difficulty in perceiving spatial relationships, such as nonverbal learning disorder. this may also manifest itself as a difficulty with motor control or with mathematics. while it is not correctable, in most cases it does not cause difficulty in daily living. most turner syndrome patients are employed as adults and lead productive lives. also, a rare