Female precocious puberty

Specialty: Gynecology and breast.

• Early thelarche
• early puberty in girls
• accelerated childhood sexual maturation

Why it occurs

• GnRH-dependent central precocious puberty (idiopathic in most cases in girls, or secondary to hypothalamic hamartomas, optic pathway gliomas, or other CNS lesions)
• GnRH-independent peripheral precocious puberty (hypersecreting autonomous follicular ovarian cysts, ovarian granulosa tumors, late-diagnosed congenital adrenal hyperplasia)
• McCune-Albright syndrome
• Accidental exogenous exposure to estrogens or endocrine disruptors

Initial workup

Basal analytical determination of levels of estradiol, LH, FSH, TSH, Prolactinemia and DHEA-S levels. Stimulation test with GnRH analogues (triptorelin or leuprorelin) with serial measurement of LH (an LH response >5 IU/L confirms central origin). X-ray of the left hand and wrist to assess bone age (which will typically be >2 years ahead of chronological age). Transabdominal pelvic ultrasound to evaluate uterine and ovarian volume. Brain MRI focused on the sellar and suprasellar region if it is of central origin.

Standard management

• Triptorelin acetate — extended-release regimen of 3.75 mg intramuscularly every 28 days, or quarterly formulations of 11.25 mg) for central precocious puberty (blocks pituitary GnRH receptors by desensitization
• Medroxyprogesterone acetate or aromatase inhibitors if the cause is peripheral and not a candidate for surgery (note: treatment must be closely monitored by pediatric endocrinology to ensure arrest of pubertal development and preserve adult height potential).