Treatment of Precocious pubertyM. Hashemipour MD

Pediatric EndocrinologistIsfahan University of Medical

Sciences

1

• A 10 y/o girl referred to clinic with complaint of precocious puberty. No significant finding in history taking. In P/E breast is in tanner stage 2. (no menstruation is occurred).

Height : 145cm

1- What is your suggestion to do as paraclinical W/U ? 2- What do you recommend to her family?

2

• A 12 y/o boy came to clinic for evaluation of puberty. In P/E testes are in tanner stage 3. Pubic hair in stage 1. No other significant finding. Height : 140 cm.

3

1- What do you recommend about the puberty of this patient? 2- Is there any need to treat this patient?

4

Growth velocity :

Growth during puberty : boys mean of 20-28 cm girls mean of 20-25 cm

• An 11.5 y/o girl referred to the clinic due to the first episode of menstruation. Breast is in tanner stage of 4. Height : 142 cm.

5

Do you recommend to start any

treatment to stop puberty?

• Growth after menarche : 1 – 7 cm

6

• A 10 y/o female brought to clinic to delaying her menstruation for improvement of height. Breast is in tanner stage 2.

Height is 122 cm.

7

What is the prediction of final height ?Do you prescribe GnRh agonist to this girl ?

8

Only pubic hair , without testicular or phallic enlargement :

DDx :

Premature adrenarche

Late onset CYP 21 defic.

• A 2 y/o girl referred to your office with chief complaint of puberty. In P/E she has breast enlargement (stage 2 tanner). Height is 87 cm. No other positive findings are detected.

1- What is your diagnosis? 2- What kind of w/u is needed?

9

• A 5 y/o girl referred to you due to questionable history of vaginal bleeding. Her mother says that she has had several episodes of spotting during last three days. Breast is in tanner stage 1.

10

What is the DDx ?What do you do as paraclinical w/u ?

Isolated vaginal bleeding in the absence of other secondary sexual characters:

foreign body sexual abuseurethral prolapse Vulvo vaginitis

11

• Girls with onset of progressive CPP before 6 years of age benefit most in terms of height from treatment

Treatment

• The decision to initiate therapy in girls with onset after the age of 6 should be individualized

• Treatment should be considered for all boys with onset of progressive CPP before 9 years of age who have compromised height potential

Treatment

Girls with onset of puberty in 6- to 8 years of age with slowly progressive puberty

and/or Acceptable predicted adult height based on

bone ageHas not been proven to have a significant effect

in improving adult height.

14

• If precocious puberty is slowly progressive, it is unlikely to compromise adult height potential.

Treatment

• If the height prediction is above

150 cm girls

160 cm boysTherapy is probably not neededConservative approach is warranted

Treatment

Criteria for Immediate Treatment of CPP

• Complete clinical precocious puberty with pubertal LH levels after GnRH stimulation test.

AND Chronological age < 7 yrs in girls and < 8 years in boys.

Bone age advanced > 2 SD beyond chronological age.

.

Criteria for Immediate Treatment of CPP

Predicted height either 2 SD (10cm) or more below genetic target height or < 150cm

Rapid deterioration of growth potential and rapid advancement of pubertal signs.

ORSevere psychologic discomfort or behavioural

reasons

18

Indications for Follow-up & Delay in Treatment

Chronological age between 7 and 8 yrs in girls and between 8 and 9 yrs in boys

Bone age advanced < 2 SD beyond chronological age.

Predicted height near target height or in the normal-to-high range.

Slow progression of pubertal signs and echographic signs with maintenance of good growth potential.

AND Absence of severe psychologic discomfort or behavioural

problems.

Adverse Effects of Treatment Transient vaginal withdrawal bleeding

injection site reactions and arthralgia.

Headache, nausea, hot flushes

Allergic reactions, headache, weight gain, increased blood pressure, episodes of blurred or abnormal vision, gastrointestinal tract discomfort with abdominal pain and vomiting, epistaxis, malaise, myalgia , emotional liability, nervousness.

Follow-up During Treatment Height, weight, growth rate, and secondary sex characteristics

Bone maturation

Uterus and ovary size

single blood sample for determination of LH and oestradiol at 2 or 12 hours after injection of the depot GnRH agonist

Thank you

22