This document discusses precocious and delayed puberty. It defines precocious puberty as the development of sexual characteristics before age 8 or menstruation before age 10. Causes can be idiopathic, an intracranial lesion, or disorders like McCune-Albright syndrome. Treatment aims to slow bone maturation and reduce gonadotropin secretion, using medications like GnRH agonists. Delayed puberty is defined as lack of breast or pubic hair development by ages 13-14 or menarche after 16. Causes include hypogonadism, chronic illness, or eugonadism. Treatment depends on the underlying cause and may involve cyclic or combined estrogen therapies.

1. PRECOCIOUS AND DELAYED PUBERTY
ANDREA.R.S

2. INTRODUCTION
 Puberty in girls is the period which links childhood
to adulthood
 It is the period of gradual development of
secondary sexual characters
 Common order is
 Beginning of growth spurt
 Breast budding(thelarche)
 Pubic and axillary hair growth(adrenarche)
 Peak growth in height
 Menstruation(menarche)
 All these changes are completed by 10-16 yrs

3. PRECOCIOUS PUBERTY
 This term is reserved for girls who exhibit any sexual
characters before the age of 8 OR menstruate
before age of 10
 TYPES-true or complete or central
pseudo or incomplete or peripheral

4.  Central-more common
 Due to premature activation of HPO axis
 The pituitary is involved
 Peripheral-rarer
 Here pituitary is not involved
 Local problem in ovaries or adrenals

5. CAUSES
Complete-Idiopathic,familial
Intracranial lesion
Incomplete-Premature thelarche
Premature puberache
Premature menarche
Precocious pseudopuberty-Feminising ovary tumors
Adrenal hyperplasia
Iatrogenic
Hypothyroidism
McCune -Albright syndrome

6. AETIOPATHOLOGY
 Constitutional-commonest
 Due to premature activation of HPO axis
 Secretion of gonadotrophins and gonadal steroids
due to premature GnRH release
 Bone maturation is accelerated
McCune Albright syndrome characterised
by sexual precocity,multiple cystic bone
lesion,endocrinopathies and café au-lait
spots

7. DIAGNOSIS
 True precocious-familial history
 tanner stages
 no cause could be detected
 Basic investigations-
 X-ray wrist for bone age
 Pelvic sonography to exclude ovarian pathology
 CT brain and MRI brain
 Serum FSH and LH


9.  Premature thelarche-isolated breast development
 Bone age not advanced
 Nipple devt. Absent
 Premature puberche-isolated devt.of axillary and or
pubic hair prior to 8yrs
 Estimation of serum 17 alpha
hydroxyprogesterone,DHEA-S and serum testosterone –in
suspected case of adrenal hyperplasia
 Premature menarche-rule out other cause of vaginal
bleeding like foreign body or trauma
 If bleeding is cyclic then diagnosis is confirmed

10. TREATMENT
 Goals- reduce gonadotrophin secretion
decrease growth rate to normal and
slowing skeletal maturation
DRUGS-
GnRH agonist
Medroxy progesterone acetate
Cyproterone acetate
Danazol

11.  GnRH agonist-arrest pre pubertal precocity and
growth velocity
 Supress premature HPO axis activation and thus
diminish estrogen secretion
 GnRH agonist supresses FSH,LH
secretion,reverses ovarian cycle,establishes
amenorrhea,causes regression of breast,pubic hair
change and other sexual characters
 Buserelin nasal spray 100 micro gram/day
 Leuprolide depot once a month

12.  Medroxy progesterone acetate-30mg/day oral or
100-200mg IM weekly
 Danazol
 Duration of treatment-upto 11 yrs usually

13. DELAYED PUBERTY
 Puberty is said to be delayed when the breast
tissue and or pubic hair have not appeared by 13-
14 years or menarche appears as late as 16 years

14. CAUSES
 Hypergonadotrophic hypogonadism
Gonadal agenesis,45XO
Pure gonadal dysgenesis 46XX,46XY
Ovarian failure 46XX
 Hypogonadotrophic hypogonadism
Constitutional delay
Chronic illness
Primary hypothyroidism
Kallmann syndrome
Intracranial lesion
 Eugonadism
Anatomical-mullerian agenesis
imperforate hymen
Androgen insensitivity syndrome

15. TREATMENT
 Hypogonadism
 Cyclic estrogen
 Unopposed estrogen 0.3mg/day for first 6 months
 Then combined estrogen and progestin,sequential
regimen is started
 Hypergonadism
 Chromosomal study