Presentation for undergraduates, post graduates and nurses about early menstruation, precocious puberty, etiology, classification and management

1. Dr Surekha Tayade, Wardha
Early
Menarche
Dr Surekha Tayade
MBBS, MD, DNB, MNAMS,FICOG
PGDHHM, FAIMER Fellow
PhD, MPH

2. Dr Surekha Tayade, Wardha
Case Scenario 1
● 10 year old girl, student of 4 th standard
● Reports with development of secondary sexual characters
● And bleeding per vaginum
● Deemed to be menses
Is this early menarche?

3. Dr Surekha Tayade, Wardha
Average age of menarche - 10 – 16 years
Sometimes delayed or early.
Overall age reducing since years
together.
What is Early Menarche?
Menarche before age of 8 years is
early menarche
The synonym is Precocious Puberty
Girls may have ISOSEXUAL PP –
Early Menarche

4. Dr Surekha Tayade, Wardha
Case 2
 3.5 years old girl with 2-month history
of breast development and rapid
growth.
 single episode of vaginal bleeding and
abdominal pain.
 No headache/ visual symptoms.
 Past history of mild eczema.
 Breast stage B3 bilateral. No pubic or
axillary hair growth. Family thought
was (puppy fat).
 Height and weight 98th centile
INVESTIGATIONS:
 TSH,FSH,LH,17B
ESTRADIOL
 Urgent MRI Head/Pituitary with
gadolinium under GA.
 Urine steroid profile.
 FBC,LFT,Ca Profile, U&E,
Creatinine, Bicarbonate, Iron
levels.
 Bone Age (Left hand & wrist).
 Pelvic and renal USG.

5. Dr Surekha Tayade, Wardha
Bone Age Report
CHRONOLOGICAL
AGE
BONE AGE
3Y 6 MONTHS 8.9 YAERS
 Diagnosis of Gonadotropin Dependent
Central Precocious Puberty.
 Discuss with paediatric endocrinologist &
parents and maternal grandfather.
 Management included Cyprototerone
acetate 50mg tablet.
 IM injections at hospitals. Gonapeptyl
depot 3.75mg

6. Dr Surekha Tayade, Wardha
● A 5-year-old girl presents breast enlargement since 4 months and
vaginal bleeding.
● No history of headache, visual problems, behavioral changes, or
neurological deficits.
● No history of head trauma or surgery, no gelastic seizures, history of
encephalitis, or radiation exposure.
● Family history was unremarkable and perinatal period was uneventful.
Case 3

7. Dr Surekha Tayade, Wardha
Physical examination
• weight = 21 kg , height = 128 cm ( +2SD)
• Elevated Areola above contour of the breast, forming “double scoop” appearance
(Tanner stage 4);
• Downy pubic hair (Tanner stage 1) and no axillary hair.
• Abdominal examination did not reveal any masses.
• Hand Bone Age - advanced over chronological age by ∼3 years.
• Pelvic ultrasound revealed - uterus 5.5 cm x 9.7 cm x 6.6 cm, with large central
vacuity line.
• uterine body/cervix ratio > 1
• 3 increased follicles in the ovary, and the maximum diameter of follicle was 9 mm

8. Dr Surekha Tayade, Wardha
GNRH test
• predominant FSH response (FSH increased
from 3.8 mIU/mL to 5 mIU/mL), modest LH
response (LH increased from 0.9 mIU/mL to
7 mIU/mL),
• LH/FSH > 1
• suggesting a central precocious puberty
(CPP).
• MRI to exclude a CNS injury.
No antecedent of excessive soya or estrogen intake.
Patient lived on a farm where several pesticides were stocked.
Asked the family to move away from pesticides.
After 1 year, the patient had a normal hormonal balance, stabilization of ultrasound measurements of the uterus
and ovary, and stabilization of height.

9. Dr Surekha Tayade, Wardha
1 in 5000 to 1 in 10000 girls
In 75%-85 % cases the cause is idiopathic
Thorough evaluation to rule out the serious disease process is mandatory.
Objectives of management includes –
• diagnosis & treatment of the serious cause ,
• correction of menstruation,
• arrest of excessive maturation,
• maximize eventual adult height
• avoidance of abuse and
• reduction of emotional problems.
How common? When to evaluate?

10. Dr Surekha Tayade, Wardha
Classification

11. Dr Surekha Tayade, Wardha
False/LHRH Independent/Pseudo Puberty

12. Dr Surekha Tayade, Wardha
Idiopathic Early Menarche
•There is no underlying medical problem
and no identifiable reason.
•Genetic factors,
•Race, Geographic location,
• Nutritional status- Increased consumption of
animal proteins, Fast food, Use of BPA plastic as
container for food, Use of Phthlates.
•Obesity/ over weight- Leptin, a hormone
involved in puberty, is secreted in Fatty tissue.
•Physical inactivity
•Psychological factors- Stressed family/Single
parent
•Use of OCP by Mothers
•Low birth weight
•Inadequate breast feeding
•Inadequate sleep
•Early exposure to sexual
material
•Age of mother at menarche

13. Dr Surekha Tayade, Wardha
Clinical Presentation
❏ Sexual development may begin
at any age & follows the
sequence observed in normal
puberty
❏ In girls early menstrual cycles
more irregular
❏ The initial cycles are usually
anovulatory
height, weight & osseous
maturation are advanced
Emotional behavior & mood
swings common
Early closure of the epiphyses
& ultimate height is less
Mental development is usually
compatible with chronological
age

14. Dr Surekha Tayade, Wardha
Clinical features
3 patterns of pubertal
progression
❏Rapid – most common pattern.
characterized by rapid physical
& osseous maturation, leading
to loss of height potential
❏Slow - parallel advancement of
osseous maturation & linear
growth, with preserved height
potential
❏ Spontaneously
regressive/unsustained - rare
In hypothalamic hamartoma
remain static in size or grow slowly
– no signs other than precocious
puberty
for symptomatic,
manifestations may be present for
1-2 yr before the tumor can be
detected radiologically
Hypothalamic signs or
symptoms include diabetes
insipidus , adipsia , hyperthermia,
unnatural crying or laughing,
obesity & cachexia
Visual signs may be the first
manifestation of optic glioma

16. McCune-Albright Syndrome

17. Granulosa Cell
Tumor
Theca Cell Tumor

18. Dr Surekha Tayade, Wardha
How to Approach
Onset of age?
Is the cause of precocity central or peripheral?
Need to ask the pattern of pubertal development
in GDPP - normal pubertal development but at an
earlier age
How quickly is the puberty progressing? rapid bone
maturation -suggest either GDPP or GIPP
Presence of headaches or seizures ? CNS lesion
Previous history of CNS disease or trauma?
Are the secondary sexual characteristics virilizing or
feminizing?
- feminizing in Sertoli cell tumor
-Virilization in CAH
Any exposure to exogenous sex steroids??
(medicinal or cosmetic sources)
Timing of pubertal onset in parents and siblings?
family history of similar symptoms?
Measurements of height, weight, and calculation of
height velocity (cm/yr)
Pubertal staging: Breast staging, pubic hair
Abdominal examination: Palpate for mass ( in ovarian
cyst and tumor)
Neurological examination (neurological deficit?)
Eye examination : Fundoscopy :look for papilledema
( in CNS lesion), Visual field
Look for signs of virilization in female? Ambiguous
genitalia? Hirsutism?
Dermatological exam to evaluate for cafe-au-lait
spots( in McCune-Albright syndrome).
Physical Examination

19. Dr Surekha Tayade, Wardha
Investigations
MRI: physiologic enlargement of pituitary gland/reveal CNS pathology

20. Dr Surekha Tayade, Wardha

21. Dr Surekha Tayade, Wardha
Management of GDPP

22. Dr Surekha Tayade, Wardha
Other available treatment
Subcutaneous injections of
aqueous leuprolide, given once
or twice daily (total dose 60
μg/kg/24 hr)
Intranasal administration of
GnRH agonist nafarelin
(Synarel) 800 μg bid.
Recommended dose of
GNRH Agonist

23. Dr Surekha Tayade, Wardha
 Decrease of growth rate to age-appropriate
values
 Enhancement of predicted height
 Breast development may regress in tanner
stages II-III development
 Breasts remains unchanged in stages III-V
Pubic hair remains stable or may
progress slowly during treatment,
reflecting the gradual increase in adrenal
androgens
Menses, cease
Pelvic sonography demonstrates a
decrease of ovarian/ uterine size.
Serum sex hormone concentrations
decrease to pre pubertal levels
• Serum LH and sex hormone levels remain suppressed for as long as therapy is continued
• Puberty resumes promptly when therapy is discontinued, typically at a “pubertal”
chronological age
Treatment results in:

24. Dr Surekha Tayade, Wardha

25. Dr Surekha Tayade, Wardha

26. Dr Surekha Tayade, Wardha
Isolated Premature Menarche

27. •Chances of short stature
•Girls are immature so difficult
management of menses
•Depression
•Poor studies
•Lonely, poor social life
•May suffer from menorrhagia &
Anemia
•Obesity and metabolic syndrome
•Early initiation of smoking or drug
abuse
•Early first sexual intercourse

28. Dr Surekha Tayade, Wardha
•STI or Teenage pregnancy
•Chances of PCOS increases with
EM,
•Cardiovascular disease
•Breast and Endometrial cancers
•Asthma is linked with EM
Multidisciplinary approach – Pediatric endocrinologist,
Psychologist, Counselor, Tender loving care, gentle handling

29. Dr Surekha Tayade, Wardha
Take Home Message
Sensitive Handling of the
young girl and parents
Treatment should be aimed
to diagnose the serious
cause of disease if any, it’s
treatment
Thorough Evaluation
Proper follow up, Arrest of
excessive maturation,
avoidance of sexual abuse,
assurance and counseling of
Parents.
Rule out CNS lesion,
differentiate betn GDPP/GIPP
Parents have most
important role in the
prevention of depression,
and psychosocial issues of
the child

30. Thank
YOU