Precocious Puberty in Girl.pptx

1. azad82d@gmail.com
azad.haleem@uod.ac
Dr.Azad A Haleem AL.Mezori
FRCPCH,DCH, FIBMS
Assistant Professor & Pediatric consultant
Pediatric Endocrinologist
University Of Duhok, College of Medicine
Pediatrics Department
Precocious Puberty in Girl

2. Thank You

3. Introduction
• Precocious puberty is more common in girls
than boys but usually represents physiological
variation .

4. POINTERS AND CRITERIA
• Breast development or pubarche before 8 years of age
or menarche before 9.5 years is considered precocious
in girls.
• Other pointers to precocious puberty include rapid
height gain , appearance of body odor or acne.

5. Pathophysiology
• Pubertal regulation involves close interaction of Gonadotropin releasing hormone -
Gonadotropin - Estradiol axis .
Inhibitory
Stimulatory
LH: increase androstenedione production by theca cells.(25 times)
FSH: induces aromatization of androstenedione to estradiol in granulosa cells.(2.5 times)
Estrogen acts on the estrogen receptor to induce breast , uterine and growth plate
maturation.
Neurokinin B

6. PUBERTAL PROGRESSION
• Ovarian development is the first change observed in puberty. multi - cystic due to
FSH effect.
• Thelarche ( development of breast nodule ), first external sign of puberty in girls .
• Stage IV breast development suggests impending menarche .
• Pubic hair follows thelarche but can precede it in 15 % cases. Pubic hair growth is
independent of GnRH.
• Vaginal mucosa reflects estrogen status (Pale and pink=puberty).
• Uterus lags behind ovaries in terms of growth. From tubular to pear shaped
structure.This is followed by increase in endometrial stripe to 3 mm. Endometrial
thickness more than 5 mm suggests impending menarche . Menarche occurs 2-2.5
years after thelarche .

7. POINTERS AND CRITERIA
• It is important to differentiate physiological causes before undertaking extensive
evaluation for precocious puberty .
• Lipomastia should be differentiated from true thelarche by observing for resistance
between the thumb and the index finger approximated at the areolar region .
• Mastitis neonatorum , neonatal breast enlargement due to transplacental estrogen
exposure , is self - limiting and does not need treatment .
• Isolated pubic hair development without progression has however been
increasingly identified in infancy .These hairs are usually vellus ( hypopigmented
and soft ) and localized in the labial region .No treatment is required for the
condition

8. ETIOLOGY

9. Isolated thelarche
( INCOMPLETE PRECOCIOUS PUBERTY)
• Isolated thelarche is associated with breast development with no progression(Lack
of thickening and pigmentation of the nipples and the areola).
• It has two distinct peaks around early childhood ( 1-3 years) and peripubertal age
group ( 6-8 years ) .
• Pointers: low LH ( usually less than 0.1 mU / L ) , detectable FSH , red and
glistening vaginal mucosa , low estradiol , normal bone age and microcystic
ovaries, no vaginal bleeding.
• Not require any treatment and the girl should be followed up for pubertal
development .
• Breast development regresses by 4-5 years of age .

10. Isolated pubarche
( INCOMPLETE PRECOCIOUS PUBERTY)
• Isolated pubarche usually presents after the age of 6 years and is frequently
associated with change in skin odor and acne ( adrenarche ) .
• The condition is frequently been encountered in small for gestational age girls with
rapid catchup and is the first manifestation of insulin resistance (DM),
Dyslipidemia & PCOS..
• Diagnosis is established by increased DHEAS levels with normal LH , FSH and
estradiol levels .
• Rapid progression , virilization ( muscularity , voice change or clitoromegaly ) or
onset before six years of age should prompt evaluation for congenital adrenal
hyperplasia and adrenal or ovarian tumor ( 170HP , DHEAS , testosterone ,
imaging)

11. Isolated vaginal bleeding
( INCOMPLETE PRECOCIOUS PUBERTY)
• Isolated vaginal bleeding without breast development is unlikely to be due to
endocrine cause and should prompt evaluation for local causes ( trauma , infection ,
abuse or rarely tumor).
• Undetectable LH , FSH and estradiol suggest the diagnosis and should be followed
up for gynecological evaluation.

12. ETIOLOGY

13. Central precocious puberty
● Idiopathic: (95%). Usually after the age of six years. Slowly progressive puberty with limited
impact on final height and remote chance of early menarche. Neuroimaging is not required.
Need followed up (no need therapy)
● Radiation: Low dose radiation lead to precocious puberty while high dose radiation causes
delayed puberty.
● Hypothalamic hamartoma : cause disrupts GnRH inhibitory pathway. usually present 1-2 years
of age with menarche, high gonadotropin levels and neurological features (seizures, gelastic
epilepsy and developmental delay). It is readily identified on MRI. Treatment with GnRH
analog. Surgical treatment is not required.
● Brain tumors : glioma, germinoma and craniopharyngioma; may be associated with precocious
puberty.
● CNS insults : trauma, infection, malformation and hydrocephalous.

14. Peripheral precocious puberty
● Precocious puberty with severely elevated estradiol level that is gonadotropin-
independent, produced by ovaries, adrenal or from exogenous estradiol source.
● There is short gap between thelarche and menarche reflecting discordant pubertal
development.
● Gonadotropin levels are undetectable and do not rise with GnRH injections.

15. Peripheral precocious puberty
● Ovarian causes: These involves ovarian production of estrogen through an ovarian cyst (
functional, hypothyroidism, McCune Albright syndrome).
● Functional ovarian cyst : Cyst will cause increase in estradiol levels results in some breast
development with disproportionate uterine development and endometrial hyperplasia and
withdrawal bleeding. diagnosed on ultrasound. The condition is self-limiting and usually
resolves over time. Surgery is required in girls with risk for ovarian torsion (size more than 5
cm) and features of malignancy (solid areas, heterogenous and cyst within cysts)
● Adrenal tumors: express aromatase and produce estradiol. Surgical removal is recommended.
● Exogenous estradiol : Exogenous estradiol administration presents with rapid breast
development with a risk of early withdrawal bleeding. The condition is rarely observed in girls
with labial adhesions treated with topical estradiol. LH and FSH levels are undetectable.

16. Peripheral precocious puberty
● Hypothyroidism :Girls with long standing untreated primary hypothyroidism present
with discordant puberty with early onset ovarian bleeding (Van Wyk Grumbach
syndrome).
● They have large ovarian cysts due to TSH effect on FSH receptor. In contradistinction
to all other forms of precocious puberty hypothyroidism presents with delayed bone
age and short stature.
● The condition improves with thyroid replacement with regression of pubertal features
and ovarian cyst. Progesterone treatment may be required in girls with prolonged
menorrhagia.

17. Peripheral precocious puberty
● McCune Albright Syndrome : (GNAS1) presenting with recurrent ovarian cysts and
peripheral precocious puberty.
● The disorder is associated with excess of GNAS1 hormones (thyrotoxicosis, GH
excess, Cushing syndrome, hypophosphatemic rickets, fibrous dysplasia and multiple
cafe-au-lait spots with irregular margins).
● The condition is treated with inhibitors of estrogen production (aromatase inhibitors)
or action (selective estrogen receptor modulator and estrogen receptor antagonists).

18. Diagnostic evaluation
• LH , FSH (normally LH less than 0.1 mU /L ) (more than 0.3 mU/L Pathological )
• GnRH stimulation test should be performed in girls with LH between 0.1-0.3 mU/L
with stimulated levels above 5 mU/L confirming central precocity.
• Estradiol levels; >10 pg/ml suggest pubertal onset.
• DHEAS levels, 17OHP, Testosterone levels (adrenal)
• Bone age.
• Ultrasound of pelvic organ:uterus, Adrena& Ovarian
• Adrenal and Ovarian imaging ( CT scan ).
• MRI of brain.

19. Approach
Adrenal Tumor CAH

20. Case 1-

21. Case 2-

22. Case 3-

23. Case 4-

24. Case 5-

25. Case 6-

26. Case 7-

27. Case 8-

28. Management of central precocious puberty
• GnRH analogs (mainstay treatment)
• progesterone (reserved for subjects with intellectual deficit).
• Indications of treatment with GnRH analog :
1. girls presenting before the age of 6 years.
2. Girls between 6-8 years of age with advanced bone age (more than 2 years above height age) and
compromised final height (predicted height below the target height range).
3. if the child is not mature enough to cope up with pubertal development.
• GnRH analogs desensitize pituitary gonadotrophs suppressing gonadotropin levels reversing
pubertal changes. Leuprolide is the most commonly used compound.

29. • Effect: Initial increase in GnRH level may temporary stimulate gonadotropins causing flare up.
This may result in breast enlargement and withdrawal bleeding in a few cases. Pubic hairs are
independent of GnRH axis and progress despite adequate control.
• Adverse effect: GnRH analogs are remarkably safe when used for appropriate indications.
• Duration of treatment :GnRH analog treatment should be continued till the age of 10 years and
bone age of 12 years. Treatment beyond this age is less beneficial in terms of height but may be
considered in girls with severely compromised height.
• Monitoring: clinical and laboratory parameters
• Pubertal development after discontinuation ; Menstrual cycles are usually achieved within 12-
18 months in girls who were menarchal at the time of initiation of treatment.

30. • PROGESTERONE
• Progesterone is used in central precocious puberty for its anti - endometrial effect
to inhibit vaginal bleeding .
• It can be used orally ( medroxyprogesterone acetate 10 mg orally once a day ) or as
injectable preparation ( 150 mg every 12 weekly ) .
• It has no benefit in height and should be reserved for girls with intellectual delay
where main concern is suppression of periods.

31. THANKS FOR YOUR ATTENTION