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Precocious puberty (Diagnosis (History (DH Meds, allergies, FH CAH,…
Precocious puberty
Diagnosis
Examination
General
Secondary sex characteristics
Investigations
Bloods
FBC, U+E, LFT, TFTs
Hormones (LH, FSH [high if central, low if peripheral],
oestrogen, testosterone, androgens)
Imaging
X-ray wrist: bone age
USS (F): uterine thickness and shape (tube to pear)
Abdo CT: adrenal tumours
CT/MRI head: pituitary/hypothalamic tumours
Bedside
Obs
Measurements (height, weight, BMI)
Tanner staging
Orchidometer
History
DH
Meds, allergies
FH
CAH, tumours, early puberty
PMH
Growth and development
Known medical conditions
SH
Living arrangements, school/nursery
PC/HPC
Secondary sexual characteristics,
order of development, rate,
polyuria, polydipsia, sleep, visual changes
Pathophysiology
Gonadotrophin dependent
Central pathology; true precocious puberty
Premature HPA axis activation
Normal sequence of pubertal development (consonant)
E.g. pituitary adenoma, hydrocephalus, hypothyroidism
Both LH and FSH will be high
Gonadptropin independent
Peripheral; pseudo-precocious puberty
Excess sex steroids outside of pituitary
Abnormal sequence of development (dissonant), with hair, acne and genital virilisation before breast development in girls
E.g. adrenal tumour, CAH, liver tumour (B-hcG), gonadal tumour
FSH and LH will be low (negative feedback)
Puberty
Breast and penis enlargement due to oestrogen/testosterone
Testicular enlargement due to GnRH pulses
Pubic hair development due to androgens from adrenal gland
Clinical
presentation
Females
Breast development
Axillary and pubic hair
Menstruation
Males
Gynaecomastia
Testicular and penile enlargement
Axillary and pubic hair
Management
Conservative
Information, advice, support
Referral to paeds/endocrine
Medical
GnRH analogues
Indication: gonadotrophin dependent
MOA: high dose continous GnRH causes
negative feedback and cessation of puberty
Anti-oestrogens
Indication: gonadotrophin independent
E.g. testolactone
MOA: inhibits oestrogen actio, suppresing
puberty (sexual characteristics and rapid growth)
Anti-androgens
Indication: gonadotrophin independent
E.g. flutamide, spironolactone
MOA: inhibit androgen
Epidemiology
Rare
Common in F>M
(ovaries more sens to Gn's)
Aetiology
Primary
Idiopathic
Secondary
Infection: meningitis, encephalitis
Trauma: hydrocephalus, TBI
Neoplastic: adrenal tumour, pituitary adenoma, gonadal tumour
Endocrine: CAH, hyporgtroidism
Differentials
Premature thalarche
Premature breast development
Females 6m-2y
No other sex characteristics, self limiting
Premature adrenarche
Premature pubic hair development
Often self limiting
Complications
Reduced final height
(early epiphyseal closure)
Definition
Early onset of puberty
(<8y F, <9y M)