EARLY MENARCHE
An
8-year-old girl is referred by the general
practitioner because her
periods have started. She was born at term by spontaneous vaginal
delivery after an uneventful pregnancy. She has had the normal childhood illnesses but there
is no significant serious medical
history of note. She takes no medication. Her physical development has been unremarkable until a year ago when she changed from being average
height to the second tallest
in her class.
Educationally she is achieving at a similar
level to her peers. She has many friends and no
behavioural problems. She is the first of three children
and her mother reports her own
periods starting at 11 years.
General examination is normal.
The girl has
significant breast bud
development and some fine pubic hair. Further
genital examination is not performed.
·
What is the diagnosis and what are the problems
associated with it?
·
How
would you investigate and manage this girl?
The
average age of menarche is 13 years,
and the start
of periods before
the age of 9 years, as in this case, is classified as precocious puberty.
In
normal puberty,
girls tend to start breast
bud development from 9–13 years,
start pubic hair growth from 10–14 years and menarche
starts at 11–15 years. An increased
rate of growth starts
at 11–12 years and
growth finishes at around 15 years. When
these changes occur early
but in the normal sequence, the precocious puberty
is usually of no significant consequence and termed constitutional early development. This is often
familial. However, if it occurs very
early or in an abnormal sequence, a pathological cause is more
likely
·
Growth:
although the growth
spurt starts early
in precocious puberty,
growth also stops prematurely
(premature epiphyseal closure) and therefore girls with precocious puberty are at risk of having
a reduced final
stature if untreated.
·
Embarrassment: early secondary sexual characteristics and the onset of periods
can be very difficult
for a girl to deal with at a young age.
·
Social interaction: difficulties can
occur when people
who do not
know the child’s chronological age
assume a level
of intellectual and
emotional maturity according to the child’s physical
maturity (apparent age).
Gonadotrophins, prolactin and thyroid hormones
should be checked
to confirm that they
correlate with normal pubertal levels.
Computerized tomography (CT) or magnetic resonance imaging (MRI) may be necessary for visualization of the pituitary stalk. Abdominopelvic ultrasound will rule out an ovarian
or adrenal tumour.
Bone scan will determine biological bone age to ascertain whether pituitary suppression is indicated.
As
the changes in this girl seem to be in a normal
sequence and she is within
two years of the
normal age of menarche she
can be managed
expectantly. However, if the changes
had started at a younger
age, pituitary suppression should be started
with gonadotrophin- releasing hormone
analogues, to delay the growth spurt and thus maintain
full final height.
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