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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