Pelvic ultrasound and color Doppler findings in different isosexual precocities

Predictive value of transabdominal pelvic ultrasonography for the diagnosis of central precocious puberty: A single-center observational retrospective study

This single-center, observational, retrospective study aimed to evaluate the diagnostic accuracy of pelvic ultrasonographic parameters for detecting central precocious puberty (CPP) in a cohort of female pediatric patients undergoing gonadotropin stimulation tests. The study population consisted of 47 female patients with a suspicion of CPP. Thirty four out of 47 patients (72.34%) were subsequently diagnosed with CPP based on the current laboratory diagnostic criteria (LH peak > 5 IU/L). The ultrasonography results of 39 out of 47 patients (82.97%) were categorized as pubertal, while 31 out of 34 participants (91.17%) in the CPP group exhibited pubertal ultrasonography features. In 13 out of 47 girls (27.65%), a CPP diagnosis was ruled out; however, among these 13 patients, eight exhibited pubertal ultrasonography features suspicious of CPP. We observed a robust concordance between the GnRH test results indicative of pubertal activation and the presence of pubertal pelvic ultrasonographic features in 31 out of 34 children (91.17%). A significant correlation was found between ovarian volume and basal LH and LH/ FSH ratio, and also for basal LH, LH peak, LH/FSH ratio and peak LH/FSH ratio (p = 0.026, p = 0.011, p = 0.031, p = 0.004, respectively). Pelvic ultrasonography had a sensitivity of 91.17% and a specificity of 38.46% in differentiating CPP from premature thelarche.

Abdominal imaging in precocious puberty in girls: can imaging determine onset of puberty?

Precocious puberty in girls is defined by the appearance of secondary sex characteristics before the age of 8 years. Precocious puberty is either peripheral or central. In most cases, the cause of central precocious puberty is unknown. Rapidly progressive forms of central precocious puberty may benefit from puberty suppression to prevent compromised final height and psychosocial problems related to the physical changes. Idiopathic central precocious puberty in girls can be a challenging diagnosis. Clinical examination, evaluation of growth charts, bone age, and hormonal tests are part of the workup. The role of pelvic ultrasound to evaluate pubertal features of the internal genitalia in this context is controversial. In this paper, we have reviewed the literature to find the scientific bases for several proposed ultrasound parameters and cutoff values for the determination of onset of puberty in girls with suspected central precocious puberty. There are no reliable cutoffs for the measurements of uterus and ovaries for the diagnosis of central precocious puberty and there is overlap in the appearance of the organs in both prepubertal and pubertal girls. The interpretation of the findings on pelvic ultrasound must be done with caution and always in close communication with the referring clinicians.

Diagnosis of Central Precocious Puberty

A thorough history and physical examination including Tanner staging and growth assessments can guide differential diagnosis and aid in the evaluation of precocious puberty. Basal luteinizing hormone levels measured using a highly sensitive assay can be helpful in diagnosing central precocious puberty (CPP). Brain MRI is indicated with males diagnosed with CPP and females under the age of 6 with CPP. As more information becomes available regarding the genetic etiologies of CPP, genetic testing may preclude the need for imaging studies and other hormonal testing, especially in familial cases.

Correlation of pelvic ultrasonography with pubertal development in girls

Objectives

This study aims to correlate pelvic ultrasound with female puberty and evaluate the usual ultrasound parameters as diagnostic tests for the onset of puberty and, in particular, a less studied parameter: the Doppler evaluation of the uterine arteries.

Methods

Cross-sectional study with girls aged from one to less than eighteen years old, with normal pubertal development, who underwent pelvic ultrasound examination from November 2020 to December 2021. The presence of thelarche was the clinical criterion to distinguish pubescent from non-pubescent girls. The sonographic parameters were evaluated using the ROC curve and the cutoff point defined through the Youden index (J).

Results

60 girls were included in the study. Uterine volume ≥ 2.45mL had a sensitivity of 93%, specificity of 90%, PPV of 90%, NPV of 93% and accuracy of 91% (AUC 0.972) for predicting the onset of puberty. Mean ovarian volume ≥ 1.48mL had a sensitivity of 96%, specificity of 90%, PPV of 90%, NPV of 97% and accuracy of 93% (AUC 0.966). Mean PI ≤ 2.75 had 100% sensitivity, 48% specificity, 62% PPV, 100% NPV and 72% accuracy (AUC 0.756) for predicting the onset of puberty.

Conclusion

Pelvic ultrasound proved to be an excellent tool for female pubertal assessment and uterine and ovarian volume, the best ultrasound parameters for detecting the onset of puberty. The PI of the uterine arteries, in this study, although useful in the pubertal evaluation, showed lower accuracy in relation to the uterine and ovarian volume.

Basal gonadotropin levels combine with pelvic ultrasound and pituitary volume: a machine learning diagnostic model of idiopathic central precocious puberty

OBJECTIVE

The current diagnosis of central precocious puberty (CPP) relies on the gonadotropin-releasing hormone analogue (GnRHa) stimulation test, which requires multiple invasive blood sampling procedures. The aim of this study was to construct machine learning models incorporating basal pubertal hormone levels, pituitary magnetic resonance imaging (MRI), and pelvic ultrasound parameters to predict the response of precocious girls to GnRHa stimulation test.

METHODS

This retrospective study included 455 girls diagnosed with precocious puberty who underwent transabdominal pelvic ultrasound, brain MRI examinations and GnRHa stimulation testing were retrospectively reviewed. They were randomly assigned to the training or internal validation set in an 8:2 ratio. Four machine learning classifiers were developed to identify girls with CPP, including logistic regression, random forest, light gradient boosting (LightGBM), and eXtreme gradient boosting (XGBoost). The accuracy, sensitivity, specificity, positive predictive value, negative predictive value, area under receiver operating characteristic (AUC) and F1 score of the models were measured.

RESULTS

The participates were divided into an idiopathic CPP group (n = 263) and a non-CPP group (n = 192). All machine learning classifiers used achieved good performance in distinguishing CPP group and non-CPP group, with the area under the curve (AUC) ranging from 0.72 to 0.81 in validation set. XGBoost had the highest diagnostic efficacy, with sensitivity of 0.81, specificity of 0.72, and F1 score of 0.80. Basal pubertal hormone levels (including luteinizing hormone, follicle-stimulating hormone, and estradiol), averaged ovarian volume, and several uterine parameters were predictors in the model.

CONCLUSION

The machine learning prediction model we developed has good efficacy for predicting response to GnRHa stimulation tests which could help in the diagnosis of CPP.

Accuracy of doppler assessment of the uterine arteries for the diagnosis of pubertal onset in girls: a scoping review

The uterine artery pulsatility index (PI) assessed by Doppler ultrasound reflects the impedance to the blood flow in the vessel distal to the sampling point. We aimed to assess the accuracy of the uterine artery PI for the diagnosis of puberty in girls. A PRISMA-ScR-compliant scoping review was performed in the MEDLINE and Embase databases with the search terms "puberty" and "Doppler ultrasonography". Studies that included girls aged 0-18 years who underwent pelvic Doppler ultrasound with calculation of uterine artery PI were eligible. Ten studies comprising 1385 girls aged 1.2-18 years were included. The selected studies included participants from Italy, Brazil, Iran, Belgium and Denmark, and were published between 1996 and 2021. Six studies selected girls who were referred for evaluation of pubertal disorders, while four studies included only healthy girls. Nine studies found a significant difference in Doppler signal pattern and PI according to pubertal stage, with PI cutoff points ranging from 2.5 to 4.6 for the diagnosis of puberty, with a sensitivity of 77%-94%, specificity of 85%-100%, and accuracy of 79%-98%. Doppler assessment of the uterine arteries with PI calculation is a useful noninvasive tool in the diagnosis of pubertal onset in girls.

Effectiveness of Pelvic Ultrasonography in the Diagnosis of Central Precocious Puberty and its Differentiation from Similar Conditions

Background: Differentiation of patients with central precocious puberty (CPP) from healthy individuals and patients with CPP-like conditions [isolated premature thelarche (IPT) and isolated premature adrenarche (IPA)] is important for selecting an appropriate treatment. The gonadotropin-releasing hormone stimulation test is used as the gold standard for differentiating CPP from other conditions. Despite its high specificity, this test has disadvantages, such as low sensitivity, time-consuming sampling, and need for multiple blood samples. Objectives: This study aimed to investigate the use of pelvic ultrasonography (US) and its parameters in distinguishing CPP patients from those with similar conditions and healthy individuals. Methods: In this case-control study, a total of 183 patients, who were referred to the endocrinology department of Ali Asghar Hospital in Tehran, Iran for the evaluation of CPP, were recruited cconsecutively from 2015 to 2019. All the participants were Iranians and classified based on the clinical and laboratory findings. Pelvic US parameters were evaluated in all groups. One-way analysis of variance (ANOVA) was used to compare the mean values of continuous variables between the groups. Moreover, a post-hoc test was performed for pairwise comparisons between the groups if the result of ANOVA test was statistically significant. Finally, the receiver-operating characteristic (ROC) curve analysis was performed to determine the best cutoff points for US parameters. Results: Of 183 children, 62 were allocated to the control group (33.87%), 93 to the CPP group (50.81%), 16 to the IPT group (8.74%), and 12 to the IPA group (6.55%). The results showed no significant difference between the groups regarding chronological age and body mass index, while the bone age (107.76 ± 19.81 months) (P < 0.001) and height (129.53 ± 8.97 cm) were significantly higher in the CPP group compared to the other groups (P = 0.003). All US parameters were significantly different between the CPP and control groups. There were also significant differences between CPP patients and those with IPT and IPA in terms of all parameters, except for the cervical anteroposterior diameter and ovarian volume. The best parameters for differentiating CPP from other conditions were the uterine volume (cutoff value, 1.40; 75.27% sensitivity; 75.56% specificity), uterine transverse diameter (cutoff value, 13.5 mm; 72.04% sensitivity; 71.11% specificity), and fundus/cervix (F/C) ratio (cutoff value, 0.98; 78.49% sensitivity; 70% specificity). Conclusions: The pelvic US parameters can improve the diagnosis of CPP and play an auxiliary role in distinguishing the treatment needed. Based on the findings, the best diagnostic parameter and its cutoff value can vary depending on ethnicity and type of study.

Accuracy of Doppler assessment of the uterine arteries in healthy girls for the diagnosis of pubertal onset

PURPOSE

To evaluate the accuracy of the uterine artery pulsatility index (PI) for the diagnosis of pubertal onset in girls.

METHODS

Cross-sectional study of girls with normal pubertal development. Puberty was diagnosed by the presence of Tanner breast development score ≥2. All girls underwent pelvic ultrasound and Doppler imaging of the uterine arteries. We evaluated the uterine artery PI and uterine, endometrial, and ovarian measurements. We used ROC curves with cutoffs determined by Youden index for data analysis.

RESULTS

We included 169 girls aged 5-16 years who underwent 202 pelvic ultrasound examinations. Prepubertal girls had a significantly higher mean PI (6.70 ± 2.15) than girls in initial puberty (4.14 ± 1.55) and in late puberty (2.81 ± 1.05) (P < 0.001 for all comparisons), which reflects a progressive increase in blood flow to the uterus with the progression of puberty. ROC curve analysis showed that the PI was able to identify the onset of puberty with a mean area under the curve of 0.838 ± 0.04 (P < 0.001), and the PI cutoff point of 5.05 had a sensitivity of 77%, specificity of 85%, positive predictive value (PPV) of 92%, and accuracy of 79%. The combination of PI < 5.05 plus uterine volume >3.75 cm³ had a sensitivity of 73%, specificity of 95%, PPV of 97%, and accuracy of 79% to detect initial puberty.

CONCLUSIONS

We found a significant reduction in the PI during pubertal development, which can possibly be a valuable noninvasive tool in the evaluation of pubertal disorders, alone or in combination with uterine and ovarian volumes.

Diagnosis and management of precocious sexual maturation: an updated review

The classic definition of precocious sexual maturation is the development of secondary sexual characteristics before 8 years of age in girls and before 9 years of age in boys. It is classified as central precocious puberty when premature maturation of the hypothalamic-pituitary-gonadal axis occurs, and as peripheral precocious puberty when there is excessive secretion of sex hormones, independent of gonadotropin secretion. Precocious sexual maturation is more common in girls, generally central precocious puberty of idiopathic origin. In boys, it tends to be linked to central nervous system abnormalities. Clinical evaluation should include a detailed history and physical examination, including anthropometric measurements, calculation of growth velocity, and evaluation of secondary sexual characteristics. The main sign to suspect the onset of puberty is breast tissue development (thelarche) in girls and testicular enlargement (≥4 mL) in boys. Hormonal assessment and imaging are required for diagnosis and identification of the etiology. Genetic testing should be considered if there is a family history of precocious puberty or other clinical features suggestive of a genetic syndrome. Long-acting gonadotropin-releasing hormone analogs are the standard of care for central precocious puberty management, while peripheral precocious puberty management depends on the etiology.Conclusion: The aim of this review is to address the epidemiology, etiology, clinical assessment, and management of precocious sexual maturation. What is Known: • The main sign to suspect the onset of puberty is breast tissue development (thelarche) in girls and testicular enlargement (≥4 mL) in boys. The classic definition of precocious sexual maturation is the development of secondary sexual characteristics before 8 years of age in girls and before 9 years of age in boys. • Long-acting gonadotropin-releasing hormone agonist (GnRHa) is the standard of care for CPP management, and adequate hormone suppression results in the stabilization of pubertal progression, a decline in growth velocity, and a decrease in bone age advancement. What is New: • Most cases of precocious sexual maturation are gonadotropin-dependent and currently assumed to be idiopathic, but mutations in genes involved in pubertal development have been identified, such as MKRN3 and DLK1. • A different preparation of long-acting GnRHa is now available: 6-month subcutaneous injection.

Diagnostic Accuracy of Female Pelvic Ultrasonography in Differentiating Precocious Puberty From Premature Thelarche: A Systematic Review and Meta-analysis

BACKGROUND

The gonadotropin-releasing hormone (GnRH) stimulation test is the benchmark for diagnosing precocious puberty (PP). However, it is invasive, time-consuming, costly, and may create an unpleasant experience for participants. Moreover, some overlaps may occur between PP and premature thelarche (PT) in the early stage of PP. Female pelvic ultrasonography may provide additional information to help differentiate PP from PT and subsequently initiate early treatment. In this study, we aimed to first directly compare pelvic ultrasonography parameters between PP and PT groups and secondly, investigate their diagnostic accuracy compared with the GnRH stimulation test.

METHODS

A systematic search of the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane Library databases was performed up to March 31, 2021. All types of studies, except for case reports and review articles, were included. The GnRH stimulation test was used to confirm PP diagnosis. Those whose organic conditions might cause PP were excluded. The mean, standard deviation, sensitivity, and specificity of each parameter were documented. Forest plots were constructed to display the estimated standardized mean differences (SMDs) from each included study and the overall calculations. A bivariate model was used to calculate the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR).

RESULTS

A total of 13 studies were included for analysis. The SMDs (95% confidence interval - CI) in ovarian volume, fundal-cervical ratio, uterine length, uterine cross-sectional area, and uterine volume between PP and PT groups were 1.12 (0.78-1.45; p < 0.01), 0.90 (0.07-1.73; p = 0.03), 1.38 (0.99-1.78; p < 0.01), 1.06 (0.61-1.50; p < 0.01), and 1.21 (0.84-1.58; p <0.01), respectively. A uterine length of 3.20 cm yielded a pooled sensitivity of 81.8% (95% CI 78.3%-84.9%), specificity of 82.0% (95% CI 61.0%-93.0%), PLR of 4.56 (95% CI 2.15-9.69), NLR of 0.26 (95% CI 0.17-0.39), and DOR of 19.62 (95% CI 6.45-59.68). The area under the summary receiver operating characteristics curve was 0.82.

CONCLUSION

Female pelvic ultrasonography may serve as a complementary tool to the GnRH stimulation test in differentiating PP from PT.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232427, ID: CRD42021232427.

Validation of an Accurate and Noninvasive Tool to Exclude Female Precocious Puberty: Pelvic Ultrasound With Uterine Artery Pulsatility Index

OBJECTIVE. The purpose of this study is to validate the accuracy of pelvic ultrasound (US) with the evaluation of uterine artery pulsatility index (PI) to exclude female precocious puberty. MATERIALS AND METHODS. Tanner breast development score, luteinizing hormone (LH) peak after gonadotropin-releasing hormone (GnRH) stimulation, and uterine and ovarian volumes and diameters were assessed with pelvic US in 495 girls at a single institution. The study population was divided as follows: prepubertal (n = 207), pubertal with physiologic activation of the hypothalamic-pituitary-ovarian axis (n = 176), and central precocious puberty (CPP; n = 112). PI was measured with spectral Doppler US at the ascending branches of the right uterine artery (50-Hz filter; time gain compensation, 73; pulse repetition frequency, 6.6). ROC analyses and t tests were performed. RESULTS. The mean (± SD) PI values in the prepubertal, pubertal, and CPP groups were 6.3 ± 1.4, 3.4 ± 1.1, and 4.1 ± 1.5, respectively (p < 0.001). The best PI cutoff value to distinguish pubertal from prepubertal girls was 4.6 (sensitivity, 83%; specificity, 94%; positive predictive value, 95%; negative predictive value, 80%; accuracy, 87%). ROC AUC values for LH peak (cutoff value, 5 mU/mL) and for spectral Doppler US PI plus longitudinal uterine diameter (i.e., the combination of a PI of 4.6 with a longitudinal uterine diameter of 35 mm) were 0.9272 and 0.9439, respectively (p = 0.7925). The negative predictive values for LH peak and for PI plus longitudinal uterine diameter were 89% and 88%, respectively. CONCLUSION. A PI greater than 4.6 at spectral Doppler US combined with a longitudinal uterine diameter less than 35 mm allows noninvasive exclusion of female precocious puberty with comparable accuracy and lower costs compared to examination of LH peak after GnRH stimulation. Therefore, PI plus longitudinal uterine diameter might be used as a noninvasive first-line test to exclude precocious puberty and thereby avoid further investigations.

Observational study pelvic ultrasound a useful tool in the diagnosis and differentiation of precocious puberty in Chinese girls

Rapid and noninvasive diagnosis on and differentiation between normal, central precocious puberty (CPP), and isolated precocious puberty (IPP) is imperative before a decision can be made with gonadotropin-releasing hormone (GnRH) agonist treatment. Our study aims to evaluate such a role by pelvic ultrasound.We consecutively enrolled 84 cases of IPP (59 with premature thelarche/ pubarche and 25 with premature menarche), 47 CPP, and 177 age-matched normal controls. The IPP and CPP were diagnosed by clinical examination and GnRH-stimulation test and confirmed by over 2 years' follow-up. All subjects underwent pelvic ultrasound examination for length, width, thickness, volume of uterine/cervix/ovaries, fundal/cervical thickness ratio, endometrial thickness, and averaged maximal diameter of largest follicles. Statistical comparisons of these sonographic parameters between disease groups were made according to age intervals.It was found that between CPP and normal girls, 10 and 12 ultrasound parameters differed significantly in the >6 to 8 and >8 to 10 years age interval, respectively. Cervical thickness and endometrial thickness was the best discriminating parameter in the 2 intervals by receiver operating characteristic (ROC) curve analysis, and the cutoff, sensitivity and specificity associated with was 0.73 cm, 93.30%, 85.70%, and 0.26 cm, 76.92%, 100%, respectively. Between CPP and IPP, 2 and 5 parameters differed significantly in the >6 to 8 and >8 to 10 years age interval. Cervical length was the best discriminating parameter in both age intervals. The cutoff, sensitivity, and specificity associated were 1.49 cm, 93.33%, 55.17%, and 1.88 cm, 100%, 71.43%, respectively; Finally between normal and IPP girls, 4, 7, and 5 parameters differed significantly in the 0 to 6, >6 to 8, and >8 to 10 years intervals, respectively. Ovarian thickness, ovarian width, and cervix thickness was the best parameter for the 3 age interval respectively, and the cutoff, sensitivity and specificity associated were 0.98 cm, 76.46%, 84.85%, 1.39 cm, 85.71%,73.81%, and 0.75 cm, 90.48%, 64.21%, respectively.Our results indicate that pelvic ultrasonography could serve as a complementary tool for differentiation between normal girls and girls with different forms of sexual precocity in China. The best discriminating parameter changes according to precocity forms and age intervals.

Central precocious puberty: revisiting the diagnosis and therapeutic management

Clinical and laboratory diagnosis and treatment of central precocious puberty (CPP) remain challenging due to lack of standardization. The aim of this revision was to address the diagnostic and therapeutic features of CPP in Brazil based on relevant international literature and availability of the existing therapies in the country. The diagnosis of CPP is based mainly on clinical and biochemical parameters, and a period of follow-up is desirable to define the "progressive" form of sexual precocity. This occurs due to the broad spectrum of pubertal development, including isolated premature thelarche, constitutional growth and puberty acceleration, progressive and nonprogressive CPP, and early puberty. Measurement of basal and stimulated LH levels remains challenging, considering that the levels are not always in the pubertal range at baseline, short-acting GnRH is not readily available in Brazil, and the cutoff values differ according to the laboratory assay. When CPP is suspected but basal LH values are at prepubertal range, a stimulation test with short-acting or long-acting monthly GnRH is a diagnostic option. In Brazil, the treatment of choice for progressive CPP and early puberty is a long-acting GnRH analog (GnRHa) administered once a month or every 3 months. In Brazil, formulations of GnRHa (leuprorelin and triptorelin) are available and commonly administered, including 1-month depot leuprorelin 3.75 mg and 7.5 mg, 1-month depot triptorelin 3.75 mg, and 3-month depot leuprorelin 11.25 mg. Monthly or 3-month depot GnRHa are effective and safe to treat CPP. Arch Endocrinol Metab. 2016;60(2):163-72.

Usefulness of pelvic ultrasonography for the diagnosis of central precocious puberty in girls

Purpose

It is difficult to differentiate between central precocious puberty (CPP) and premature thelarche (PT) in girls. The aim of this study was to investigate the diagnostic usefulness of pelvic ultrasonography to distinguish between CPP and PT in girls with early breast development.

Methods

This study included girls with early breast development who visited the clinic between January 2012 and December 2013. Clinical, laboratory, and pelvic ultrasonographic data were evaluated. CPP and PT were confirmed using the gonadotropin-releasing hormone stimulation test.

Results

A total of 248 girls aged 7-8 years were included, among whom 186 (75.0%) had CPP and 62 (25.0%) had PT. The uterine length, transverse diameter, fundus, volume, and cross-sectional area were significantly larger in the CPP group (uterine length, 2.45±0.50 cm vs. 2.63±0.49 cm, P=0.015; uterine volume, 0.95±0.62 cm³ vs. 1.35±0.76 cm³, P<0.001). However, there were no differences in the fundus/cervix ratio and ovarian measurements. In receiver operating characteristic analysis, a uterine volume of at least 1.07 cm³ was the most predictive parameter for CPP with an area under the curve of 0.670 (95% confidence interval, 0.593-0.747).

Conclusion

Uterine measurements by pelvic ultrasonography in girls with early pubertal development were significantly larger in the CPP group. However, the diagnostic value of ultrasonographic parameters was not high because of a considerable overlap of values between the two groups. Therefore, pelvic ultrasonography in combination with clinical and laboratory tests may be useful to distinguish between CPP and PT in girls.

Precocious puberty

PURPOSE OF REVIEW

Precocious puberty continues to elicit great interest and concern among medical practitioners, as well as the public.

RECENT FINDINGS

Studies have elucidated neural regulation of puberty by kisspeptin, neurokinin B, and other factors. Cohort studies from the North America and Europe suggest that the age of thelarche may be earlier than determined 2 decades ago, and menarche may be slightly earlier, but the causes are unclear. Long-term outcomes of gonadotropin-releasing hormone analog therapy demonstrate increases in final height in the youngest treated patients, with no apparent adverse bone or reproductive consequences.

SUMMARY

Although the appropriate threshold age of onset of central puberty remains uncertain, gonadotropin-releasing hormone analog therapy is well tolerated and effective in suppressing luteinizing hormone pulses and ovarian activity.

Value of pelvic sonography in the diagnosis of various forms of precocious puberty in girls

PURPOSE

To evaluate the role of pelvic sonography (US) in the diagnosis and differentiation of various forms of precocious puberty in girls, and to explore reliable cutoff points of pelvic US measurements for differentiating between these conditions.

METHODS

Uterine length, uterine cross-sectional area, uterine volume, fundocervical ratio, and ovarian volumes of 143 healthy girls were compared with those of 125 girls with different forms of sexual precocity. Ovaries were morphologically classified as homogenous, paucicystic, multicystic, macrocystic, and isolated cystic.

RESULTS

Almost all US measurements of girls with central precocious puberty in the 0- to 8-year age group were significantly increased compared with controls and girls with premature thelarche and adrenarche (p < 0.05, except for ovarian volumes in premature thelarche group), whereas no statistically significant difference was found in the 8- to 10-year group (p > 0.05). Ovarian morphology distributions did not differ significantly between patient subgroups, but all had more mature forms compared with controls. Due to the wide overlap between the measurements, no reliable cutoff points could be determined by charting receiver operating characteristics curves.

CONCLUSIONS

Pelvic US can improve the diagnosis of central precocious puberty in girls of 0-8 years of age but provides no reliable type differentiation alone. It provides no valuable information for this diagnosis in girls of 8-10 years of age.

Clinical and laboratory characteristics of children referred for early puberty: preponderance in 7-8 years of age

OBJECTIVE

The aim of this study was to evaluate the girls referred to the pediatric outpatient clinic with a presumptive diagnosis of early puberty due to early onset of breast development or pubarche.

METHODS

Within the study period, we evaluated 289 subjects referred for concerns about early onset of puberty. History, anthropometric data, bone age (BA), hormones including luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, and dehydroepiandrosterone sulfate, as well as pelvic ultrasonography (USG)-derived ovarian and uterine volumes were analyzed.

RESULTS

Of the 289 girls referred for early onset of pubertal development, 64 (22.1%) had false alarms for puberty. Of the remaining 225 girls, 41 (18.2%) were diagnosed as premature pubarche, 56 (24.9%) as premature thelarche (PT), and 128 (56.9%) as precocious puberty (PP). Girls with early-onset puberty had more advanced BA, greater uterine and ovarian volumes, and also higher LH values than subjects with PP and PT. Nearly half of these girls were 7-8 years of age. Body mass index (BMI) standard deviation score was significantly higher in the PP cases.

CONCLUSIONS

There is a need for primary care physicians to be more knowledgeable on puberty and on puberty problems. There seems to be a preponderance of PP in 7-8-year-old children . Increased BMI may have a role in the trend towards earlier onset of puberty.

Plasma kisspeptin levels in girls with premature thelarche

OBJECTIVE

Premature thelarche (PT) is defined as isolated breast development without secondary sex characteristics in girls below the age of eight. We aimed to determine whether the level of kisspeptin, which plays a role in the release of gonadotropins, is associated with PT.

METHODS

The patient group included children with PT aged 3-8 years (n=20) and the control group included healthy children in the same age range (n=20). Height standard deviation scores (HSDSs), bone maturation and growth velocity were evaluated in the two groups. Basal follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), prolactin (PRL), and sex hormone-binding globulin (SHBG) levels were also measured in the two groups by immunochemiluminometric assay (ICMA). A gonadotropin-releasing hormone (GnRH) test was also conducted in the patient group and the peak levels of FSH and LH were determined. Kisspeptin levels were measured using enzyme immunoassay (EIA).

RESULTS

No differences were found between the groups in terms of age, HSDS, annual growth rate and bone age. While the plasma basal FSH, LH and E2 levels in the patient and control groups did not show statistically significant differences, PRL levels were higher in the patient group (p<0.05). Peak LH response to GnRH test was at the prepubertal level (<5 ng/mL) in patients with PT. In the patient group, kisspeptin levels were significantly higher compared to the levels in the control group (2.96 ± 1.21 ng/dL vs. 1.19 ± 0.41 ng/dL, p<0.05), and kisspeptin levels showed a significant correlation with PRL, FSH, LH, and E2 levels (p<0.05).

CONCLUSIONS

In this study, plasma kisspeptin levels were found to be higher in patients with PT and to show a positive correlation with increased PRL levels. Kisspeptin is one of the neuropeptides that plays a role in the onset of puberty. Our results support the hypothesis that PT may result from the temporary activation of central stimulants.

Pelvic ultrasonography in the evaluation of central precocious puberty: comparison with leuprolide stimulation test

OBJECTIVE

To compare the ovarian and uterine structure demonstrated sonographically with baseline and leuprolide-stimulated luteinizing hormone (LH) and estradiol values in females with suspected precocious puberty.

STUDY DESIGN

Retrospective chart review. Fifty females (age 3.1 to 9.5 years) underwent stimulation testing with leuprolide (20 μg/kg) and pelvic ultrasonography. Subjects were grouped as (1) prepubertal (baseline and stimulated LH and estradiol in prepubertal range); (2) early pubertal (baseline LH and estradiol in prepubertal range but stimulated LH or estradiol in pubertal range); and (3) pubertal (baseline and stimulated LH or estradiol in pubertal range). Sonographic data were compared with baseline and leuprolide-stimulated LH and estradiol.

RESULTS

Baseline and stimulated LH and stimulated estradiol significantly correlated with ovarian and uterine volumes. Ovarian and uterine volumes were significantly higher in females in the pubertal group than in females in the prepubertal group. No significant differences were noted in the ovarian or uterine dimensions between the prepubertal and early pubertal groups. There was significant overlap in ovarian and uterine volumes among females in all three groups.

CONCLUSION

Contrary to leuprolide stimulation, pelvic ultrasonography alone cannot distinguish between prepubertal females and those in the early stages of puberty.

Sonographic measurement of uterus and ovaries in premenarcheal healthy girls between 6 and 13 years old: correlation with age and pubertal status

BACKGROUND

To provide normal references of sonographic uterine and ovarian size in premenarcheal healthy girls aged 6-13 years in different stages of puberty.

METHODS

Two hundred forty girls were enrolled into the study (mean age ± SD, 9.5 ± 1.7 years [range, 6-13.5 years]). Pubertal status was classified according to Tanner staging. All subjects underwent pelvic sonographic examination for the measurement of uterine volume, body and cervical length, anteroposterior diameter of fundus, body, and cervix, ovarian volume, and both right and left prominent follicular diameter.

RESULTS

A gradual increase with age was observed in all uterine and ovarian measurements. Both uterine and ovarian parameters were significantly correlated to age, height and weight, and stages of puberty. Uterine volume was <3.5 cm(3) in 98% of prepubertal girls, and in stage 2 it was significantly more than in stage 1 (3 ± 3.2 versus 1.7 ± 1.7, respectively) (p < 0.001). Uterine body length was also significantly greater in stage 2 than stage 1 (17.5 ± 4.5 versus 14.6 ± 3.3, respectively) (p < 0.001).

CONCLUSION

The reference values for uterus and ovaries were determined in healthy girls. There is a progressive increase in size of internal female genitalia in relation to age, height, weight, and puberty. Uterine volume and body length presented the best correlation with age and stage of puberty.

Consensus statement on the use of gonadotropin-releasing hormone analogs in children

OBJECTIVE

Gonadotropin-releasing hormone analogs revolutionized the treatment of central precocious puberty. However, questions remain regarding their optimal use in central precocious puberty and other conditions. The Lawson Wilkins Pediatric Endocrine Society and the European Society for Pediatric Endocrinology convened a consensus conference to review the clinical use of gonadotropin-releasing hormone analogs in children and adolescents.

PARTICIPANTS

When selecting the 30 participants, consideration was given to equal representation from North America (United States and Canada) and Europe, an equal male/female ratio, and a balanced spectrum of professional seniority and expertise.

EVIDENCE

Preference was given to articles written in English with long-term outcome data. The US Public Health grading system was used to grade evidence and rate the strength of conclusions. When evidence was insufficient, conclusions were based on expert opinion.

CONSENSUS PROCESS

Participants were put into working groups with assigned topics and specific questions. Written materials were prepared and distributed before the conference, revised on the basis of input during the meeting, and presented to the full assembly for final review. If consensus could not be reached, conclusions were based on majority vote. All participants approved the final statement.

CONCLUSIONS

The efficacy of gonadotropin-releasing hormone analogs in increasing adult height is undisputed only in early-onset (girls <6 years old) central precocious puberty. Other key areas, such as the psychosocial effects of central precocious puberty and their alteration by gonadotropin-releasing hormone analogs, need additional study. Few controlled prospective studies have been performed with gonadotropin-releasing hormone analogs in children, and many conclusions rely in part on collective expert opinion. The conference did not endorse commonly voiced concerns regarding the use of gonadotropin-releasing hormone analogs, such as promotion of weight gain or long-term diminution of bone mineral density. Use of gonadotropin-releasing hormone analogs for conditions other than central precocious puberty requires additional investigation and cannot be suggested routinely.

Sonographic assessment of uterine and ovarian development in normal girls aged 1 to 12 years

PURPOSE

To provide normal references of sonographic uterine and ovarian size in girls aged 1-12 years.

METHOD

Ninety-nine girls were enrolled in the study (mean age +/- SD, 6.9 +/- 2.4 years [range, 1-12 years]). Pubertal status was classified according to Tanner staging, whereas for height and weight assessment a standard stadiometer and weight scale were employed. All subjects underwent pelvic sonographic examination for the measurement of uterine length, volume, ratio of anteroposterior diameter at the fundus divided by the anteroposterior diameter at the cervix (fundal-cervical [F/C] ratio), and ovarian volume and morphology.

RESULTS

A gradual increase with age was observed in all uterine and ovarian measurements. Cubic model analysis provided the best curve estimation for uterine length, uterine volume, and ovarian volume in relation to age. Uterine length, uterine volume, ovarian volume and F/C ratio were significantly correlated to both age and height. With respect to ovarian morphology, there was a gradual decrease in frequency of the homogeneous and the paucicystic appearances with increasing age. The macrocystic appearance was observed after the age of 6 years, and its frequency increased gradually with age.

CONCLUSION

There is a continuous increase in size of internal female genitalia from early childhood until the onset of puberty. We have provided reference percentile charts of normal uterine length, uterine volume, and ovarian volume in girls aged 1-12 years.

Evaluation of pelvic ultrasonography in the diagnosis and differentiation of various forms of sexual precocity in girls

OBJECTIVES

This study was conducted to assess the role of pelvic ultrasound variables in discriminating between normal girls and girls with different forms of sexual precocity, and to establish reliable cut-off limits of pelvic ultrasound measurements for differentiating between these conditions.

METHODS

Eighty-eight girls with different forms of sexual precocity (23 with premature thelarche, 15 with premature pubarche and 50 with central precocious puberty) were enrolled. All diagnoses were based on clinical examination with confirmation using the gonadotropin-releasing hormone-stimulation test. Additionally, 81 prepubertal girls, aged 0-10 years, were included as a control group. For statistical analysis and to facilitate comparisons, the groups were subdivided by age intervals (0-6, > 6-8 and > 8-10 years). All subjects underwent pelvic ultrasound examination for the measurement of uterine length, uterine volume, ovarian volume and the anteroposterior diameter at the fundus divided by the anteroposterior diameter at the cervix (fundal/cervical ratio, (F/C)). Finally, the morphological appearance of the ovaries was assessed.

RESULTS

Patients with central precocious puberty had significantly higher values for all the ultrasound variables (with the exception of uterine length in the 1-6-year age group) in comparison to normal girls. Patients with premature thelarche and patients with premature pubarche showed similar pelvic ultrasound parameters to those of normal girls. Ovarian volume was the best parameter for identifying patients with central precocious puberty (a cut-off of 3.04 cm(3) had a sensitivity of 100% and a specificity of 97.1% for age interval 0-6 years, a cut-off of 3.35 cm(3) had a sensitivity of 100% and a specificity of 89.5% for age interval > 6-8 years, and a cut-off of 4.46 cm(3) had a sensitivity of 80.8% and a specificity of 88.5% for age interval > 8-10 years). Uterine length was the best parameter for distinguishing between patients with central precocious puberty and patients with premature thelarche (a cut-off of 3.185 cm had a sensitivity of 85.7% and a specificity of 91.7% for age interval 0-6 years, and a cut-off of 3.83 cm had a sensitivity of 82.4% and a specificity of 90.9% for age interval > 6-8 years).

CONCLUSIONS

Ultrasound examination of the uterus and ovaries could serve as a complementary tool for the diagnosis of central precocious puberty and, consequently, for the early initiation of appropriate treatment.

Female precocious puberty, obesity and polycystic-like ovaries

OBJECTIVE

To evaluate the characteristics of obese girls with gonadotropin releasing hormone-dependent precocious puberty with and without polycystic-like ovaries.

METHODS

Forty-seven overweight (> 75(th) centile of the Italian reference data) girls with a diagnosis of isosexual precocious puberty underwent auxological analysis, hormonal assay and utero-ovarian sonographic and Doppler evaluation. On the basis of sonography the patients were subdivided into two groups, girls presenting normal ovaries (Group I; n = 31) and those with polycystic-like ovaries (Group II; n = 16).

RESULTS

The mean body weight was significantly higher (P = 0.003) in Group II than it was in Group I. In addition, the patients with polycystic-like ovaries fell within our definition of superobese (> or = 97(th) centile of the Italian reference data) in 44% of cases. The uterine and ovarian volumes were significantly greater in Group II compared with Group I patients. The Doppler evaluation showed intraparenchymal ovarian vascularization and low downstream impedance to flow in all patients in Group II.

CONCLUSIONS

Girls with precocious puberty and polycystic ovaries, compared with those without polycystic ovaries, have a higher incidence of body weight exceeding the 85(th) centile of the Italian reference data (obesity).