1
|
Smets AM, Sofia C, Bruno C, Ključevšek D, Lobo ML, Napolitano M, Ozcan HN, Stafrace S, Petit P, Müller LSO. Abdominal imaging in precocious puberty in girls: can imaging determine onset of puberty? Pediatr Radiol 2024:10.1007/s00247-024-05992-8. [PMID: 39069591 DOI: 10.1007/s00247-024-05992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024]
Abstract
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.
Collapse
Affiliation(s)
- Anne M Smets
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Costanza Bruno
- Radiology Department, AOUI Verona (Azienda Ospedaliera Universitaria Integrata), Verona, Italy
| | - Damjana Ključevšek
- Department of Radiology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Maria Luisa Lobo
- Unidade Local de Saúde de Santa Maria (ULSSM, Former CHULN), Av Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Marcello Napolitano
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital, Milan, Italy
| | - H Nursun Ozcan
- Department of Radiology/Division of Pediatric Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Samuel Stafrace
- McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Philippe Petit
- Department of Pediatric Radiology, Hôpital Timone Enfants, Aix Marseille-Université, Marseille, France
| | - Lil-Sofie Ording Müller
- Division of Radiology and Nuclear Medicine, Department of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Jia R, Xu Z, Zhou Y, Zeng B, Chen C, Huang P, Ren F, Kong FS, Ma Y. Diagnostic Value of Stimulated Urine Luteinizing Hormone After Triptorelin Stimulation Test in Girls with Central Precocious Puberty. Exp Clin Endocrinol Diabetes 2024; 132:389-395. [PMID: 38684204 DOI: 10.1055/a-2316-4772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
OBJECTIVE To investigate the diagnostic value of urine luteinizing hormone (ULH) after the triptorelin stimulation test detected by immunochemiluminometric assay (ICMA) in girls with central precocious puberty (CPP). METHODS The girls with precocious puberty were included. The triptorelin stimulation test at 8:30 a.m. was performed. Two consecutive 12-hour urine samples were collected after the test, defined as the first 12-hour and second 12-hour urine, respectively. ICMA measured ULH. Urine creatinine (Cr) concentration was measured. CPP and peripheral precocious puberty (PPP) were diagnosed by the same pediatric endocrinologist based on clinical symptoms, signs, and progression of clinical development. RESULTS A total of 97 cases (CPP n=69; PPP n=28) were included, with 12 cases not meeting the receiver operating characteristic analysis criteria. The first and second 12-hour ULH/Cr in the CPP group were higher than those in the PPP group. When the first 12-hour ULH/Cr was≥287.252 IU/mol, the sensitivity and specificity for diagnosing CPP were 87.3% and 90.9%, respectively. When the second 12-hour ULH/Cr was≥152.769 IU/mol, the sensitivity and specificity for diagnosing CPP were 92.1% and 90.9%, respectively. The area under the curve of the first and second 12-hour ULH/Cr were 0.933 and 0.954, respectively. CONCLUSION The ULH detection method after the triptorelin stimulation test has clinical significance for diagnosing CPP in girls. When blood sampling compliance in girls with precocious puberty is poor, the first 12-hour ULH/Cr≥288 IU/mol (or second 12-hour≥153 IU/mol) after the triptorelin stimulation test can serve as a laboratory indicator for diagnosis of CPP.
Collapse
Affiliation(s)
- Ruofan Jia
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| | - Zhuangjian Xu
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Yuan Zhou
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| | - Beilei Zeng
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| | - Chunmei Chen
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi Sixth People's Hospital, Binhu District Mashan Street Community Health Centre, Wuxi 214091, China
| | - Panwang Huang
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| | - Feng Ren
- Department of Clinical laboratory, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Fan-Sheng Kong
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| | - Yaping Ma
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| |
Collapse
|
3
|
Kaplowitz PB, Lee PA. Females with Breast Development before Three Years of Age. Endocrinol Metab Clin North Am 2024; 53:195-201. [PMID: 38677862 DOI: 10.1016/j.ecl.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Breast development in a girl 3 years of age or younger is a commonly encountered scenario. Nearly all of these cases will either regress or fail to progress during follow-up, confirming a diagnosis of premature thelarche (PT). Studies show that these girls will have onset of true puberty and menses at a normal age. The authors present evidence that laboratory testing, particularly basal and gonadotropin hormone-releasing hormone -stimulated gonadotropin levels, will show overlap between girls with PT and the rare patients with the onset of central precocious puberty before age 3, mainly of whom have hypothalamic hamartomas.
Collapse
Affiliation(s)
- Paul B Kaplowitz
- Division of Endocrinology, Children's National Hospital, George Washington School of Medicine and Health Sciences, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Peter A Lee
- Division of Pediatric Endocrinology, Penn State School of Medicine, Milton S. Hershey Medical Center, 500 University Avenue, Hershey, PA 17033, USA.
| |
Collapse
|
4
|
Bangalore Krishna K, Silverman LA. Diagnosis of Central Precocious Puberty. Endocrinol Metab Clin North Am 2024; 53:217-227. [PMID: 38677865 DOI: 10.1016/j.ecl.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
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.
Collapse
Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology and Diabetes, UPMC Childrens Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Lawrence A Silverman
- Division of Pediatric Endocrinology, Goryeb Children's Hospital, Atlantic Health System, 100 Madison Avenue, Morristown, NJ 07960, USA
| |
Collapse
|
5
|
Kim MR, Jung MK, Yoo EG. Slower progression of central puberty in overweight girls presenting with precocious breast development. Ann Pediatr Endocrinol Metab 2023; 28:178-183. [PMID: 35798297 PMCID: PMC10556445 DOI: 10.6065/apem.2244062.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Overweight (OW)/obese girls tend to have an earlier pubertal onset than girls with normal weight. However, only a few studies have reported the progression of puberty in these girls. This study aimed to identify risk factors for rapid pubertal progression in OW/obese girls presenting with precocious breast development. METHODS This retrospective cohort study reviewed the medical records of 110 OW (body mass index [BMI] ≥85th percentile for age and sex) and 213 nonoverweight (NW, BMI <85th percentile for age and sex) girls who presented with breast budding before 8 years of age. OW girls were divided into 2 subgroups: girls with central puberty progression before 9 years of age (OW-RP) and those without (OW-SP). RESULTS Progression to central puberty before the age of 9 was more common in NW girls than in OW girls (83.8 % vs. 65.2 % in NW vs. OW group, p<0.001), and progression-free survival for 1, 2, and 3 years was higher in the OW group (p<0.001). In a subgroup analysis of OW girls, the OW-RP subgroup had more advanced bone age (BA) at the first visit (p=0.047) and higher initial luteinizing hormone (LH, p=0.010) levels than the OW-SP subgroup. Being NW (p=0.001) and having more advanced BA (p=0.023) at the initial workup were the risk factors for pubertal progression before age 9. CONCLUSION Pubertal progression seems to be slower in OW girls than in NW girls presenting with precocious breast development. However, it can progress rapidly in OW girls with particularly pronounced BA advancement and high LH levels at the initial workup.
Collapse
Affiliation(s)
- Mi Ra Kim
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Eun-Gyong Yoo
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| |
Collapse
|
6
|
Kilberg MJ, Vogiatzi MG. Approach to the Patient: Central Precocious Puberty. J Clin Endocrinol Metab 2023; 108:2115-2123. [PMID: 36916130 DOI: 10.1210/clinem/dgad081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/24/2023] [Accepted: 02/07/2023] [Indexed: 03/15/2023]
Abstract
Central precocious puberty (CPP) classically refers to premature activation of the hypothalamic-pituitary-gonadal axis with onset of sexual development before the age of 8 years in girls and 9 years in boys. A decrease in the age of thelarche has been reported over the past several decades; however, the tempo of pubertal progression can be slower and adult height may not be adversely affected in many of the girls who experience thelarche at 6-8 years. Outside of this secular trend in the development itself, the past several decades have also brought about advances in diagnosis and management. This includes the widespread use of an ultrasensitive luteinizing hormone assay, decreasing the need for stimulation testing and a better understanding of the genetics that govern the onset of puberty. Additionally, management of CPP using gonadotropin-releasing hormone analogs (GnRHas) has changed with the advent of new longer-acting formulations. Emerging long-term outcomes of GnRHa administration with regards to obesity, cardiovascular risk factors and fertility are reassuring. Despite these advancements, clinical care in CPP is hampered by the lack of well-designed controlled studies, and management decisions are frequently not supported by clear practice guidelines. Data in boys with CPP are limited and this article focuses on the diagnosis and management of CPP in girls, particularly, in those who present with thelarche at the age of 6-8 years.
Collapse
Affiliation(s)
- Marissa J Kilberg
- Children's Hospital of Philadelphia, Endocrinology and Diabetes, Philadelphia, PA 19104, USA
| | - Maria G Vogiatzi
- Children's Hospital of Philadelphia, Endocrinology and Diabetes, Philadelphia, PA 19104, USA
| |
Collapse
|
7
|
Neuroimaging in 205 consecutive Children Diagnosed with Central Precocious Puberty in Denmark. Pediatr Res 2023; 93:125-130. [PMID: 35365758 DOI: 10.1038/s41390-022-02047-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/01/2022] [Accepted: 03/13/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION A brain magnetic resonance image (MRI) is considered part of routine evaluation in children diagnosed with central precocious puberty (CPP) to rule out intracranial pathology. We evaluated the occurrence of pathological findings on neuroimaging among children diagnosed with CPP. METHODS A retrospective study based on an evaluation of 1544 children referred with early signs of puberty from 2009-2019. Of these, 205 children (29 boys) with confirmed CPP had a brain MRI performed, and we report MRI results, pubertal stage, bone age, and hormonal analyses. All abnormal MRI results were re-evaluated by a trained neuroradiologist. RESULTS A new intracranial pathology was found by brain MRI in 6 out of 205 patients aged 1.5 to 6.1 years. The occurrence of intracranial pathology was 3/162 (1.8%) and 3/24 (12.5 %) in girls and boys respectively. CONCLUSION Organic causes of precocious puberty are more frequent in boys with CPP than in girls. No cases of organic CPP were seen above age 6.1 years of age. The age cut off value for routine brain MRI could be lowered to seven or perhaps even six years of age for girls, except in rapidly progressing puberty or presence of neurological symptoms. IMPACT In our study of children with central precocious puberty (CPP), intracranial pathology is a rare cause and occurs only in younger children. It supports the general trend, that younger children are at higher risk of having organic causes to CPP and supports the clinical practice, that only high-risk patients with CPP should undergo routine brain MRI.
Collapse
|
8
|
Han XX, Zhao FY, Gu KR, Wang GP, Zhang J, Tao R, Yuan J, Gu J, Yu JQ. Development of precocious puberty in children: Surmised medicinal plant treatment. Biomed Pharmacother 2022; 156:113907. [DOI: 10.1016/j.biopha.2022.113907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 11/29/2022] Open
|
9
|
Zhao M, Liu M, Cao B, Gong C. Associations between body mass index and pubertal development based on the outcomes of girls with early breast development. Front Endocrinol (Lausanne) 2022; 13:991908. [PMID: 36339403 PMCID: PMC9633657 DOI: 10.3389/fendo.2022.991908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate the associations between physical and pubertal development based on the breast development outcomes in girls. Methods This was a retrospective study. A total of 452 girls aged 6~8 years were included. Based on their breast development outcomes, the patients were divided into an idiopathic central precocious puberty (ICPP) group and a premature thelarche (PT) group. Anthropometry included measurements of height, weight, and BMI. ICPP was diagnosed when five diagnostic criteria from the current guidelines were met. Results The girls with breast development at initial evaluation had a median age of 6.9 years. In total, 31.4% of patients were diagnosed with ICPP, and ICPP was rare in girls <7 years old (19%). Patients who presented with recurrence of breast development in the PT group accounted for 38.4%. At initial evaluation, the height, weight, BMI and bone age (BA) of the girls in the PT group corresponded to those of a normally developing girl at ages 7.8 years, 8.2 years, 8.6 years and 7.6 years, respectively. The girls in the ICPP group had a mean age of 7.3 years, and their mean height, weight, and BMI were 129.6 cm, 28.4 kg, and 17.0 kg/m2, which corresponded to the mean of a normally developing girl at ages 8.5 years, 9.1 years, and 10.5 years, respectively; these patients had BA of 9.2 years. Additionally, based on receiver operating characteristic (ROC) curve analysis, when the basal luteinizing hormone (LH) level was 0.32 IU/L and BMI reached 16.4 kg/m2, CPP was diagnosed in patients meeting all five diagnostic criteria for CPP, and the specificity and sensitivity were 71.9% and 88.2%, respectively. Conclusions Girls with breast development before 8 years old had a high proportion of recurrence of breast development. The physical development of these girls at the time of breast development preceded that of normally developing girls by 1-2 years. BMI is an independent risk factor for early pubertal development, and is a simple and clear predictor of ICPP. In addition to the five classic diagnostic criteria, CPP is diagnosed when physical development corresponds to the mean for a 10.5 years old girl.
Collapse
Affiliation(s)
- Manman Zhao
- Department of Endocrinology, Genetics and Metabolism, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, Beijing, China
- Department of Pediatrics, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Meijuan Liu
- Department of Endocrinology, Genetics and Metabolism, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
10
|
Bakhtiani P, Geffner M. Early Puberty. Pediatr Rev 2022; 43:483-492. [PMID: 36045159 DOI: 10.1542/pir.2021-005059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Priyanka Bakhtiani
- Keck School of Medicine of the University of Southern California, Los Angeles, CA.,Children's Hospital Los Angeles, Los Angeles, CA
| | - Mitchell Geffner
- Keck School of Medicine of the University of Southern California, Los Angeles, CA.,Children's Hospital Los Angeles, Los Angeles, CA.,The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, CA
| |
Collapse
|
11
|
Vukovic R, Milenkovic T, Soldatovic I, Pekic S, Mitrovic K, Todorovic S. Triptorelin stimulated luteinizing hormone concentrations for diagnosing central precocious puberty: study of diagnostic accuracy. Endocrine 2022; 75:934-941. [PMID: 34826116 PMCID: PMC8616750 DOI: 10.1007/s12020-021-02947-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/13/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Gonadotropin-releasing hormone (GnRH) stimulation test is the gold standard for diagnosing central precocious puberty (CPP). However, intravenous GnRH is not always readily available. The aim of the present study was to evaluate the diagnostic accuracy of triptorelin-stimulated luteinizing hormone (LH) concentrations in the diagnosis of CPP among girls presenting with premature thelarche compared to the gold standard GnRH test. METHODS A prospective, case-control (CPP vs isolated premature thelarche), clinical study evaluating the diagnostic accuracy of triptorelin-stimulated LH concentrations in 60 girls with premature thelarche was performed. All girls underwent stimulation with subcutaneous triptorelin injection and intravenous GnRH in a randomized order. During the stimulation test with triptorelin, LH and FSH were measured at time 0, 30, 60, 90, 120, and 180 min after the injection. Estradiol was sampled 24 h after the injection. During the GnRH test, LH and FSH were measured at time 0, 30, 45, and 60 min. Girls with peak GnRH-stimulated LH concentrations ≥5.0 IU/L were classified as having CPP. Area under the curve (AUC) for triptorelin-stimulated LH concentrations was assessed using the receiver operating characteristic (ROC) analysis. RESULTS Triptorelin-stimulated LH concentrations were significantly higher in girls who had CPP according to the GnRH test (53.3%). LH peaked at 180 min after the triptorelin injection. The highest diagnostic accuracy for CPP (AUC = 0.973, sensitivity 96.9%, specificity 89.3%) at 180 min was at a LH concentration ≥3.4 IU/L. The 24 h estradiol concentration did not improve the predictive model. CONCLUSIONS Measuring LH concentrations 180 min after triptorelin injection with a cut-off value of ≥3.4 IU/L demonstrated a high diagnostic accuracy compared to the GnRH test. Thus, stimulation with triptorelin can be used as a reliable alternative for diagnosing CPP in girls with premature thelarche.
Collapse
Affiliation(s)
- Rade Vukovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia.
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia.
| | - Tatjana Milenkovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia
| | - Ivan Soldatovic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia
| | - Sandra Pekic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia
- Neuroendocrinology Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11 000, Belgrade, Serbia
| | - Katarina Mitrovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia
| | - Sladjana Todorovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia
| |
Collapse
|
12
|
Kaplowitz PB. For Premature Thelarche and Premature Adrenarche, the Case for Waiting before Testing. Horm Res Paediatr 2022; 93:573-576. [PMID: 33352558 DOI: 10.1159/000512764] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Paul B Kaplowitz
- Division of Endocrinology, Children's National Hospital, Washington, District of Columbia, USA,
| |
Collapse
|
13
|
Cheuiche AV, da Silveira LG, de Paula LCP, Lucena IRS, Silveiro SP. Diagnosis and management of precocious sexual maturation: an updated review. Eur J Pediatr 2021; 180:3073-3087. [PMID: 33745030 DOI: 10.1007/s00431-021-04022-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/17/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Amanda Veiga Cheuiche
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Leticia Guimarães da Silveira
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Leila Cristina Pedroso de Paula
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Sandra Pinho Silveiro
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. .,Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
| |
Collapse
|
14
|
Peterkova VA, Alimova IL, Bashnina EB, Bezlepkina OB, Bolotova NV, Zubkova NA, Kalinchenko NU, Kareva MA, Kiyaev AV, Kolodkina AA, Kostrova IB, Makazan NV, Malievskiy OA, Orlova EM, Petryaykina EE, Samsonova LN, Taranushenko TE. [Clinical guidelines «Precocious puberty»]. PROBLEMY ĖNDOKRINOLOGII 2021; 67:84-103. [PMID: 34766494 DOI: 10.14341/probl12821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 11/06/2022]
Abstract
The precocious puberty is an urgent problem of pediatric endocrinology characterized by clinical and pathogenetic heterogeneity. The appearance of secondary sex characteristics before the age of 8 years in girls and 9 years in boys requires timely diagnosis and the appointment of pathogenetically justified treatment in order to achieve the target indicators of final growth and prevent social deprivation. The developed clinical guidelines are the main working tool of the practitioner. They briefly and structurally present the main information about the epidemiology and modern classification of рrecocious puberty, methods of its diagnosis and treatment based on the principles of evidence-based medicine.
Collapse
Affiliation(s)
| | | | - E B Bashnina
- North-Western State Medical University named after I.I. Mechnikov
| | | | - N V Bolotova
- Saratov State Medical University named after V. I. Razumovsky
| | | | | | | | | | | | - I B Kostrova
- N.M. Kuraev Children's Republican Clinical Hospital
| | | | | | | | - E E Petryaykina
- Russian Children's Clinical Hospital, Pirogov Russian National Research Medical University
| | - L N Samsonova
- Russian Medical Academy of Continuous Professional Education
| | - T E Taranushenko
- Krasnoyarsk State Medical University named after V.F. Voino-Yasenetsky
| |
Collapse
|
15
|
Durá-Travé T, Gallinas-Victoriano F, Malumbres-Chacon M, Ahmed-Mohamed L, -Guindulain MJC, Berrade-Zubiri S. Clinical data and basal gonadotropins in the diagnosis of central precocious puberty in girls. Endocr Connect 2021; 10:164-170. [PMID: 33416514 PMCID: PMC7983482 DOI: 10.1530/ec-20-0651] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to analyze whether some auxological characteristics or a single basal gonadotropin measurement will be sufficient to distinguish the prepubertal from pubertal status. METHODS Auxologycal characteristics were recorded and serum LH and FSH were measured by immunochemiluminescence assays before and after GnRH stimulation test in a sample of 241 Caucasian girls with breast budding between 6- and 8-years old. Peak LH levels higher than 5 IU/L were considered a pubertal response. Area under the curve, cut-off points, sensitivity, and specificity for auxologycal variables and basal gonadotropins levels were determined by receiver operating curves. RESULTS There were no significant differences in age at onset, weight, height, BMI and height velocity between both groups. Bone age was significantly higher in pubertal girls (P < 0.05), although with limited discriminatory capacity. The sensitivity and specificity for the basal LH levels were 89 and 82%, respectively, for a cut off point of 0.1 IU/L. All girls in the pubertal group had a basal LH higher than 1.0 IU/L (positive predictive value of 100%). There was a wide overlap of basal FSH and LH/FSH ratio between prepubertal and pubertal girls. CONCLUSIONS Auxologycal characteristics should not be used only in the differential diagnosis between prepubertal from pubertal status in 6- to 8-year-old girls. We found a high specificity of a single basal LH sample and it would be useful for establishing the diagnosis of puberty in this age group, reducing the need for GnRH stimulation testing.
Collapse
Affiliation(s)
- Teodoro Durá-Travé
- Department of Pediatrics, School of Medicine, University of Navarra, Pamplona, Spain
- Department of Pediatrics, Navarra Hospital Complex, Pamplona, Spain
- Navarra Institute for Health Research (IdisNA), Pamplona, Spain
- Correspondence should be addressed to T Durá-Travé:
| | | | | | | | - María Jesús Chueca -Guindulain
- Department of Pediatrics, Navarra Hospital Complex, Pamplona, Spain
- Navarra Institute for Health Research (IdisNA), Pamplona, Spain
| | - Sara Berrade-Zubiri
- Department of Pediatrics, Navarra Hospital Complex, Pamplona, Spain
- Navarra Institute for Health Research (IdisNA), Pamplona, Spain
| |
Collapse
|
16
|
Kutlu E, Özgen İT, Bulut H, Koçyiğit A, Otçu H, Cesur Y. Serum Irisin Levels in Central Precocious Puberty and Its Variants. J Clin Endocrinol Metab 2021; 106:e247-e254. [PMID: 33034623 DOI: 10.1210/clinem/dgaa720] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Indexed: 02/08/2023]
Abstract
AIM The exact mechanisms that trigger the onset of puberty are not well known. Adipomyokines are postulated to stimulate the central neural network. In the present study, we investigated irisin levels in girls with central precocious puberty (CPP), slowly progressing precocious puberty (SPPP), or premature thelarche (PT); we also studied prepubertal girls and to determine if this adipomyokine could be used as a marker in this context. METHODS A total of 94 girls including 33 with CPP, 31 with precocious puberty (PP) variants (SPPP or PT), and 30 healthy controls were enrolled to the study. The mean irisin levels were compared between groups. The bivariate correlations of irisin levels with clinical and laboratory parameters were assessed. Multivariate linear regression analysis was performed to determine independent predictive factors of irisin levels. RESULTS Irisin levels were higher in the CPP group compared with the other groups (CPP group: 723.25 ± 62.35 ng/mL; PP variants group: 529.60 ± 39.66 ng/mL; and control group: 325.03 ± 27.53 ng/mL) (P < 0.001). Irisin levels were positively correlated with body mass index standard deviation scores (BMI-SDS), height-SDS, weight-SDS, bone age, uterus long axis, ovary size, baseline FSH and LH, and peak LH levels. Multivariate linear regression analysis revealed that irisin levels had the strongest correlation with peak LH. The other independent predictive factor of irisin levels was BMI-SDS. CONCLUSIONS The mean irisin levels were higher in patients with CPP compared with other groups. The results of this study imply that increased irisin levels may be used as a marker of CPP provided that these findings are confirmed in larger prospective studies.
Collapse
Affiliation(s)
- Esra Kutlu
- Department of Pediatrics, Division of Pediatric Endocrinology, Faculty of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - İlker Tolga Özgen
- Department of Pediatrics, Division of Pediatric Endocrinology, Faculty of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Huri Bulut
- Faculty of Medicine, Department of Biochemistry, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Abdurrahim Koçyiğit
- Faculty of Medicine, Department of Biochemistry, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Hafize Otçu
- Faculty of Medicine, Department of Radiology, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| | - Yaşar Cesur
- Department of Pediatrics, Division of Pediatric Endocrinology, Faculty of Medicine, Bezmialem Vakif University, Fatih, Istanbul, Turkey
| |
Collapse
|
17
|
Nguyen NN, Huynh LBP, Do MD, Yang TY, Tsai MC, Chen YC. Diagnostic Accuracy of Female Pelvic Ultrasonography in Differentiating Precocious Puberty From Premature Thelarche: A Systematic Review and Meta-analysis. Front Endocrinol (Lausanne) 2021; 12:735875. [PMID: 34539579 PMCID: PMC8442957 DOI: 10.3389/fendo.2021.735875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/13/2021] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Nam Nhat Nguyen
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Linh Ba Phuong Huynh
- Ph.D. Program in School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Minh Duc Do
- Center for Molecular Biomedicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tien Yun Yang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Meng-Che Tsai
- Division of Genetics, Endocrinology, and Metabolism, Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
- College of Medicine, National Cheng Kung University, Tainan, Taiwan
- *Correspondence: Meng-Che Tsai, ; Yang-Ching Chen,
| | - Yang-Ching Chen
- Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- *Correspondence: Meng-Che Tsai, ; Yang-Ching Chen,
| |
Collapse
|
18
|
Seymen Karabulut G, Atar M, Çizmecioğlu Jones FM, Hatun Ş. Girls with Premature Thelarche Younger than 3 Years of Age May Have Stimulated Luteinizing Hormone Greater than 10 IU/L. J Clin Res Pediatr Endocrinol 2020; 12:377-382. [PMID: 32349465 PMCID: PMC7711634 DOI: 10.4274/jcrpe.galenos.2020.2019.0202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/16/2020] [Indexed: 12/01/2022] Open
Abstract
Objective Premature thelarche (PT) is defined as isolated breast development in girls before eight years of age. Gonadotropin-releasing hormone (GnRH) stimulation test is sometimes used to distinguish between PT and central precocious puberty (CPP), although the interpretation of the test at early ages is challenging. The objective of this study was to determine the follicle stimulating hormone (FSH) and luteinizing hormone (LH) responses to GnRH stimulation in girls with PT below 3 years of age. Methods A standardized GnRH stimulation test, bone age and pelvic ultrasound were evaluated and those without pubertal progression after a minimum of one-year follow up were included in the study. Results On GnRH stimulation test, the median (range) baseline LH was 0.29 (0.10-0.74) IU/L, baseline FSH was 4.96 (3.18-7.05) mIU/mL, and the peak median LH was 5.75 (3.31-8.58) IU/L with the peak mean±standard deviation FSH was 40.38±20.37 mIU/mL. Among the patients, 33.3% (n=10) had baseline LH >0.3 IU/L, 67% (n=20) had peak LH >5 IU/l and 16.6% (n=5) >10 IU/L. The mean peak LH/FSH ratio was 0.17±0.09 and was ≤0.43 in all participants. Conclusion Although consensus statements usually define baseline LH >0.3-0.5 IU/L, peak LH >5 IU/L, and LH/FSH ratios >0.66-1.0 as diagnostic cut-offs for CPP, in children below 3 years of age, the baseline and peak LH values may be similar to pubertal values, possibly due to mini-puberty. A dominant FSH response on GnRH stimulation test is more valuable than the peak LH response in the diagnosis of PT.
Collapse
Affiliation(s)
- Gülcan Seymen Karabulut
- Ümraniye Training and Research Hospital, Clinic of Pediatric Endocrinology, İstanbul, Turkey
| | - Müge Atar
- Süleyman Demirel University Faculty of Medicine, Department of Pediatric Endocrinology, Isparta, Turkey
| | | | - Şükrü Hatun
- Koç University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| |
Collapse
|
19
|
Abstract
Precocious puberty (PP) is a common reason for referral to pediatric endocrinology clinics, with a strong female predominance. PP is a broad term encompassing benign variants of normal development, gonadotropin-dependent precious puberty (GDPP), and gonadotropin-independent precocious puberty (GIPP). This article reviews the definitions, physiology, clinical presentation, evaluation and treatment of these conditions.
Collapse
Affiliation(s)
- Mariam Gangat
- Unit of Pediatric Endocrinology, Department of Pediatrics, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA -
| | - Sally Radovick
- Unit of Pediatric Endocrinology, Department of Pediatrics, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| |
Collapse
|
20
|
Su H, Su Z, Pan L, Wang L, Xu Z, Peng G, Li X. Factors affecting bone maturation in Chinese girls aged 4-8 years with isolated premature thelarche. BMC Pediatr 2020; 20:356. [PMID: 32727432 PMCID: PMC7388507 DOI: 10.1186/s12887-020-02256-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background In isolated premature thelarche (IPT) girls, bone age (BA) is considered consistent with chronological age. However, some IPT girls confirmed by gonadotropin-releasing hormone (GnRH) stimulation test could show another trend. We analysed BA and possible potentiating factors in a selected group of girls aged 4–8 years with IPT. Methods IPT girls confirmed by GnRH stimulation test aged 4–8 years hospitalized from January 2015 to April 2018 at Shenzhen Children’s Hospital were included in this retrospective study. They were divided into two groups with advanced BA of 2 years as the cut-off. Body mass index (BMI) and hormone levels were the main outcome measures, and regression analysis was used to identify independent risk factors. IPT girls were divided into subgroups according to the levels of BMI standard deviation score (SDS), insulin-like growth factor-1 (IGF-1) SDS and dehydroepiandrosterone sulfate (DHEAS) SDS for comparisons of advanced BA. Results Overall, 423 subjects were included and classified into the advanced BA group (48.7%, n = 206) and control group (51.3%, n = 217). The advanced BA group had significantly higher BMI SDS, serum DHEAS SDS, IGF-1 SDS, androstenedione and fasting insulin and significantly lower sex hormone binding globulin (all p < 0.001). Serum IGF-1 SDS (OR = 1.926, p<0.001), BMI SDS (OR = 1.427, p = 0.001) and DHEAS SDS (OR = 1.131, p = 0.005) were independent risk factors for significantly advanced BA. In the multiple linear regression model, serum IGF-1 SDS, BMI SDS and DHEAS SDS were the strongest predictors of advanced BA, accounting for 19.3% of the variance. According to BMI, 423 patients were classified into three groups: normal weight (56.03%, n = 237), overweight (19.15%, n = 81) and obesity (24.82%, n = 105). The proportion of advanced BA in obesity group was significantly higher than those of normal weight and overweight groups (χ2 = 18.088, p<0.001). In the subgroup with normal weight, higher serum IGF-1 SDS (p = 0.009) and DHEAS SDS (p = 0.003) affected BA advancement independent of BMI SDS. Conclusions Girls with IPT confirmed by GnRH stimulation test aged 4–8 years might have significantly advanced BA. Obesity was highly associated with advanced BA. Age-specific serum IGF-1 SDS and DHEAS SDS were risk factors for BA advancement independent of BMI.
Collapse
Affiliation(s)
- Huiping Su
- Department of Endocrinology, Shenzhen Children's Hospital, No. 7019, Yitian Road, Futian District, 518038, Shenzhen, Guangdong Province, People's Republic of China
| | - Zhe Su
- Department of Endocrinology, Shenzhen Children's Hospital, No. 7019, Yitian Road, Futian District, 518038, Shenzhen, Guangdong Province, People's Republic of China.
| | - Lili Pan
- Department of Endocrinology, Shenzhen Children's Hospital, No. 7019, Yitian Road, Futian District, 518038, Shenzhen, Guangdong Province, People's Republic of China
| | - Li Wang
- Department of Endocrinology, Shenzhen Children's Hospital, No. 7019, Yitian Road, Futian District, 518038, Shenzhen, Guangdong Province, People's Republic of China
| | - Zhongwei Xu
- Department of Endocrinology, Shenzhen Children's Hospital, No. 7019, Yitian Road, Futian District, 518038, Shenzhen, Guangdong Province, People's Republic of China
| | - Gang Peng
- Department of Adolescent Gynecology, Shenzhen Children's Hospital, Shenzhen, China
| | - Xianglei Li
- Department of Endocrinology, Shenzhen Children's Hospital, No. 7019, Yitian Road, Futian District, 518038, Shenzhen, Guangdong Province, People's Republic of China
| |
Collapse
|
21
|
Bangalore Krishna K, Fuqua JS, Rogol AD, Klein KO, Popovic J, Houk CP, Charmandari E, Lee PA, Freire AV, Ropelato MG, Yazid Jalaludin M, Mbogo J, Kanaka-Gantenbein C, Luo X, Eugster EA, Klein KO, Vogiatzi MG, Reifschneider K, Bamba V, Garcia Rudaz C, Kaplowitz P, Backeljauw P, Allen DB, Palmert MR, Harrington J, Guerra-Junior G, Stanley T, Torres Tamayo M, Miranda Lora AL, Bajpai A, Silverman LA, Miller BS, Dayal A, Horikawa R, Oberfield S, Rogol AD, Tajima T, Popovic J, Witchel SF, Rosenthal SM, Finlayson C, Hannema SE, Castilla-Peon MF, Mericq V, Medina Bravo PG. Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium. Horm Res Paediatr 2020; 91:357-372. [PMID: 31319416 DOI: 10.1159/000501336] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022] Open
Abstract
This update, written by authors designated by multiple pediatric endocrinology societies (see List of Participating Societies) from around the globe, concisely addresses topics related to changes in GnRHa usage in children and adolescents over the last decade. Topics related to the use of GnRHa in precocious puberty include diagnostic criteria, globally available formulations, considerations of benefit of treatment, monitoring of therapy, adverse events, and long-term outcome data. Additional sections review use in transgender individuals and other pediatric endocrine related conditions. Although there have been many significant changes in GnRHa usage, there is a definite paucity of evidence-based publications to support them. Therefore, this paper is explicitly not intended to evaluate what is recommended in terms of the best use of GnRHa, based on evidence and expert opinion, but rather to describe how these drugs are used, irrespective of any qualitative evaluation. Thus, this paper should be considered a narrative review on GnRHa utilization in precocious puberty and other clinical situations. These changes are reviewed not only to point out deficiencies in the literature but also to stimulate future studies and publications in this area.
Collapse
Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA,
| | - John S Fuqua
- Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Alan D Rogol
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Karen O Klein
- University of California, San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Jadranka Popovic
- Division of Pediatric Endocrinology, Pediatric Alliance, Pittsburgh, Pennsylvania, USA
| | - Christopher P Houk
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Peter A Lee
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Xue J, Song W, Si M, Sun C, Li K, Wang W, Liang S, Xiao Y. Serum Kisspeptin and AMH Levels Are Good References for Precocious Puberty Progression. Int J Endocrinol 2020; 2020:3126309. [PMID: 33293954 PMCID: PMC7700058 DOI: 10.1155/2020/3126309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/16/2020] [Accepted: 10/31/2020] [Indexed: 11/18/2022] Open
Abstract
AIM The aim of this study was to evaluate the levels of kisspeptin and AMH in children with PT or CPP or controls to provide a reference for diagnosis and prognosis. METHODS 38 Chinese children with central precocious puberty (CPP), 38 Chinese children with premature thelarche (PT), and 75 controls were recruited. RESULTS In CPP girls, AMH levels decreased significantly compared to control girls at T2 stage. Compared with the PT and control groups, AMH is the lowest in girls in the CPP group at T3 stage. Kisspeptin decreased significantly in girls in the PT group and increased significantly in girls in the control group from T2 stage to T3 stage. At T3 stage, kisspeptin was significantly higher in girls in the CPP and control groups than in the PT group. In the control group, kisspeptin was significantly higher in boys than in girls at T2 stage. AMH and height were negatively correlated in the girls group. CONCLUSIONS Kisspeptin and AMH have a unique significance in the auxiliary diagnosis, the differential diagnosis, the treatment, and prognosis of sexual puberty disorder.
Collapse
Affiliation(s)
- Jiang Xue
- Department of Pediatrics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Department of Pediatrics, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Song
- Department of Pediatrics, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Min Si
- Department of Intensive Care Unit, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chao Sun
- Department of Central Laboratory, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kailin Li
- Department of Central Laboratory, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Wang
- Department of Interventional Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shuang Liang
- Department of Pediatrics, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yanfeng Xiao
- Department of Pediatrics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| |
Collapse
|
23
|
Österbrand M, Fors H, Norjavaara E. Prevalence of Premature Thelarche at 18 Months of Age: A Population- and Hospital-Based Study of Prevalence and Incidence in Girls Born at Northern Älvsborg County Hospital in Sweden. Horm Res Paediatr 2019; 91:203-209. [PMID: 31167216 DOI: 10.1159/000500356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/14/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this work was to investigate the prevalence of premature thelarche (PT) in 18-month-old girls, and the incidence of clinically evaluated PT for girls aged 18-36 months. METHODS In the prevalence substudy, a prospective population-based cohort of 3,140 girls born at Northern Älvsborg county hospital (NÄL) in Trollhättan, Sweden, was followed for 2 years. Girls with breast development at the 18-month health check were referred to one pediatric center in NÄL for evaluation. All girls with PT were included and followed for clinical outcome and 17β-estradiol. The prospective incidence substudy covered 8 years in a 10-year period and included all girls aged 18-36 months born at NÄL who were clinically evaluated for PT. RESULTS The prevalence of PT at 18 months in our cohort was 1.6/1,000. The 5 girls with PT no longer showed symptoms at the follow-up 3-6 months later. The incidence was 1.1/1,000 for girls aged 18-36 months and 1.0/1,000 for girls aged 18-30 months who were clinically evaluated for their PT. CONCLUSION This is the first prospective population-based study of PT and it shows a prevalence of PT at age 18 months of 1.6/1,000. The incidence of clinically evaluated PT was 1.1/1,000. Our result is in line with other studies reporting the incidence of PT from medical records (0.4-40/1,000). The outcome of PT in our study, as in the other studies, is that the great majority of girls show only benign symptoms.
Collapse
Affiliation(s)
| | - Hans Fors
- Gothenburg Pediatric Growth Research Center, Sahlgrenska Academy at University of Gothenburg, Institute of Clinical Sciences, Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Ensio Norjavaara
- Gothenburg Pediatric Growth Research Center, Sahlgrenska Academy at University of Gothenburg, Institute of Clinical Sciences, Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
| |
Collapse
|
24
|
Neeman B, Bello R, Lazar L, Phillip M, de Vries L. Response to Letter to the Editor: "Central Precocious Puberty as a Presenting Sign of Nonclassical Congenital Adrenal Hyperplasia: Clinical Characteristics". J Clin Endocrinol Metab 2019; 104:5808-5809. [PMID: 31322673 DOI: 10.1210/jc.2019-01511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 07/15/2019] [Indexed: 02/13/2023]
Affiliation(s)
- Bar Neeman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Bello
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Liora Lazar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Moshe Phillip
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Liat de Vries
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| |
Collapse
|
25
|
Coincidental Central Precocious Puberty and Wilms Tumor in a 5-Year-Old Girl. Case Rep Pediatr 2019; 2019:5427207. [PMID: 31583153 PMCID: PMC6754913 DOI: 10.1155/2019/5427207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/09/2019] [Indexed: 11/26/2022] Open
Abstract
Wilms tumor is the most frequent pediatric renal malignancy, and its usual presentation is an abdominal mass or hematuria. Unusual presentations have also been reported, such as paraneoplastic syndromes (acquired von Willebrand disease, sudden death due to pulmonary embolism, and Cushing syndrome). These conditions can precede, occur concomitantly, or present in a later phase of tumor development. Precocious puberty, as paraneoplastic endocrine syndrome, has already been described in children with malignant tumors (brain, gonadal, adrenal tumors, and hepatoblastoma). However, little is known about central precocious puberty, as paraneoplastic manifestation of nephroblastoma or secondary to its specific chemotherapy. Here, we report a case of Wilms tumor and simultaneous precocious puberty in a 5-year-old girl. The initial diagnosis was premature telarche, but the clinical and biological pubertal progression changed our diagnosis to idiopathic central precocious puberty. Chemotherapy and nephrectomy were well tolerated, and we began treatment with a gonadotropin-releasing hormone agonist which showed favorable outcomes over the short term. We highlight the need for early diagnosis and work-up in all patients of precocious puberty, in order to institute timely management.
Collapse
|
26
|
Jeong HR, Lee HJ, Shim YS, Kang MJ, Yang S, Hwang IT. Serum Makorin ring finger protein 3 values for predicting Central precocious puberty in girls. Gynecol Endocrinol 2019; 35:732-736. [PMID: 30806524 DOI: 10.1080/09513590.2019.1576615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
This study evaluated the serum level of MKRN3 and investigated its diagnostic usefulness in girls with central precocious puberty (CPP). In total, 41 girls with CPP and 35 age-matched normal control girls were enrolled. Serum values of MKRN3 were measured in both groups. Gonadotropin and estradiol concentrations were evaluated after 6 and 12 months of GnRH agonist (GnRHa) treatment in CPP patients. The MKRN3 concentrations were much lower in the patient group than in the control group (p = .005). Over 1 year of GnRHa treatment in patients, the gonadotropin concentrations were significantly decreased (p < .05), while the MKRN3 concentrations were unchanged (p > .05). MKRN3 levels were inversely correlated to standard deviation (SD) in height (r = -0.46, p = .000), SD in weight (r = -0.32, p = .005), Tanner stage (r = -0.41, p = .000), and bone age (r = -0.46, p = .000). Based on ROC analysis, the area under curve was 0.758 for MKRN3, with 82.9% sensitivity and 68.5% specificity. The measurement of serum MKRN3 level may provide some help for CPP prediction, but relatively various values need further validation.
Collapse
Affiliation(s)
- Hwal Rim Jeong
- a Departement of Pediatrics , Soonchunhyang University, College of Medicine, Cheonan Hospital , Cheonan , Korea
| | - Hye Jin Lee
- b Departement of Pediatrics , Gangnam Sacred Heart Hospital , Seoul , Korea
| | - Yeong Suk Shim
- c Departement of Pediatrics , Dongtan Sacred Heart Hospital , Hwaseong , Korea
| | - Min Jae Kang
- d Departement of Pediatrics , Sacred Heart Hospital , Anyang , Korea
| | - Seung Yang
- e Departement of Pediatrics, Kangdong Sacred Heart Hospital , Hallym University, College of Medicine , Seoul , Korea
| | - Il Tae Hwang
- e Departement of Pediatrics, Kangdong Sacred Heart Hospital , Hallym University, College of Medicine , Seoul , Korea
| |
Collapse
|
27
|
Zhang J, Xu J, Liu L, Xu X, Shu X, Yang Z, Lv L, Cai X, Jin X, Gu Z, Fu J. The prevalence of premature thelarche in girls and gynecomastia in boys and the associated factors in children in Southern China. BMC Pediatr 2019; 19:107. [PMID: 30975105 PMCID: PMC6458611 DOI: 10.1186/s12887-019-1426-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background To investigate the prevalence and risk factors of premature thelarche (PT) in girls and gynecomastia (GM) in boys in Southern China. Methods We conducted a cross-sectional study of preschool children across 9 cities in Zhejiang province. A total of 6273 children in the age-group of 2–7 years were recruited from January 2014 to March 2015. Relevant information was collected from mothers through face-to-face interviews. Logistic regression models were used to examine the correlates of PT and GM. Odds ratios (ORs) with 95% confidence intervals (CIs) are reported. Results The prevalence of PT among girls was 4.8% and that of GM among boys was 0.8%. One hundred girls were diagnosed with PT before the age of 2 years; 69 (69.0%) of these girls experienced spontaneous resolution of PT. Twenty-four boys were diagnosed with GM before the age of 2 years; 10 (41.7%) of these experienced spontaneous resolution of GM. Children borne of mothers with early onset of menarche and those belonging to high-income families were at a higher risk of premature breast development. Greater consumption of eggs was associated with premature breast development in early childhood. Conclusions Socioeconomic status of family, early onset of menarche in mother, and consumption of eggs were strongly associated with premature breast development in early childhood.
Collapse
Affiliation(s)
- Jianwei Zhang
- Department of Endocrinology, Children's Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, China.,Shaoxing women and children hospital, Shaoxing, Zhejiang, China.,Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Jinliang Xu
- Shaoxing women and children hospital, Shaoxing, Zhejiang, China.,Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Lifang Liu
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Xiaohua Xu
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Xinxian Shu
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Zhifeng Yang
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Lanqiu Lv
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Xiding Cai
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Xianjiang Jin
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Zaiyan Gu
- Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China
| | - Junfen Fu
- Department of Endocrinology, Children's Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, China. .,Quality control center of children's growth and development of Zhejiang province, Hangzhou, Zhejiang, China.
| |
Collapse
|
28
|
Central precocious puberty in girls: Diagnostic study and auxological response to triptorelin treatment. ACTA ACUST UNITED AC 2019; 66:410-416. [PMID: 30808564 DOI: 10.1016/j.endinu.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 12/12/2018] [Accepted: 12/16/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There are several controversies regarding the diagnostic tests and management of central precocious puberty (CPP). The aim of this study is to present the experience acquired in a group of girls with CPP treated with triptorelin, and to analyze the auxological characteristics and diagnostic tests. MATERIAL AND METHODS An observational, retrospective study in a group of 60 girls with CPP was conducted between January 2010 and December 2017. Sociodemographic, auxological and hormonal data were recorded at diagnosis, and pelvic ultrasound and magnetic resonance imaging of the head were performed. Girls were treated with triptorelin and monitored after treatment discontinuation until menarche. RESULTS At treatment start, chronological age and bone age were 7.7±0.7 and 9.7±0.8 years respectively, and growth velocity was 8.3±1.6cm/year. Target height was 161.1±5.8cm. Peak LH level after stimulation was 16.6±12.1 IU/l. Ovarian volumes were greater than 3mL in 35% of cases. MRI of the head was pathological in seven girls (11.7%). At treatment completion, chronological age and bone age were 10.3±1.1 and 11.2±0.8 years respectively, and growth velocity was 4.7±1.4cm/year. At the age of menarche (11.9±0.9 years), height was 157.5±5.7cm. CONCLUSIONS Treatment of CPP with triptorelin appears to be beneficial. The possibility to block pubertal development and slow skeletal maturation allows patients to reach their target height. However, individualized auxological monitoring would be mandatory.
Collapse
|
29
|
Cantas-Orsdemir S, Garb JL, Allen HF. Prevalence of cranial MRI findings in girls with central precocious puberty: a systematic review and meta-analysis. J Pediatr Endocrinol Metab 2018; 31:701-710. [PMID: 29902155 DOI: 10.1515/jpem-2018-0052] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/14/2018] [Indexed: 12/12/2022]
Abstract
Background Some pediatric endocrinologists recommend that girls with central precocious puberty (CPP) have cranial magnetic resonance imaging (MRI) performed only if they are younger than 6 years of age. However, no practice guidelines exist. The objective of this review was to assess the frequency of intracranial lesions in girls with CPP. Content We searched six electronic databases (PubMed, Cochrane, Web of Science, SCOPUS, ProQuest, and Dissertation & Theses) from 1990 through December 2015. We included studies on girls with CPP and MRI data. Case reports, case series, studies from the same author/group with the same patient population, and studies with conditions predisposing to CPP were excluded. Two physicians independently reviewed the search results and extracted data. A random-effects model was used to obtain pooled prevalence of positive MRI's across studies. Heterogeneity among studies was evaluated with the Q-statistic. Publication bias was assessed with funnel plots and Egger's test. Pooled prevalence was computed by age group. A linear regression assessed the relationship between intracranial lesion prevalence and healthcare availability. We included 15 studies with a total of 1853 girls <8 year old evaluated for CPP. Summary The pooled prevalence from all studies was 0.09 [95% confidence interval (CI) 0.06-0.12]. There was a significant heterogeneity, indicating the appropriateness of a random effects model in computing pooled prevalence. In the few studies stratified by age group, pooled prevalence was 25% in girls <6 years vs. 3% in girls 6-8 of age. Outlook Our results support that the benefit of routine MRIs in girls with CPP older than 6 years of age without any neurological concerns is not clear-cut.
Collapse
Affiliation(s)
- Sena Cantas-Orsdemir
- University of California Irvine, School of Medicine, Department of Pediatrics/Division of Pediatric Endocrinology, 333 City Blvd West, City Tower #800, Orange, CA 92868, USA, Phone: +919-259-2681
| | - Jane L Garb
- UMMS-Baystate Medical Center, Division of Academic Affairs, Springfield, MA, USA
| | - Holley F Allen
- UMMS-Baystate Medical Center, Department of Pediatrics, Division of Pediatric Endocrinology, Springfield, MA, USA
| |
Collapse
|
30
|
Disorders of puberty. Best Pract Res Clin Obstet Gynaecol 2018; 48:62-89. [DOI: 10.1016/j.bpobgyn.2017.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 10/24/2017] [Accepted: 11/03/2017] [Indexed: 01/08/2023]
|
31
|
Çiçek D, Savas-Erdeve S, Cetinkaya S, Aycan Z. Clinical follow-up data and the rate of development of precocious and rapidly progressive puberty in patients with premature thelarche. J Pediatr Endocrinol Metab 2018; 31:305-312. [PMID: 29373318 DOI: 10.1515/jpem-2017-0247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 12/22/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aimed to evaluate the clinical follow-up data of patients with premature thelarche and determine the rate of development of precocious and early puberty in these patients. METHODS The charts of 158 girls with premature thelarche who were followed-up in our pediatric endocrinology polyclinic were reviewed. The patients were divided into three groups according to the age at onset: group 1 (0-1 month) (n=12), group 2 (1-24 months) (n=40) and group 3 (2-8 years) (n=106). RESULTS At admission, the mean height standard deviation score (SDS), body weight (BW)-SDS, body mass index (BMI) and BMI-SDS were significantly higher in group 3 than in group 1 and group 2. At admission, 8.8% of the patients were obese and 24% of the patients were overweight. The majority of patients who were obese and overweight were in group 3. At the end of the follow-up, thelarche regressed in 24.7%, persisted in 32.9%, progressed in 25.9% and had a cyclic pattern in 16.5% of the patients. Precocious or rapidly progressive puberty developed in 47 of the 158 patients (29.7%). The mean age at progression to early or rapidly progressive puberty was 98.1±17.6 months. A total of 89.3% of the patients who progressed to early or rapidly progressive puberty were in group 3. CONCLUSIONS Precocious or rapidly progressive puberty developed in 29.7% of subjects with premature thelarche. As patients who developed rapidly progressive puberty had a higher BW-SDS and BMI-SDS than those who did not, it is suggested that the increase in weight could stimulate rapidly progressive puberty in cases with premature thelarche.
Collapse
Affiliation(s)
- Dilek Çiçek
- Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Pediatric Endocrinology Department, Ankara, Turkey
| | - Senay Savas-Erdeve
- Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Pediatric Endocrinology Department, Ankara, Turkey
| | - Semra Cetinkaya
- Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Pediatric Endocrinology Department, Ankara, Turkey
| | - Zehra Aycan
- Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Pediatric Endocrinology Department, Ankara, Turkey
| |
Collapse
|
32
|
Österbrand M, Fors H, Allvin K, Norjavaara E. 17β-Estradiol and Gonadotropin Levels for the Diagnosis of the Benign Form of Breast Development in Girls Aged up to 4 Years in Real-Life Clinical Practice. Horm Res Paediatr 2018; 87:315-323. [PMID: 28399535 DOI: 10.1159/000470841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/03/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early onset of breast development in a young girl is usually a benign and isolated prepubertal condition, i.e., premature thelarche (PT), but can sometimes be progressive and the first sign of pubertal precocity (PP). Serum 17β-estradiol (17β-E2) level is a possible marker to differentiate between benign and pathological forms of breast development. We defined an upper serum 17β-E2 level for benign, "classic" PT for girls aged 9-48 months. METHODS Serum 17β-E2 was analysed with a highly sensitive extraction radioimmunoassay (RIA). Gonadotropins, Tanner breast stage, growth, other investigations, and clinical outcome were assessed in 125 girls with breast development, in a population-based study in West Sweden. RESULTS A total of 125 of 128 girls had a benign form of breast development with a mean serum 17β-E2 level of 15.2 pmol/L and a mean + 2 SD of 31 pmol/L, which was regarded as the upper limit for benign PT; 3 girls with PP had 17β-E2 levels above 70 pmol/L. CONCLUSION This is the first study to define an upper serum 17β-E2 level associated with benign PT. Girls aged 9-48 months with PT and Tanner breast stage 2 have 17β-E2 levels below 32 pmol/L using extraction RIA. LH below the detection limit (0.1 IU/L) and measurable FSH support benign PT.
Collapse
Affiliation(s)
- Martin Österbrand
- Department of Pediatrics, Gothenburg Pediatric Growth Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Queen Silvia Children's Hospital, Gothenburg, Sweden.,Department of Pediatrics, NU Hospital Group, Trollhättan, Sweden
| | - Hans Fors
- Department of Pediatrics, Gothenburg Pediatric Growth Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Queen Silvia Children's Hospital, Gothenburg, Sweden.,Department of Pediatrics, NU Hospital Group, Trollhättan, Sweden
| | - Kerstin Allvin
- Department of Pediatrics, Gothenburg Pediatric Growth Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Ensio Norjavaara
- Department of Pediatrics, Gothenburg Pediatric Growth Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Queen Silvia Children's Hospital, Gothenburg, Sweden
| |
Collapse
|
33
|
Durmaz E, Asci A, Erkekoglu P, Balcı A, Bircan I, Koçer-Gumusel B. Urinary bisphenol A levels in Turkish girls with premature thelarche. Hum Exp Toxicol 2018; 37:1007-1016. [PMID: 29405766 DOI: 10.1177/0960327118756720] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
There is a growing concern over the timing of pubertal breast development and its possible association with exposure to endocrine disrupting chemicals (EDCs), such as bisphenol A (BPA). BPA is abundantly used to harden plastics. The aim of this study was to investigate the relation between premature thelarche (PT) and BPA by comparing the urinary BPA levels of PT girls with those of healthy subjects. Twenty-five newly diagnosed nonobese PT subjects (aged 4-8 years) who were admitted to the Pediatric Endocrinology Department at Akdeniz University were recruited. The control group composed of 25 age-matched girls without PT and other endocrine disorders. Urinary BPA levels were measured by high pressure liquid chromatography. The median urinary concentrations of BPA were found to be significantly higher in the PT group compared to the healthy control group (3.2 vs. 1.62 μg/g creatinine, p < 0.05). We observed a weak positive correlation between uterus volume and urinary BPA levels. There was a weak correlation between estradiol and urinary BPA levels ( r = 0.166; p = 0.37); and luteinizing hormone and urinary BPA levels ( r = 0.291; p = 0.08) of PT girls. Our results suggest that exposure to BPA might be one of the underlying factors of early breast development in prepubertal girls and EDCs may be considered as one of the etiological factors in the development of PT.
Collapse
Affiliation(s)
- E Durmaz
- 1 Department of Pediatric Endocrinology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - A Asci
- 2 Department of Toxicology, Faculty of Pharmacy, Atatürk University, Erzurum, Turkey
| | - P Erkekoglu
- 3 Department of Toxicology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - A Balcı
- 3 Department of Toxicology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - I Bircan
- 1 Department of Pediatric Endocrinology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - B Koçer-Gumusel
- 3 Department of Toxicology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| |
Collapse
|
34
|
Deodati A, Sallemi A, Maranghi F, Germani D, Puglianiello A, Baldari F, Busani L, Mancini FR, Tassinari R, Mantovani A, Cianfarani S. Serum Levels of Polybrominated Diphenyl Ethers in Girls with Premature Thelarche. Horm Res Paediatr 2018; 86:233-239. [PMID: 27035145 DOI: 10.1159/000444586] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 02/09/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Polybrominated diphenyl ethers (PBDEs) are widely used as flame retardants and have shown endocrine disruption properties in experimental studies. The aim of this study was to investigate the association between the exposure to PBDEs and alterations of puberty in girls referred for idiopathic central precocious puberty (ICPP) and premature thelarche (PT). METHODS A case-control study was conducted in 124 girls: 37 girls with ICPP (mean age 7.4 ± 0.9 years), 56 with PT (mean age 5.7 ± 2.1 years) and 31 controls (mean age 5.4 ± 1.9 years). PBDE serum concentrations, hormone levels and anthropometry were assessed. PBDE concentrations were corrected for total serum lipid content. Individual exposure to PBDEs was evaluated through ad hoc questionnaires. RESULTS PBDE serum concentrations corrected for total lipid content were significantly higher in girls with PT (mean 1.49 ± 0.63 log ng/g) than in controls (mean 1.23 ± 0.54 log ng/g; p < 0.05). PT girls showed higher levels of PBDE than ICPP girls (1.49 ± 0.63 vs. 1.37 ± 0.49 log ng/g), though this was not significant. An analysis of the questionnaires revealed no significant differences in exposure between the three groups. CONCLUSION Our findings suggest that higher concentrations of serum PBDEs are associated with PT in girls.
Collapse
Affiliation(s)
- Annalisa Deodati
- Department of Pediatrics (DPUO), 'Bambino Gesù' Children's Hospital, 'Tor Vergata' University, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Xu Y, Li G, Li Y. Advanced bone age as an indicator facilitates the diagnosis of precocious puberty. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
36
|
Xu YQ, Li GM, Li Y. Advanced bone age as an indicator facilitates the diagnosis of precocious puberty. J Pediatr (Rio J) 2018; 94:69-75. [PMID: 28866322 DOI: 10.1016/j.jped.2017.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/08/2017] [Accepted: 02/15/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Diagnosis of central precocious puberty has always been challenging in clinical practice. As an important method in the diagnosis of central precocious puberty, luteinizing hormone-releasing hormone stimulation test is complex and time-consuming. In many cases, clinical traits are inconsistent with luteinizing hormone-releasing hormone stimulation test results, therefore not reliable for diagnosis. In this study, the authors intended to find an indicator that predicts the results of the luteinizing hormone-releasing hormone stimulation test among subjects with early pubertal signs. METHODS Cases of 382 girls with early breast development before 8 years old and luteinizing hormone-releasing hormone stimulation test before 9 years old were included and underwent follow-up tests. Patients with peak luteinizing hormone level ≥5IU/L were considered positive in the luteinizing hormone-releasing hormone stimulation test. Anthropometric data, body mass index, bone age evaluation, blood hormones levels of luteinizing hormone, estradiol, follicle-stimulating hormone, and uterine and ovarian volumes were analyzed. RESULTS Subjects with positive results in the initial test demonstrated early bone maturation, accelerated growth, and elevated basal blood luteinizing hormone, estradiol, and follicle-stimulating hormone levels, when compared with subjects with negative results in the initial test. Subjects with positive results in the follow-up test presented a more advanced bone age and more accelerated linear growth, when compared with subjects with negative results in the follow-up test. CONCLUSIONS According to the statistical analysis, advanced bone age is the most effective predictor of the result of luteinizing hormone-releasing hormone stimulation test.
Collapse
Affiliation(s)
- Yue-Qin Xu
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Pediatrics, 9677 Jinshi Road, Jinan 250014, China; Shandong Qianfoshan Hospital Affiliated to Shandong University, Department of Children Healthcare, 16766 Jinshi Road, Jinan 250014, China
| | - Gui-Mei Li
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Pediatrics, 9677 Jinshi Road, Jinan 250014, China.
| | - Yan Li
- Shandong Qianfoshan Hospital Affiliated to Shandong University, Department of Children Healthcare, 16766 Jinshi Road, Jinan 250014, China
| |
Collapse
|
37
|
Abstract
Premature thelarche is a benign condition that affects young girls and may be interpreted as a sign of central precocious puberty (CPP). Parental concern is common when breast development is noted in a young girl. It is important to differentiate premature thelarche from CPP, as the latter is a more serious disorder that may affect final adult height and menarcheal age, and may have psychological implications as well. Distinguishing between the two conditions clinically may help the patients avoid unnecessary testing. Pediatricians can play a pivotal role by providing reassurance to families and helping alleviate parental anxiety. This article reviews the clinical presentation of premature thelarche, its usual course, and implications. [Pediatr Ann. 2018;47(1):e12-e15.].
Collapse
|
38
|
Bereket A. A Critical Appraisal of the Effect of Gonadotropin-Releasing Hormon Analog Treatment on Adult Height of Girls with Central Precocious Puberty. J Clin Res Pediatr Endocrinol 2017; 9:33-48. [PMID: 29280737 PMCID: PMC5790330 DOI: 10.4274/jcrpe.2017.s004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 12/01/2022] Open
Abstract
Central precocious puberty (CPP) is a diagnosis that pediatric endocrinologists worldwide increasingly make in girls of age 6-8 years and is mostly idiopathic. Part of the reason for increasing referral and diagnosis is the perception among the doctors as well as the patients that treatment of CPP with long-acting gonadotropin-releasing hormon analogues (GnRHa) promote height of the child. Although, the timing and the tempo of puberty does influence statural growth and achieved adult height, the extent of this effect is variable depending on several factors and is modest in most cases. Studies investigating GnRHa treatment in girls with idiopathic CPP demonstrate that treatment is able to restore adult height compromised by precocious puberty. However, reports on untreated girls with precocious puberty demonstrate that some of these girls achieve their target height without treatment as well, thus, blurring the net effect of GnRHa treatment on height in girls with CPP. Clinical studies on treatment of girls with idiopathic CPP on adult stature suffers from the solid evidence-base due mainly to the lack of well-designed randomized controlled studies and our insufficiencies of predicting adult height of a child with narrow precision. This is particularly true for girls in whom age of pubertal onset is close to physiological age of puberty, which are the majority of cases treated with GnRHa nowadays. Heterogeneous nature of pubertal tempo (progressive vs. nonprogressive) leading to different height outcomes also complicates the interpretation of the results in both treated and untreated cases. This review will attemp to summarize and critically appraise available data in the field.
Collapse
Affiliation(s)
- Abdullah Bereket
- Marmara University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| |
Collapse
|
39
|
Ucakturk A, Gunindi F, Aydin M. Apparent cyclic vaginal bleeding in a child: factitious disorder. Clin Pediatr Endocrinol 2017; 26:189-192. [PMID: 28804211 PMCID: PMC5537216 DOI: 10.1297/cpe.26.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/14/2017] [Indexed: 11/21/2022] Open
Abstract
A 20-mo-old girl was brought to our department by her mother because of breast
enlargement. She was diagnosed with premature thelarche. One month later, she returned to
our hospital with a complaint of vaginal bleeding. During the subsequent 6 mo, her vaginal
bleeding recurred every month while her breast development disappeared. We performed
laboratory tests and imaging. At the end of 6 mo, we realized that her mother’s menstrual
bleeding and the patient’s blood staining were concurrent. The mother confessed applying
her vaginal flow to her daughter’s underwear. Factitious disorder should be included in
the differential diagnosis of unexplained vaginal bleeding in childhood.
Collapse
Affiliation(s)
- Ahmet Ucakturk
- Department of Pediatric Endocrinology, Ankara Children's Hematology and Oncology Training Hospital, Ankara, Turkey
| | - Figen Gunindi
- Department of Pediatric Endocrinology, Medical Park Hospital, Samsun, Turkey
| | - Murat Aydin
- Department of Pediatric Endocrinology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| |
Collapse
|
40
|
Abstract
BACKGROUND Premature thelarche is a self-limited condition characterized by Tanner stage II-III breast development in girls younger than 8 years of age with no evidence of advancing puberty. Evaluation concentrates on excluding central or peripheral causes of precocious puberty. CASE A girl aged 2 years 4 months with profound hypotonia and delayed developmental milestones presented with Tanner II breast development, elevated follicle-stimulating hormone levels, suppressed luteinizing hormone level, normal growth and skeletal development, and prepubertal uterine length and ovarian volume. Monitoring until 8 years of age revealed no pubertal progression. Whole exome sequencing at 8 years revealed an autosomal-dominant mutation in the purine-rich element-binding protein A (PURA) gene. Previous patients with PURA syndrome have had pituitary dysfunction and precocious puberty. CONCLUSION Purine-rich element-binding protein A syndrome can be associated with premature thelarche.
Collapse
|
41
|
Vestergaard ET, Schjørring ME, Kamperis K, Petersen KK, Rittig S, Juul A, Kristensen K, Birkebæk NH. The follicle-stimulating hormone (FSH) and luteinizing hormone (LH) response to a gonadotropin-releasing hormone analogue test in healthy prepubertal girls aged 10 months to 6 years. Eur J Endocrinol 2017; 176:747-753. [PMID: 28348072 DOI: 10.1530/eje-17-0042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/21/2017] [Accepted: 03/27/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Premature thelarche and precocious puberty are frequently diagnosed in girls even below 6 years of age and may be difficult to differentiate in the early stages. A GnRH test is often included in the diagnostic work-up, although interpretation of the GnRH test in girls below 6 years of age is challenging, as no reference interval exists for this age group. The objective is to determine the normal FSH and LH response to a GnRH test in healthy prepubertal girls below 6 years of age. DESIGN AND METHODS A standardized GnRH test, baseline reproductive hormones, clinical evaluation and bone age were determined in all participants. Forty-eight healthy normal-weight girls aged 3.5 ± 0.2 years (range: 0.8-5.9 years) were included. Serum concentrations of LH and FSH were measured before and 30 min after the gonadorelin injection. RESULTS The 30-min LH responses (mean ± 2 s.d.) were 5.2 ± 4.0 and 2.9 ± 2.5 IU/L and the FSH responses were 23.3 ± 16.2 and 14.5 ± 10.3 IU/L in girls aged 0.8-3.0 years and 3.0-5.9 years respectively. This corresponds to upper cut-off limits for LH of 9.2 IU/L (<3 years) and 5.3 IU/L (3-6 years). The stimulated LH/FSH ratio was 0.23 ± 0.19 (range 0.06-0.43) and did not correlate with age. CONCLUSIONS We found that LH increases up to 9.2 IU/L during GnRH test in healthy normal-weight girls below 3 years of age and that the stimulated LH/FSH ratio did not exceed 0.43. Our findings have important implications for appropriate diagnosis of central precocious puberty in girls below 6 years of age.
Collapse
Affiliation(s)
- Esben T Vestergaard
- Medical Research LaboratoryAarhus University, Aarhus, Denmark
- Department of PediatricsRanders Regional Hospital, Randers, Denmark
- Pediatrics and Adolescent MedicineAarhus University Hospital, Aarhus, Denmark
| | - Mia E Schjørring
- Pediatrics and Adolescent MedicineAarhus University Hospital, Aarhus, Denmark
| | | | | | - Søren Rittig
- Pediatrics and Adolescent MedicineAarhus University Hospital, Aarhus, Denmark
| | - Anders Juul
- Department of Growth and Reproduction and EDMaRCRigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kurt Kristensen
- Pediatrics and Adolescent MedicineAarhus University Hospital, Aarhus, Denmark
| | - Niels H Birkebæk
- Pediatrics and Adolescent MedicineAarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
42
|
Brito VN, Spinola-Castro AM, Kochi C, Kopacek C, Silva PCAD, Guerra-Júnior G. Central precocious puberty: revisiting the diagnosis and therapeutic management. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2017; 60:163-72. [PMID: 27191050 DOI: 10.1590/2359-3997000000144] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/10/2016] [Indexed: 11/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Vinícius Nahime Brito
- Departamento de Endocrinologia Pediátrica, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil
| | - Angela Maria Spinola-Castro
- Departamento de Endocrinologia Pediátrica, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil
| | - Cristiane Kochi
- Departamento de Endocrinologia, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brasil
| | - Cristiane Kopacek
- Departamento de Endocrinologia, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brasil
| | - Paulo César Alves da Silva
- Departamento de Endocrinologia Pediátrica, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil
| | - Gil Guerra-Júnior
- Departamento de Endocrinologia, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brasil
| |
Collapse
|
43
|
Varimo T, Huttunen H, Miettinen PJ, Kariola L, Hietamäki J, Tarkkanen A, Hero M, Raivio T. Precocious Puberty or Premature Thelarche: Analysis of a Large Patient Series in a Single Tertiary Center with Special Emphasis on 6- to 8-Year-Old Girls. Front Endocrinol (Lausanne) 2017; 8:213. [PMID: 28878739 PMCID: PMC5572337 DOI: 10.3389/fendo.2017.00213] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/09/2017] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION We describe the etiology, MRI findings, and growth patterns in girls who had presented with signs of precocious puberty (PP), i.e., premature breast development or early menarche. Special attention was paid to the diagnostic findings in 6- to 8-year-olds. MATERIALS AND METHODS We reviewed the medical records of 149 girls (aged 0.7-10.3 years) who had been evaluated for PP in the Helsinki University Hospital between 2001 and 2014. RESULTS In 6- to 8-year-old girls, PP was most frequently caused by idiopathic gonadotropin-releasing hormone (GnRH)-dependent PP (60%) and premature thelarche (PT; 39%). The former subgroup grew faster (8.7 ± 2.0 cm/year, n = 58) than the girls with PT (7.0 ± 1.1 cm/year, n = 32) (P < 0.001), and the best discrimination for GnRH-dependent PP was achieved with a growth velocity cut-off value of 7.0 cm/year (sensitivity 92% and specificity 58%) [area under the curve 0.82, 95% confidence interval (CI) 0.73-0.91, P < 0.001]. Among asymptomatic and previously healthy 6- to 8-year-old girls with GnRH-dependent PP, one (1.7%, 95% CI 0.3-9.7%) had a pathological brain MRI finding requiring surgical intervention (craniopharyngioma). In girls younger than 3 years, the most frequent cause of breast development was PT, and, in 3- to 6-year-olds, GnRH-dependent PP. CONCLUSION In 6- to 8-year-old girls, analysis of growth velocity is helpful in differentiating between PT and GnRH-dependent PP. Although the frequency of clinically relevant intracranial findings in previously healthy, asymptomatic 6- to 8-year-old girls was low, they can present without any signs or symptoms, which favors routine MRI imaging also in this age group.
Collapse
Affiliation(s)
- Tero Varimo
- Children’s Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Heta Huttunen
- Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Päivi Johanna Miettinen
- Children’s Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Research Programs Unit, Molecular Neurology, Biomedicum Stem Cell Center, University of Helsinki, Helsinki, Finland
| | - Laura Kariola
- Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Johanna Hietamäki
- Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Annika Tarkkanen
- Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Matti Hero
- Children’s Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Taneli Raivio
- Children’s Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, Department of Physiology, University of Helsinki, Helsinki, Finland
- *Correspondence: Taneli Raivio,
| |
Collapse
|
44
|
Sømod ME, Vestergaard ET, Kristensen K, Birkebæk NH. Increasing incidence of premature thelarche in the Central Region of Denmark - Challenges in differentiating girls less than 7 years of age with premature thelarche from girls with precocious puberty in real-life practice. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2016; 2016:4. [PMID: 26909102 PMCID: PMC4763410 DOI: 10.1186/s13633-016-0022-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/25/2016] [Indexed: 11/10/2022]
Abstract
Background Premature thelarche (PT) seems to be increasing and it is difficult to differentiate its early stages from precocious puberty (PP). Clinical and biochemical parameters are warranted to differentiate the two diagnoses. Methods One hundred ninety-one girls aged 0.5–7 years were included. Diagnoses were validated and the girls were categorized to the groups PP (n = 27) and PT (n = 164). Anthropometry, Tanner stages, ethnicity, bone age, and biochemistry, were recorded. Conventional variables for diagnosing PP were compared between the groups at time of referral to identify parameters predictive for the diagnosis. Results The referral rate of PT increased from 1998–2013. Girls with PT and PP differed with regards to age at referral, body mass index standard deviation scores (BMISDS), ethnicity, bone age advancement, basal luteinizing hormone (LH), gonadotropin releasing hormone (GnRH) stimulated LH and follicle stimulating hormone (FSH), basal and stimulated LH/FSH ratio, and sex-hormone binding globulin (SHBG). Apart from SHBG there was considerable overlap of the variables between the PT and the PP groups. Conclusions First, the incidence of PT appears to increase. Second, SHBG was the variable which best discriminated PT from PP. Third, stimulated LH in 1–3 years old girls with PT is similar to stimulated LH in 5–7 years old girls with PP. Age, BMISDS, ethnicity, bone age, stimulated gonadotropins and LH/FSH and SHBG are all useful variables for differentiating PP from PT. However normative data for stimulated LH and FSH in the age group 0.5–7 years are warranted.
Collapse
Affiliation(s)
- Mia Elbek Sømod
- Department of Pediatrics, Aarhus University Hospital, Skejby, Palle Juul Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Esben Thyssen Vestergaard
- Medical Research Laboratory, Aarhus University, Nørrebrogade 44 building 3B, DK-8000 Aarhus C, Denmark.,Department of Pediatrics, Randers Regional Hospital, DK-8930 Randers, Denmark
| | - Kurt Kristensen
- Department of Pediatrics, Aarhus University Hospital, Skejby, Palle Juul Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Niels Holtum Birkebæk
- Department of Pediatrics, Aarhus University Hospital, Skejby, Palle Juul Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| |
Collapse
|
45
|
Abstract
Concerns about possible early pubertal development are a common cause for referral to pediatric medical subspecialists. Several recent studies have suggested that onset of breast and/or pubic hair development may be occurring earlier than in the past. Although there is a chance of finding pathology in girls with signs of puberty before 8 years of age and in boys before 9 years of age, the vast majority of these children with signs of apparent puberty have variations of normal growth and physical development and do not require laboratory testing, bone age radiographs, or intervention. The most common of these signs of early puberty are premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (nonprogressive breast development, usually occurring before 2 years of age), and lipomastia, in which girls have apparent breast development which, on careful palpation, is determined to be adipose tissue. Indicators that the signs of sexual maturation may represent true, central precocious puberty include progressive breast development over a 4- to 6-month period of observation or progressive penis and testicular enlargement, especially if accompanied by rapid linear growth. Children exhibiting these true indicators of early puberty need prompt evaluation by the appropriate pediatric medical subspecialist. Therapy with a gonadotropin-releasing hormone agonist may be indicated, as discussed in this report.
Collapse
|
46
|
Bourayou R, Giabicani E, Pouillot M, Brailly-Tabard S, Brauner R. Premature pubarche before one year of age: distinguishing between mini-puberty variants and precocious puberty. Med Sci Monit 2015; 21:955-63. [PMID: 25832117 PMCID: PMC4395023 DOI: 10.12659/msm.893139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The aim of this study was to facilitate the distinction between the benign “mini-puberty of early infancy” and precocious puberty (PP). Material/Methods We compared 59 patients (21 boys and 38 girls) seen for pubic hair development before one year of age diagnosed as mini-puberty to 13 patients (2 boys) in whom pubertal development before one year revealed a PP. Results The boys with mini-puberty presented with pubic hair development and prepubertal testicular volume, with low plasma testosterone concentrations. Their gonadotropin responses to gonadotropin releasing hormone (GnRH) test showed predominant luteinising hormone increase in 9/13. The girls presented with pubic hair development that was accompanied by breast development in 47% of cases, with low plasma estradiol concentrations. Their gonadotropin responses showed predominant follicle-stimulating hormone increase in the 17 evaluated. The patients with PP had organic central PP (5 hypothalamic hamartoma) or idiopathic central PP (n=6), or peripheral PP (one ovarian tumor and one congenital adrenal hyperplasia). The diagnosis was challenging only in 3 girls with idiopathic central PP presenting with prepubertal plasma estradiol concentrations and responses to GnRH test. Conclusions The diagnosis of PP was easily determined based on the clinical presentation and the pubertal concentrations of testosterone in boys or of estradiol in girls, as was the diagnosis of central or peripheral origin of PP based on gonadotropin response to the GnRH test. Once PP is excluded, these patients need careful follow–up and physician consultation is needed if clinical pubertal signs progress.
Collapse
Affiliation(s)
- Rafik Bourayou
- Pediatric Endocrinology Unit, Fondation Ophtalmologique Adolphe de Rothschild and Université Paris Descartes, Paris, France
| | - Eloïse Giabicani
- Pediatric Endocrinology Unit, Fondation Ophtalmologique Adolphe de Rothschild and Université Paris Descartes, Paris, France
| | - Monique Pouillot
- Pediatric Endocrinology Unit, Fondation Ophtalmologique Adolphe de Rothschild and Université Paris Descartes, Paris, France
| | - Sylvie Brailly-Tabard
- Department of Molecular Genetics, Pharmacogenetics, Hormonology, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, and Université Paris Sud, Le Kremlin Bicêtre, France
| | - Raja Brauner
- Pediatric Endocrinology Unit, Fondation Ophtalmologique Adolphe de Rothschild and Université Paris Descartes, Paris, France
| |
Collapse
|
47
|
Kumar M, Mukhopadhyay S, Dutta D. Challenges and controversies in diagnosis and management of gonadotropin dependent precocious puberty: An Indian perspective. Indian J Endocrinol Metab 2015; 19:228-235. [PMID: 25729684 PMCID: PMC4319262 DOI: 10.4103/2230-8210.149316] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Managing precocious puberty (PP) has been a challenge due to lack of standardized definition, gonadotrophins assay, gonadotrophin stimulation, timings for blood sampling, and parameters for assessing outcomes. This review evaluated available literature to simplify the algorithm for managing gonadotrophin dependent/central PP (CPP), with an Indian perspective. CPP is one of the commonest forms of PP and mimics the normal course of puberty, at an age <8 and 9 years for girls and boys respectively. Basal and post gonadotrophin hormone releasing hormone analog (GnRHa) luteinizing hormone (LH) ≥0.3-0.6 IU/L and ≥4-5 IU/L (30-60 min after GnRH/GnRHa administration) respectively, using modern ultrasensitive automated chemiluminescence assays, can be considered positive for central puberty initiation. Uterine length of >3.5 cm and uterine volume of >1.8 ml are two most specific indicators for true CPP. Therapy is indicated in children with CPP with accelerated bone age, height advancement, or psychosocial stress. Treatment goal is to halt puberty progression to a socially acceptable age, allowing the child to attain optimal height potential. GnRHa is the treatment of choice, with best height outcomes when initiated <6 years age. Treatment is recommended till 11 years age. LH suppression to <3 U/L may be a reasonable target in patients on GnRHa therapy. Medroxyprogesterone acetate holds an important place in managing PP in India, cause of high costs associated with GnRHa therapy. There is an urgent need for clinical trials from India, for establishing Indian cut-off for diagnosis, treatment and follow-up of children with PP.
Collapse
Affiliation(s)
- Manoj Kumar
- Department of Endocrinology and Metabolism, Institute of Post-graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology and Metabolism, Institute of Post-graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
| | - Deep Dutta
- Department of Endocrinology, Post-graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| |
Collapse
|
48
|
Telarquia precoz en la niñez: causas y estudio. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|