Treatment of Precocious puberty M. Hashemipour MD Pediatric Endocrinologist Isfahan University of Medical Sciences

A 10 y/o girl referred to clinic with complaint of precocious puberty A 10 y/o girl referred to clinic with complaint of precocious puberty. No significant finding in history taking. In P/E breast is in tanner stage 2. (no menstruation is occurred). Height : 145cm 1- What is your suggestion to do as paraclinical W/U ? 2- What do you recommend to her family?

A 12 y/o boy came to clinic for evaluation of puberty A 12 y/o boy came to clinic for evaluation of puberty. In P/E testes are in tanner stage 3. Pubic hair in stage 1. No other significant finding. Height : 140 cm. 1- What do you recommend about the puberty of this patient? 2- Is there any need to treat this patient?

Growth velocity : Growth during puberty : boys mean of 20-28 cm girls mean of 20-25 cm

Do you recommend to start any treatment to stop puberty? An 11.5 y/o girl referred to the clinic due to the first episode of menstruation. Breast is in tanner stage of 4. Height : 142 cm. Do you recommend to start any treatment to stop puberty?

Growth after menarche : 1 – 7 cm

What is the prediction of final height ? A 10 y/o female brought to clinic to delaying her menstruation for improvement of height. Breast is in tanner stage 2. Height is 122 cm. What is the prediction of final height ? Do you prescribe GnRh agonist to this girl ?

Only pubic hair , without testicular or phallic enlargement : DDx : Premature adrenarche Late onset CYP 21 defic.

1- What is your diagnosis? 2- What kind of w/u is needed? A 2 y/o girl referred to your office with chief complaint of puberty. In P/E she has breast enlargement (stage 2 tanner). Height is 87 cm. No other positive findings are detected. 1- What is your diagnosis? 2- What kind of w/u is needed?

What do you do as paraclinical w/u ? A 5 y/o girl referred to you due to questionable history of vaginal bleeding. Her mother says that she has had several episodes of spotting during last three days. Breast is in tanner stage 1. What is the DDx ? What do you do as paraclinical w/u ?

Isolated vaginal bleeding in the absence of other secondary sexual characters: foreign body sexual abuse urethral prolapse Vulvo vaginitis

Treatment Girls with onset of progressive CPP before 6 years of age benefit most in terms of height from treatment

Treatment The decision to initiate therapy in girls with onset after the age of 6 should be individualized Treatment should be considered for all boys with onset of progressive CPP before 9 years of age who have compromised height potential

Girls with onset of puberty in 6- to 8 years of age with slowly progressive puberty and/or Acceptable predicted adult height based on bone age Has not been proven to have a significant effect in improving adult height.

Treatment If precocious puberty is slowly progressive, it is unlikely to compromise adult height potential.

Treatment If the height prediction is above 150 cm girls 160 cm boys Therapy is probably not needed Conservative approach is warranted

Criteria for Immediate Treatment of CPP Complete clinical precocious puberty with pubertal LH levels after GnRH stimulation test. AND Chronological age < 7 yrs in girls and < 8 years in boys. Bone age advanced > 2 SD beyond chronological age. . In girls when puberty begins before the age of 7 years and is progressive, the decision to treat is mandatory to preserve height potential. It remains debatable whether girls with borderline early onset of puberty (7-8 yrs) have a high risk of significantly short stature in adulthood if not treated. GnRH agonist treatment may be suggested for use only in girls who have psychological difficulties in coping with early and fast puberty.

Criteria for Immediate Treatment of CPP Predicted height either 2 SD (10cm) or more below genetic target height or < 150cm Rapid deterioration of growth potential and rapid advancement of pubertal signs. OR Severe psychologic discomfort or behavioural reasons

Indications for Follow-up & Delay in Treatment Chronological age between 7 and 8 yrs in girls and between 8 and 9 yrs in boys Bone age advanced < 2 SD beyond chronological age. Predicted height near target height or in the normal-to-high range. Slow progression of pubertal signs and echographic signs with maintenance of good growth potential. AND Absence of severe psychologic discomfort or behavioural problems.

Adverse Effects of Treatment Transient vaginal withdrawal bleeding injection site reactions and arthralgia. Headache, nausea, hot flushes Allergic reactions, headache, weight gain, increased blood pressure, episodes of blurred or abnormal vision, gastrointestinal tract discomfort with abdominal pain and vomiting, epistaxis, malaise, myalgia , emotional liability, nervousness. Initial ovarian stimulation at treatment initiation, followed by the treatment-induced oestrogen withdrawal, may lead, in the first month, to vaginal bleeding of mild or moderate intensity.

Follow-up During Treatment Height, weight, growth rate, and secondary sex characteristics Bone maturation Uterus and ovary size single blood sample for determination of LH and oestradiol at 2 or 12 hours after injection of the depot GnRH agonist

Thank you