Diagnosis & therapy options
Diagnosis & therapy options
Diagnosis and appropriate treatment are of paramount importance to ensure normal physical and psychological development of children with suspected precocious puberty.
Assessment may include the following:
Areas of inquiry can include clinical, family, and social aspects of the child, such as:
- Age of onset, sequence, and progression of pubertal changes
- Family history: timing of onset of puberty in mother and siblings
- Neurological symptoms
- Exogenous sex steroid exposure from plant estrogens (e.g., lavender oil, tea tree oil),
- Drugs, or cosmetics (e.g., steroid creams, estrogen, anabolic steroids)
- Social history: history of adoption or abuse
Height and weight measurements plotted using age-specific growth charts (Figure 1):
- Body mass index
- Pubertal Tanner staging
- Neurological examination
- Examination of eyes including visual fields and fundoscopy
- Skin lesions (e.g., cafe au lait spots)
- Abdominal examination
- Examination of external genitalia
- Signs of virilization: enlarged clitoris, deepening of voice, hirsutism
The GnRH stimulation test is the gold standard test for diagnosing CPP.
It is performed by measuring FSH and LH levels 30 to 60 minutes after administering a GnRH agonist bolus and measuring hormone levels 24 hours after the injection.
In CPP, GnRH-induced stimulation results in LH often above 8 mIU/mL and an LH:FSH ratio >1 (Figure 2).
Various biochevmical/laboratory assessments are used to rule out other endocrine gland conditions. Not all children require all of these tests to be performed:
- Serum LH and FSH levels (baseline)
- GnRH stimulation test (LH and FSH)
- Gonadal steroids: Estradiol/testosterone levels
- Thyroid assessment: Free thyroxine and thyroid-stimulating hormone
- Serum prolactin levels (may be increased in chronic hypothyroidism or prolactinomas)
- Adrenal assessment:
- Urinary steroid profile (to identify and quantify excess adrenal androgens)
- Adrenal steroids (which are increased incongenital adrenal hyperplasia and with adrenal tumors)
- Adrenocorticotrophic hormone (ACTH) stimulation test (to identify steroid synthesis defects)
Evaluation using various imaging technologies. 
Not all children require all of these tests:
- Left wrist X-ray for bone age
- Cranial MRI/CT to exclude a CNS lesion (e.g., a tumor).
- CT adrenals (adrenal masses)
- Pelvic ultrasound (size, shape of uterus, endometrial thickness and ovarian morphology)
- Skeletal survey/bone scan (other syndromes that affect bone)
Include arresting physical maturation, preventing early menarche in girls, bringing predicted adult height closer to genetic expectations, and allowing normal psychosocial development. 
- Tirumuru SS, Arya P, Latthe P, Kirk J. Understanding precocious puberty in girls. Obstet Gynaecol. 2012;14(2):121-129. Doi: 10.1111/j.1744-4667.2012.00094.x.
- Partsch C-J. Sippell WG. Pathogenesis and epidemiology of precocious puberty. Effects of exogenous oestrogens. Hum Reproduct. 2001;7(3):292-302. AND Tirumuru SS, Arya P, Latthe P, Kirk J. Understanding precocious puberty in girls. Obstet Gynaecol. 2012;14(2):121-129. Doi: 10.1111/j.1744-4667.2012.00094.x.
- Krishna KB, Fuqua JS, Rogol AD, et al. Use of gonadotropin- releasing hormone analogs in children: Update by an international consortium. Horm Res Paediatr 2019;91:357–372. AND Kaplowitz PB, Precocious puberty. https://emedicine.medscape.com/article/924002-overview. Updated March 11, 2020. Accessed March 20, 2020.
- Effects of exogenous oestrogens. Hum Reproduct. 2001;7(3):292-302.
- National Organization for Rare Disorders (NORD). Precocious Puberty. https://rarediseases.org/rare-diseases/precocious-puberty/. Accessed October 3, 2019.