Precocious Puberty

Abstract

A 3-year-old girl was brought by her mother with the complaint of progressive development of breast for the last 6 months. It was not accompanied with appearance of pubic hair or history of vaginal bleed, though there was history of vaginal discharge occasionally. It was also noticed that she had sudden increase in her height over the last 6 months. There was no history of “waxing and waning” in the breast size. She did not have history of headache, visual disturbances, seizures, head injury, meningitis/encephalitis, cranial irradiation, pain in the abdomen, or palpable abdominal mass. She did not have symptoms suggestive of hypothyroidism. There was no history of any drug intake or use of estrogen or “hormone dust” exposure. On examination, her height was 103 cm (97^th percentile, +2SDS) and weight 15 Kg (75^th percentile), with a target height of 159 cm (25^th percentile). She did not have cafe-au-lait macule, adenoma sebaceum, shagreen patch, neurofibroma, or bony deformity. She had no goiter and deep tendon reflexes were normal. Visual field and acuity were normal. Her Tanner staging was A_−, P_1, B₃. Systemic examination was unremarkable. On investigations, hormonal profile revealed serum LH 2.3 mIU/ml (N < 0.3), FSH 3.9 mIU/ml, 17 β-estradiol 78.4 pg/ml (N < 10), T₄ 6.7 μg/dl (N 4.8–12.7), TSH 1.38 μIU/ml (N 0.27–4.2), and prolactin 21.2 ng/ml (N 4.7–23.3). GnRH agonist stimulation test (triptorelin 0.1 mg/m²) showed serum LH 56.3 mIU/ml at 3 h and 17 β-estradiol 185.3 pg/ml at 24 h. Her bone age was 7 years (Greulich and Pyle). Ultrasonography of the pelvis showed uterine length 4.1 cm and ovarian volume of 3 ml (right) and 1.5 ml (left) with multiple follicles. CEMRI sella showed convex upper border of anterior pituitary and the rest of the other areas were normal. With this clinical and biochemical profile, a diagnosis of idiopathic gonadotropin-dependent precocious puberty (GDPP) was considered and the patient was initiated with depot leuprolide (3.75 mg monthly). At 3 months of follow-up, she did not have a flare and had regression of secondary sexual characteristics (B₃ to B₂). Serum LH, basal and stimulated (3 h after the next dose of injection), was 1.7 mIU/ml and 14.7 mIU/ml, respectively. Basal serum estradiol was 23.7 pg/ml. The dose of depot leuprolide was increased to 7.5 mg once a month and advised to have a regular follow-up at three monthly intervals (Fig. 6.1).