Types of benign pubertal variants

Etiology	Clinical features	Bone age	Additional evaluation
Premature adrenarche (boys or girls)	Isolated pubarche. Gonads are prepubertal in size and there is no breast development in girls. Typical age of onset 4 to 8 years. Seen more commonly in African-American and Hispanic girls and in children with obesity and insulin resistance.	↑ to ↑↑*	Further investigations needed only if there is significant progressive virilization, to help exclude peripheral precocity. Mild elevation in DHEAS for chronologic age (but appropriate for bone age). Prepubertal concentrations of 17-OHP and testosterone.
Premature thelarche (girls)	Isolated breast development with normal growth velocity. Most commonly seen in girls less than 3 years of age.	Normal (prepubertal)	No further evaluation needed in most cases, unless evidence of pubertal progression. Basal LH concentrations typically <0.2 to 0.3 mIU/L^¶.
Nonprogressive or intermittently progressive precocious puberty (boys or girls)	Development of gonadarche (breast or testicular enlargement) with pubarche (pubic and/or axillary hair), with either no progression or intermittent slow progression in clinical pubertal signs.	Normal to ↑	Basal LH concentrations typically <0.2 to 0.3 mIU/L, although can be in early pubertal range in some children. Lower stimulated LH:FSH ratio compared with children with progressive central precocious puberty^Δ. Patients with nonprogressive precocious puberty do not need treatment with GnRH agonist, because final height untreated is concordant with mid-parental height.

If further evaluation is needed and performed, patients with benign pubertal variants typically have prepubertal basal LH concentrations (<0.2 to 0.3 mIU/L) and/or stimulated LH concentration post-GnRH agonist of <3.3 to 5.0 mIU/L.

↑: elevated for chronologic age; DHEAS: dehydroepiandrosterone sulfate; 17-OHP: 17-hydroxyprogesterone; LH: luteinizing hormone; FSH: follicle-stimulating hormone; GnRH: gonadotropin-releasing hormone.
* Up to 30% of children with premature adrenarche can have a bone age more than 2 years advanced than their chronologic age^[1].
¶ Interpretation of basal LH and stimulated LH concentrations can be difficult in girls younger than 2 years of age because normal gonadotropin concentrations can be elevated as part of the mini-puberty of infancy^[2].
Δ A peak LH:FSH ratio <0.66 suggests nonprogressive precocious puberty, whereas a ratio >0.66 is typically seen with central precocious puberty^[3].

DeSalvo, DJ, Mehra R, Vaidyanathan P, Kaplowitz PB. In children with premature adrenarche, bone age advancement by 2 or more years is common and generally benign. J Pediatr Endocrinolo Metab 2013; 26: 215.
Bizzarri C, Spadoni G, Bottaro G et al. The response to gonadotropin releasing hormone (GnRH) stimulation test does not predict the progression to true precocious puberty in girls with onset of premature thelarche in the first three years of life. JCEM 2014; 99:433.
Oerter KE, Uriarte MM, Rose SR, et al. Gonadotropin secretory dynamics during puberty in normal girls and boys. J Clin Endocrinol Metab 1990; 71:1251.

Graphic 72054 Version 15.0

خرید پکیج

Types of benign pubertal variants