Clinical_Rounds_in_Endocrinology_Volume_II_-_Pediatric_Endocrinology

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adrenarche/isolated premature pubarche. Fasting plasma insulin and glucose

should be measured in children with obesity. If a child has premature pubarche

along with other signs of androgenization (clitoromegaly in girls and penile

enlargement in boys) or bone age is significantly advanced, child should be

actively evaluated for pathological causes of premature pubarche. The evalua-

tion includes 17α-hydroxyprogesterone (17-OHP), serum DHEAS, and total

testosterone. A baseline serum 17-OHP of >2 ng/ml mandates ACTH stimula-

tion test; serum 17-OHP level 10–100 ng/ml suggests a diagnosis of late-onset

congenital adrenal hyperplasia, and serum 17-OHP level >100 ng/ml confirms

the diagnosis of simple virilizing CAH due to 21α-hydroxylase deficiency.

Serum testosterone >0.6 nmol/L and DHEAS >115 μg/dl suggest androgen

excess, while a serum testosterone >6.94 nmol/L and DHEAS >700 μg/dl sug-

gest virilizing ovarian and adrenal neoplasm, respectively. A scheme of workup

for premature pubarche is illustrated below (Fig. 6.4).

Premature pubarche

Bone age

Significantly advanced* Normal/Slightly advanced

• Premature adrenarche


• Isolated premature
  pubarche

Total

Testosterone

(>0.6nmol/L)

DHEAS

(>115 μg/dl)

17 OHP

(>2 ng/ml)

CAH • Virilizing ovarian/adrenal neoplasm

• Glucocorticoid resistance syndrome


• Exogenous androgen exposure

* Bone age>2.5 SD for chronological age

Fig. 6.4 Approach to a child with premature pubarche

6 Precocious Puberty