© Springer India 2016 171
A. Bhansali et al., Clinical Rounds in Endocrinology,
DOI 10.1007/978-81-322-2815-8_6
6
Precocious Puberty
6.1 Case Vignette
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 appear-
ance 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 hypothyroid-
ism. There was no history of any drug intake or use of estrogen or “hormone dust”
exposure. On examination, her height was 103 cm (97th percentile, +2SDS) and
weight 15 Kg (75th percentile), with a target height of 159 cm (25th percentile). She
did not have cafe-au-lait macule, adenoma sebaceum, shagreen patch, neurofi-
broma, or bony deformity. She had no goiter and deep tendon reflexes were nor-
mal. Visual field and acuity were normal. Her Tanner staging was A−, P1, B 3.
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), T 4 6.7 μg/dl (N 4.8–12.7), TSH 1.38 μIU/ml (N 0.27–4.2), and prolac-
tin 21.2 ng/ml (N 4.7–23.3). GnRH agonist stimulation test (triptorelin 0.1 mg/m^2 )
showed serum LH 56.3 mIU/ml at 3h and 17 β-estradiol 185.3 pg/ml at 24h. Her
bone age was 7 years (Greulich and Pyle). Ultrasonography of the pelvis showed
uterine length 4.1 cm and ovarian volume 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 (B 3 to B 2 ). Serum LH, basal and
stimulated (3h after the next dose of injection), was 1.7 mIU/ml and 14.7 mIU/ml,