Question 29

A 2 yo female presents with her mother. She has a 3 month history of breast growth without vaginal bleeding. Physical exam showed that she is 75thpercentile for height and 90th percentile for weight. She also has Tanner stage 3 breast development and Tanner stage 1 pubic hair development. The most appropriate combination of tests to assess this patient is:

Answer Choices:

GnRH agonist stimulation test and pelvic ultrasound

FSH, LH and prolactin levels

DHEAS and testosterone levels

Estradiol and TSH levels plus bone age

Growth hormone stimulation tests and vaginoscopy

Correct Answer:

Estradiol and TSH levels plus bone age

Explanation:

  • Thelarche is estradiol-dependent growth of the breast tissue

  • This is typically the first physical sign of puberty and depends on nutritional status and adiposity

  • Premature thelarche is breast development before age 8. Half of these cases happen from age 6 months to 2 years. Many will regress, some persist without progression to puberty and 10-15% develop precocious puberty

  • Initial evaluation of premature thelarche: medical history, review of growth records, physical exam, blood estradiol and TSH levels, bone age

  • Hypothyroidism can be associated with premature puberty and functional ovarian cysts

  • Premature thelarche can have normal to slightly increased growth velocity and bone age

  • No treatment necessary but close follow up needed to evaluate for development of precocious puberty (see every 4-6 months).