Introduction of Adolescent Medicine
青春期医学概论
Children’s hospital Fu Dan University
复旦大学附属儿科医院 俞建
Adolescence
? Adolescence,puberty
between childhood and adulthood
? feature
stressful developmental
major changes
physical maturity sexuality
cognitive 认知 emotional feelings
relationships with others
? Range,boy 11～ 19 girl 10 ～ 21
Adolescent Medicine
Objective
teenager juvenile youngster
addressing identified health concerns
1,the complicated interactions of developmental
changes on healthcare needs
2,the effectiveness of treatment
3,health education
4,health promotion
Contents
Preclinical Medicine
Clinical Medicine
Pedagogy or Education
Psychology
Hygiene
Social Medicine
Behavior Medicine
Normal developmental period Puberty
1,Physiological basis
2,Development & changes
? Sexual character by stages
? Physical build,constitution,statue
? Mentality behavior
Classification of Sex Maturity
Stages in Girls
Tanner breast pubic hairs
stages 乳房 阴毛
P1 prepubertal B1 PH1
P2 early stage B2 PH2
P3 metaphase B3 PH3
P4 anaphase B4 PH4
P5 adult stage B5 PH5
Classification of Sex Maturity
Stages in Boys
Tanner Genitalia Pubic hairs
stages 外生殖器 阴毛
P1 prepubertal G1 PH1 None
P2 early stage G2 PH2 Scanty,long,slightly
pigmented
P3 metaphase G3 PH3 Darker,start to curl
small in amount
P4 anaphase G4 PH4 Resembles adult type
less in quantity,curly
P5 adult stage G5 PH5 adult distribution
rhombus in shape
Precocious Puberty
? Definition
Onset of secondary sexual characteristics
before 8y in girls and 9Y in boys
? Global Incidence
0.6～ 1％ boys ∶ girls ＝ 1∶ 5
1998 Shanghai 30,000 1%
Classification and Conditions Causing
Precocious Puberty
True P.P,Pseudo.P.P Incomplete P.P.
1,Idiopathic 1.Tumors 1.Premature thelarche
特发性 (体质性 ) Ovarian T,单纯性乳房早发育
2,CNS Disorders Leydig cell T,2,Premature adrenarche
*space-occupying 2.adrenal disorders 单纯性阴毛早现
lesions *Congenital adrenal 3,Premature menarche
*congenital CNS hyperplasia 孤立性早潮
anomalies *Secondary adrenal
*postinfection or hyperplasia
tramua *adrenal tumor
3,Hypothyroidism 3.GnRH induced Tumor
4,Exogenous sex hormones
5.McCune-Albright Syndrome
Gonadotrophin-dependent P.P,
(True P.P.)
Idiopathic P.P.
Encephalic Tumor
Congenital Hypothyroidism
Gonadotrophin-independent P.P.
(pseudo P.P.)
Ovarian Tumor
Congenital Adrenal Hyperplasia
Secondary Adrenal Hyperplasia
GnRH induced Tumor
Exogenous sex-steroids
McCune-Albright Syndrome
Incomplete Precocious Puberty
(partial P.P.)
? Premature Thelarche
单纯性乳房早发育
? Premature Adrenarche
单纯性阴毛早现
? Premature Isolated menarche
孤立性早潮
Laboratory Test
? Bone age GP（ Greulich-Pyle) / TW2 / TW3
? Pelvic Ultrasonography
? Sex Steroids
? GnRH Stimulation Test
? MRI
? Radiography tubular bone
Differential Diagnosis
? Differential Diagnosis
Treatment of P.P.
? Medication
? Traditional Chinese Medicine
The Endocrine Changes of Puberty
Hypothalamus- Pituitary - Gonads,Adrenal Glands Axis
neurotransmitters Noradrenalin
C.N.S ? 神经递质 去甲肾上腺素 ?
? GABA 5-HT
Median Eminence (MLT前体 ) ?
下丘脑神经内分泌细胞 ? GnRH
? (-)(+)
Pituitary ? Gn,LH,FSH
?
Gonads
Ovary（ E2) testicle (T)
Secondary Sexual Development
Normal puberty (average)
girls 10y～ 11y boys 12～ 13y
Factors
individual,hereditary,nutritional,morbid,
psychological
Normal Sexual Development Sequence
Girls,
breast－ labia – pigmentation- vaginal secretion
-pubic hair-menarche
13y
boys：
Testis-penis-scrotum-pubic & axillary hair
–beard-Adam's apple - spermatorrhea
15ys
Changes in physical build and statue
1,Linearity growth
The pubertal growth spurt 2Y
增长高峰（ PHV）
Girls,10Y-18Y 25cm 16Y
Boys,12Y-20y 28cm 17Y
Foot-calf-thigh-trunk
Top /lower part
Preadolescence= 1.1
Postadolescence=0.9
Changes in physical build and statue
2,Acromion / Iliac Crest 双肩峰距 /双髂嵴距
male 1.37 female 1.35-1.27
boys Viscerocranium-frontal sinus mandible
3,Body composition
lean body mass( LBM)
Prepuberty
boys ≈ girls
Puberty
boys’ LBM,bone ≈ 1.5 times of girls’
Girls’ body fat ≈ 2.0 times of boys’
Tanner Staging
Girls(B1)
Prepubertal,
elevation of papilla only
Tanner Staging
Girls(B2)
Breast bud appears
under enlarged areola
Tanner Staging
Girls(B3)
Breast tissue grows
beyond areola without
contour separation
Tanner Staging
Girls(B4)
Projection of areola
and papilla forms a
secondary mound
Tanner Staging
Girls(B5)
Adult breast contour
with projection of
papilla only
Tanner Staging
Girls(PH1)
Prepubertal
villus hair only
Tanner Staging
Girls(PH2)
Sparse growth of
slightly pigmented
hair along the labia
Tanner Staging
Girls(PH3)
Hair is coarser,
curled and pigmented
spreads across the
pubes
Tanner Staging
Girls(PH4)
Adult-type hair but no
spread to medial thigh
Tanner Staging
Girls(PH5)
Adult-type hair with
spread to medial thigh
but not up linea alba
Tanner Staging
Boys(G1,PH1)
Prepubertal
Testes,< 2.5 cm
villus hair only
Tanner Staging
Boys (G2,PH 2)
Thinning and reddening
of scrotum
Testes,2.5 to 3.2 cm
Sparse growth of
slightly pigmented
hair at base of penis
(12.3 years)
Tanner Staging
Boys(G3,PH3)
Growth of penis,
especially length (13.2
years)
Testes,3.3 to 4.0 cm
Thicker,curlier hair
spreads to the mons
pubis
Tanner Staging
Boys(G4,PH4)
Growth of penis and
glands,darkening of
scrotum
Testes,4.1 to 4.5 cm
Adult-type hair but no
spread to medial thigh
Tanner Staging
Boys(G5,PH5)
Adult genitalia
Testes,> 4.5 cm
Adult-type hair with
spread to medial
thighs but not up linea
alba
True P.P.
? GnRH-independent
? Hypothalamus-Pituitary-Gonad-Axis
? Premature activation & hyperfunction
? Reproductive capacity
Pseudo P.P.
? GnRH-Independent
? Endogenous/Exogenous
? Hypothalamus-pituitary-axis ↙
? None reproductive capacity
Exogenous
Intake of exogenous sex steroids
contraceptive避孕药 royal jelly蜂王浆
chick embryo鸡胚 silkworm chrysalis蚕蛹
colostrum动物初乳 pollen花粉 etc.
Idiopathic P.P.
80% True P.P.
The Neuroendocrine Functional Factors
① Nutritional Factors
② Environmental Factors
detergent(alkylated phenol) （ 烷基化苯酚类 ）
agrochemicals(organochlorine)（ 有机氯残留 ）
plastic material (plasticizer - santicizer 218a,bisphenol A )
(邻苯二甲酸酯类及双酚 A）
③ Social factor
Intracranial Tumor
Man > Women
Encephalic space occupying lesion,
Symptoms:
polydipsia,polyuria hyperphagia obeseness
Disorders:
hamartoma,astrocytoma,ependymocytoma,pinealoma
错构瘤、星形细胞瘤、室管膜瘤、松果体瘤
Congenital Hypothyroidism
Prolonged/Untreated
? T4?-Feedback ?
? Hypothalamus TRH?
? Pituitary PRL? TSH? FSH,LH?
McCune-Albright Syndrome
Somatic cell mutations
None germline
Genetic but not heritable
Mutations
stimulatory G-protein subunit
adenyl cyclase system
affected cells membrane receptor
Premature Thelarche
? Transient condition <2y None Progressive
? Isolated breast development unilateral
? Benign –? first sign True P.P,or Pseudo P.P.
?? Exogenous exposure to estrogen
Premature Adrenarche
? pubic andaxillary hair
？ nonclassic 21-hydroxylase deficiency
? Bone age / growth velocity
? Some girls
mild insulin resistance
polycystic ovary syndrome
not a benign condition
Idiopathic Precocious Puberty
? 80%girls,40% boys,some familial
? Onset 4-8ys/Infancy
? Normal pubertal sequence
girls
breast -public and axillary hair - menache
Boys
testicular -penile - public and axillary hair
? Epiphyseal closure early
? Mature into short adults
Idiopathic Precocious Puberty
Encephalic Tumor
Congenital Hypothyroidism
Prolonged/Untreated
Girls:Breast development
Boys,testis enlargement
Other symptoms
Coarsed facies,lethargy,hypotonia,constipation,
anemia,mental retardation,dull response,etc.
Growth and Maturation of Bone laggard behind
Congenital adrenal hyperplasia
? Simple Virilizing
11-hydroxylase（ 11-羟化酶缺陷）
Boys：
isosexual precocious puberty
Girls:
heterosexual precocious puberty
pseudohermaphrodism 假两性畸形
Intake of exogenous sex steroids
? Symptoms of pseudo P.P.
Girls
breast enlargerment
areola乳晕 nympha小阴唇 pigmentation
vagina discharge irregular vaginal bleeding
Boys
breast enlargerment
areola pigmentation
testis/ penis No enlargerment
Precocious Puberty with
Polyostotic Fibrous Dysplasia
and Abnormal Pigmentation
Radiographic Atlas of the Hand and Wrist
Additional Assessment
? T3,T4,TSH ?
Congenital Hypothyroidism
? T,E2?
Ovarian Tumor / Ledig Cell Tumor
? 17-OHP ? /（ 17－ KS) ?
Congenital Adrenal Hyperplasia
GnRH Stimulation Test
? LHRH,0’-30’-60’-90’-120’
pituitary cell reserving function
Differention of True P.P,with Pseudo P.P.
MRIMRI
Diagnosis and Differential Diagnosis
Initial assessment
Clinical history and physical examination
Pubertal milestone and growth chart
Radiograph of left wrist for bone age
Unremarkable Normal Variation Abnormal
Diagnosis Possible diagnoses Differential
diagnosis
Actions Actions Actions
Treatment Treatment
Unremarkable
? Clinical evaluation is unremarkable and reveals
an early but otherwise normal puberty with
normal milestone sequence
? Bone age is greater than chronologic age
Diagnosis
True
Idiopathic Precocious Puberty
Actions
1.Observation/reevaluation
2.Consider additional assessment
(FSH,LH,Estradial or testosterone,
TSH,thyroid hormone and hCG levels
a GnRH stimulation test)
Idiopathic Precocious Puberty
MRI to exclude a pathologic cause (e.g.CNS lesion)
Treatment
1.Psychologic support
2.Consider suppression of FSH and LH
with GnRH analog in selected patients
Normal Variation
? Clinical evaluation is unremarkable
except for a pattern consistent with
a normal variation of puberty
? Bone age in consistent with chronologic age
Possible diagnoses
Benign premature adrenarche
Girls:
Benign premature thelarche(乳房初发育 )
Benign premature menarche(月经初潮 )
Boys:
Benign gynecomastia (男性乳房发育 )
Familial gynecomastia
Actions
1.Observation/reevaluation
2.Consider additional assessment
to confirm diagnosis
Treatment
? Reassurance for patient and parents
Abnormal
? Clinical evaluation is abnormal or the normal
pubertal milestone sequence is disturbed
? Bone age may or may not be appropriate for age
(premature associated with central lesions may
appear normal)
Differential Diagnosis
? Central causes:
CNS or pituitary lesion
Gonadotropin-secreting tumor
Profound hypothyroidism
? Chronic adrenal insufficiency
? Peripheral causes:
McCune-Albright syndrome
Adrenal hyperplasia/tumor
Differential Diagnosis
? Girls:
Ovarian tumor/cysts
Exogenous estrogen
? Boys:
Testicular tumor
Autonomous Legdig function
Exogenous androgens
Differential Diagnosis
Contrasexual development (异性化发育）
Girls：
Virilizing adrenal tumors（男性化肾上腺肿瘤）
Congenital adrenal hyperplasia
(先天性肾上腺皮质增生）
Functional hyperandrogenism
(功能性雄激素过多症）
Boys:
Feminizing adrenal tumor (女性化肾上腺肿瘤）
Actions
1.Assessment for exposure to exogenous sex
steroids
2.Additional testing directed at underlying cause
suggested by initial clinical assessment
Treatment
1.GnRH analog 促性腺激素释放激素拟似剂
2.Cyproterone acetate (环丙孕酮，色普龙）
3.Danazol (达那唑）
Different kinds of GnRH analogs
Brand structure relative efficiency dosage
（天然 GnRH =1） （ μg/kg）
Lueprolin D-Leu6 15 20-50 H
亮丙瑞林 140-300 M
Buserelin D-Ser6 20 1200-1800 喷鼻
布舍瑞林 20-40 H
Triptorelin D-Trp6 36 20-40 H
曲普瑞林 50-100 M
Deslorelin D-Trp6 144 4-8 H
色氨瑞林
Nafarelin D-Nal6 200 800-1600 喷鼻
那法瑞林 4 H
Histrelin D-His6 210 8-10H
组氨瑞林
Traditional Chinese Medicine
①,阴虚火旺型
治法：滋阴降火
方药：知柏地黄丸 （ 汤 ） 加减
②,肝郁肾虚型
治法：滋阴降火，疏肝解郁
方药：知柏地黄丸合丹栀逍遥散
思考题
1,真性性早熟与乳房早发育如何鉴别?
2,真性性早熟的治疗方法有哪些？
再 见
青春期医学概论
Children’s hospital Fu Dan University
复旦大学附属儿科医院 俞建
Adolescence
? Adolescence,puberty
between childhood and adulthood
? feature
stressful developmental
major changes
physical maturity sexuality
cognitive 认知 emotional feelings
relationships with others
? Range,boy 11～ 19 girl 10 ～ 21
Adolescent Medicine
Objective
teenager juvenile youngster
addressing identified health concerns
1,the complicated interactions of developmental
changes on healthcare needs
2,the effectiveness of treatment
3,health education
4,health promotion
Contents
Preclinical Medicine
Clinical Medicine
Pedagogy or Education
Psychology
Hygiene
Social Medicine
Behavior Medicine
Normal developmental period Puberty
1,Physiological basis
2,Development & changes
? Sexual character by stages
? Physical build,constitution,statue
? Mentality behavior
Classification of Sex Maturity
Stages in Girls
Tanner breast pubic hairs
stages 乳房 阴毛
P1 prepubertal B1 PH1
P2 early stage B2 PH2
P3 metaphase B3 PH3
P4 anaphase B4 PH4
P5 adult stage B5 PH5
Classification of Sex Maturity
Stages in Boys
Tanner Genitalia Pubic hairs
stages 外生殖器 阴毛
P1 prepubertal G1 PH1 None
P2 early stage G2 PH2 Scanty,long,slightly
pigmented
P3 metaphase G3 PH3 Darker,start to curl
small in amount
P4 anaphase G4 PH4 Resembles adult type
less in quantity,curly
P5 adult stage G5 PH5 adult distribution
rhombus in shape
Precocious Puberty
? Definition
Onset of secondary sexual characteristics
before 8y in girls and 9Y in boys
? Global Incidence
0.6～ 1％ boys ∶ girls ＝ 1∶ 5
1998 Shanghai 30,000 1%
Classification and Conditions Causing
Precocious Puberty
True P.P,Pseudo.P.P Incomplete P.P.
1,Idiopathic 1.Tumors 1.Premature thelarche
特发性 (体质性 ) Ovarian T,单纯性乳房早发育
2,CNS Disorders Leydig cell T,2,Premature adrenarche
*space-occupying 2.adrenal disorders 单纯性阴毛早现
lesions *Congenital adrenal 3,Premature menarche
*congenital CNS hyperplasia 孤立性早潮
anomalies *Secondary adrenal
*postinfection or hyperplasia
tramua *adrenal tumor
3,Hypothyroidism 3.GnRH induced Tumor
4,Exogenous sex hormones
5.McCune-Albright Syndrome
Gonadotrophin-dependent P.P,
(True P.P.)
Idiopathic P.P.
Encephalic Tumor
Congenital Hypothyroidism
Gonadotrophin-independent P.P.
(pseudo P.P.)
Ovarian Tumor
Congenital Adrenal Hyperplasia
Secondary Adrenal Hyperplasia
GnRH induced Tumor
Exogenous sex-steroids
McCune-Albright Syndrome
Incomplete Precocious Puberty
(partial P.P.)
? Premature Thelarche
单纯性乳房早发育
? Premature Adrenarche
单纯性阴毛早现
? Premature Isolated menarche
孤立性早潮
Laboratory Test
? Bone age GP（ Greulich-Pyle) / TW2 / TW3
? Pelvic Ultrasonography
? Sex Steroids
? GnRH Stimulation Test
? MRI
? Radiography tubular bone
Differential Diagnosis
? Differential Diagnosis
Treatment of P.P.
? Medication
? Traditional Chinese Medicine
The Endocrine Changes of Puberty
Hypothalamus- Pituitary - Gonads,Adrenal Glands Axis
neurotransmitters Noradrenalin
C.N.S ? 神经递质 去甲肾上腺素 ?
? GABA 5-HT
Median Eminence (MLT前体 ) ?
下丘脑神经内分泌细胞 ? GnRH
? (-)(+)
Pituitary ? Gn,LH,FSH
?
Gonads
Ovary（ E2) testicle (T)
Secondary Sexual Development
Normal puberty (average)
girls 10y～ 11y boys 12～ 13y
Factors
individual,hereditary,nutritional,morbid,
psychological
Normal Sexual Development Sequence
Girls,
breast－ labia – pigmentation- vaginal secretion
-pubic hair-menarche
13y
boys：
Testis-penis-scrotum-pubic & axillary hair
–beard-Adam's apple - spermatorrhea
15ys
Changes in physical build and statue
1,Linearity growth
The pubertal growth spurt 2Y
增长高峰（ PHV）
Girls,10Y-18Y 25cm 16Y
Boys,12Y-20y 28cm 17Y
Foot-calf-thigh-trunk
Top /lower part
Preadolescence= 1.1
Postadolescence=0.9
Changes in physical build and statue
2,Acromion / Iliac Crest 双肩峰距 /双髂嵴距
male 1.37 female 1.35-1.27
boys Viscerocranium-frontal sinus mandible
3,Body composition
lean body mass( LBM)
Prepuberty
boys ≈ girls
Puberty
boys’ LBM,bone ≈ 1.5 times of girls’
Girls’ body fat ≈ 2.0 times of boys’
Tanner Staging
Girls(B1)
Prepubertal,
elevation of papilla only
Tanner Staging
Girls(B2)
Breast bud appears
under enlarged areola
Tanner Staging
Girls(B3)
Breast tissue grows
beyond areola without
contour separation
Tanner Staging
Girls(B4)
Projection of areola
and papilla forms a
secondary mound
Tanner Staging
Girls(B5)
Adult breast contour
with projection of
papilla only
Tanner Staging
Girls(PH1)
Prepubertal
villus hair only
Tanner Staging
Girls(PH2)
Sparse growth of
slightly pigmented
hair along the labia
Tanner Staging
Girls(PH3)
Hair is coarser,
curled and pigmented
spreads across the
pubes
Tanner Staging
Girls(PH4)
Adult-type hair but no
spread to medial thigh
Tanner Staging
Girls(PH5)
Adult-type hair with
spread to medial thigh
but not up linea alba
Tanner Staging
Boys(G1,PH1)
Prepubertal
Testes,< 2.5 cm
villus hair only
Tanner Staging
Boys (G2,PH 2)
Thinning and reddening
of scrotum
Testes,2.5 to 3.2 cm
Sparse growth of
slightly pigmented
hair at base of penis
(12.3 years)
Tanner Staging
Boys(G3,PH3)
Growth of penis,
especially length (13.2
years)
Testes,3.3 to 4.0 cm
Thicker,curlier hair
spreads to the mons
pubis
Tanner Staging
Boys(G4,PH4)
Growth of penis and
glands,darkening of
scrotum
Testes,4.1 to 4.5 cm
Adult-type hair but no
spread to medial thigh
Tanner Staging
Boys(G5,PH5)
Adult genitalia
Testes,> 4.5 cm
Adult-type hair with
spread to medial
thighs but not up linea
alba
True P.P.
? GnRH-independent
? Hypothalamus-Pituitary-Gonad-Axis
? Premature activation & hyperfunction
? Reproductive capacity
Pseudo P.P.
? GnRH-Independent
? Endogenous/Exogenous
? Hypothalamus-pituitary-axis ↙
? None reproductive capacity
Exogenous
Intake of exogenous sex steroids
contraceptive避孕药 royal jelly蜂王浆
chick embryo鸡胚 silkworm chrysalis蚕蛹
colostrum动物初乳 pollen花粉 etc.
Idiopathic P.P.
80% True P.P.
The Neuroendocrine Functional Factors
① Nutritional Factors
② Environmental Factors
detergent(alkylated phenol) （ 烷基化苯酚类 ）
agrochemicals(organochlorine)（ 有机氯残留 ）
plastic material (plasticizer - santicizer 218a,bisphenol A )
(邻苯二甲酸酯类及双酚 A）
③ Social factor
Intracranial Tumor
Man > Women
Encephalic space occupying lesion,
Symptoms:
polydipsia,polyuria hyperphagia obeseness
Disorders:
hamartoma,astrocytoma,ependymocytoma,pinealoma
错构瘤、星形细胞瘤、室管膜瘤、松果体瘤
Congenital Hypothyroidism
Prolonged/Untreated
? T4?-Feedback ?
? Hypothalamus TRH?
? Pituitary PRL? TSH? FSH,LH?
McCune-Albright Syndrome
Somatic cell mutations
None germline
Genetic but not heritable
Mutations
stimulatory G-protein subunit
adenyl cyclase system
affected cells membrane receptor
Premature Thelarche
? Transient condition <2y None Progressive
? Isolated breast development unilateral
? Benign –? first sign True P.P,or Pseudo P.P.
?? Exogenous exposure to estrogen
Premature Adrenarche
? pubic andaxillary hair
？ nonclassic 21-hydroxylase deficiency
? Bone age / growth velocity
? Some girls
mild insulin resistance
polycystic ovary syndrome
not a benign condition
Idiopathic Precocious Puberty
? 80%girls,40% boys,some familial
? Onset 4-8ys/Infancy
? Normal pubertal sequence
girls
breast -public and axillary hair - menache
Boys
testicular -penile - public and axillary hair
? Epiphyseal closure early
? Mature into short adults
Idiopathic Precocious Puberty
Encephalic Tumor
Congenital Hypothyroidism
Prolonged/Untreated
Girls:Breast development
Boys,testis enlargement
Other symptoms
Coarsed facies,lethargy,hypotonia,constipation,
anemia,mental retardation,dull response,etc.
Growth and Maturation of Bone laggard behind
Congenital adrenal hyperplasia
? Simple Virilizing
11-hydroxylase（ 11-羟化酶缺陷）
Boys：
isosexual precocious puberty
Girls:
heterosexual precocious puberty
pseudohermaphrodism 假两性畸形
Intake of exogenous sex steroids
? Symptoms of pseudo P.P.
Girls
breast enlargerment
areola乳晕 nympha小阴唇 pigmentation
vagina discharge irregular vaginal bleeding
Boys
breast enlargerment
areola pigmentation
testis/ penis No enlargerment
Precocious Puberty with
Polyostotic Fibrous Dysplasia
and Abnormal Pigmentation
Radiographic Atlas of the Hand and Wrist
Additional Assessment
? T3,T4,TSH ?
Congenital Hypothyroidism
? T,E2?
Ovarian Tumor / Ledig Cell Tumor
? 17-OHP ? /（ 17－ KS) ?
Congenital Adrenal Hyperplasia
GnRH Stimulation Test
? LHRH,0’-30’-60’-90’-120’
pituitary cell reserving function
Differention of True P.P,with Pseudo P.P.
MRIMRI
Diagnosis and Differential Diagnosis
Initial assessment
Clinical history and physical examination
Pubertal milestone and growth chart
Radiograph of left wrist for bone age
Unremarkable Normal Variation Abnormal
Diagnosis Possible diagnoses Differential
diagnosis
Actions Actions Actions
Treatment Treatment
Unremarkable
? Clinical evaluation is unremarkable and reveals
an early but otherwise normal puberty with
normal milestone sequence
? Bone age is greater than chronologic age
Diagnosis
True
Idiopathic Precocious Puberty
Actions
1.Observation/reevaluation
2.Consider additional assessment
(FSH,LH,Estradial or testosterone,
TSH,thyroid hormone and hCG levels
a GnRH stimulation test)
Idiopathic Precocious Puberty
MRI to exclude a pathologic cause (e.g.CNS lesion)
Treatment
1.Psychologic support
2.Consider suppression of FSH and LH
with GnRH analog in selected patients
Normal Variation
? Clinical evaluation is unremarkable
except for a pattern consistent with
a normal variation of puberty
? Bone age in consistent with chronologic age
Possible diagnoses
Benign premature adrenarche
Girls:
Benign premature thelarche(乳房初发育 )
Benign premature menarche(月经初潮 )
Boys:
Benign gynecomastia (男性乳房发育 )
Familial gynecomastia
Actions
1.Observation/reevaluation
2.Consider additional assessment
to confirm diagnosis
Treatment
? Reassurance for patient and parents
Abnormal
? Clinical evaluation is abnormal or the normal
pubertal milestone sequence is disturbed
? Bone age may or may not be appropriate for age
(premature associated with central lesions may
appear normal)
Differential Diagnosis
? Central causes:
CNS or pituitary lesion
Gonadotropin-secreting tumor
Profound hypothyroidism
? Chronic adrenal insufficiency
? Peripheral causes:
McCune-Albright syndrome
Adrenal hyperplasia/tumor
Differential Diagnosis
? Girls:
Ovarian tumor/cysts
Exogenous estrogen
? Boys:
Testicular tumor
Autonomous Legdig function
Exogenous androgens
Differential Diagnosis
Contrasexual development (异性化发育）
Girls：
Virilizing adrenal tumors（男性化肾上腺肿瘤）
Congenital adrenal hyperplasia
(先天性肾上腺皮质增生）
Functional hyperandrogenism
(功能性雄激素过多症）
Boys:
Feminizing adrenal tumor (女性化肾上腺肿瘤）
Actions
1.Assessment for exposure to exogenous sex
steroids
2.Additional testing directed at underlying cause
suggested by initial clinical assessment
Treatment
1.GnRH analog 促性腺激素释放激素拟似剂
2.Cyproterone acetate (环丙孕酮，色普龙）
3.Danazol (达那唑）
Different kinds of GnRH analogs
Brand structure relative efficiency dosage
（天然 GnRH =1） （ μg/kg）
Lueprolin D-Leu6 15 20-50 H
亮丙瑞林 140-300 M
Buserelin D-Ser6 20 1200-1800 喷鼻
布舍瑞林 20-40 H
Triptorelin D-Trp6 36 20-40 H
曲普瑞林 50-100 M
Deslorelin D-Trp6 144 4-8 H
色氨瑞林
Nafarelin D-Nal6 200 800-1600 喷鼻
那法瑞林 4 H
Histrelin D-His6 210 8-10H
组氨瑞林
Traditional Chinese Medicine
①,阴虚火旺型
治法：滋阴降火
方药：知柏地黄丸 （ 汤 ） 加减
②,肝郁肾虚型
治法：滋阴降火，疏肝解郁
方药：知柏地黄丸合丹栀逍遥散
思考题
1,真性性早熟与乳房早发育如何鉴别?
2,真性性早熟的治疗方法有哪些？
再 见
