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plz mark this essay Posted by Sarwat F.
A mother brings her eight years old daughter to see you. She is anxious because this child has obvious breast development and has menstruated. Justify your investigations and immediate management?

The problem of precocious puberty with which this child has presented has adverse physical and psychological consequences. Investigations will be done keeping in mind the possible aetiology of the condition. More than 90% cases of precocious puberty are constitutional. Other causes include various neurological conditions like cerebral tumors, hydrocephalus, and conditions like neurofibromatosis, various endocrinopathies like hypothyroidism, adrenal and ovarian tumors and use of estrogens. Patient will be assessed by taking history, performing clinical examination and performing certain investigations. In history events preceding first period should be asked, development of secondary sexual characteristics like breast development and if they preceded menturation or vice versa. Presence of any other symptoms like mental slowness for hypothyroidism, headaches, visual disturbances and field defects for possibility of cerebral tumors. Family history should be asked like age of menarche in sisters and mother, as this may point towards constitutional cause. Clinical examination is done; secondary sexual characteristics are checked according to their staging classification. Presence of caf? au lait spots for neurofibromatosis and presence of any visual field defects. Investigations will include measuring serum LH, FSH and estradiol. These investigations will help to now the cause of the problem as value may vary if the problem is due to constitutional cause or any ovarian tumor. Thyroid function tests are done for hypothyroidism. Serum androstanedione will help to determine adrenal cause. Ultrasound abdomen and pelvis are done to exclude ovarian and adrenal tumors. X- ray skull will help in diagnosing cerebral tumors.
Management will aim to minimize physical and psychological morbidity. In the presence of any underlying disease it should be treated. For endocrinopathies a pediatric endocrinologist should be involved. Ovarian and adrenal tumors may need surgical removal. For constitutional cause gonadotrophin releasing hormone analogues are given. Other options include cyproterone acetate and danazol but side effects limits its use. Social management is especially important in this case. Counselling should be done regarding possibility of pregnancy. Patient may get psychologically upset on having menstruation. Adequate behaviour therapy and psychological counseling is required. Another important thing is that patient’s height may stop growing because of earlier closure of epiphyses. Use of gonadotrophin releasing hormone analogues is especially important in this case as it will suppress ovarian and hence estrogen activity. In conclusion patient need adequate psychological support to cope with the stress of precocious puberty as well as physical treatment.
Posted by Sarwat F.
Thankyou Dr. Paul for your reply. This is the actual question that appeared in MRCOG part 2 exam in september 2000.
Posted by Sarwat F.
Thankyou Dr. Paul for your reply. This is the actual question that appeared in MRCOG part 2 exam in september 2000.