Precocious puberty

Last reviewed: 24 Feb 2023
Last updated: 28 Feb 2020



History and exam

Key diagnostic factors

  • presence of risk factors
  • boys: testes >4 mL
  • girls: breast development
  • pubic/axillary hair
  • menarche
  • increased growth velocity
  • tall stature
More key diagnostic factors

Other diagnostic factors

  • café au lait spots
  • symptoms of other autonomous endocrine hyperfunction
  • polyostotic fibrous dysplasia
  • neurofibromas, axillary freckling, and kyphoscoliosis
  • facial dysmorphism
  • clitoromegaly
  • eye abnormalities
  • motor deficits
  • abnormal head size
Other diagnostic factors

Risk factors

  • brain tumours
  • cranial irradiation
  • McCune-Albright syndrome
  • gonadal tumours
  • congenital adrenal hyperplasia (CAH)
  • positive family history
  • exposure to exogenous hormones
  • head injury
  • neurofibromatosis type 1
  • previous central nervous system infections
  • hydrocephalus
  • congenital pituitary abnormalities
  • adoption
  • sexual abuse
More risk factors

Diagnostic investigations

1st investigations to order

  • bone age assessment
  • basal follicle-stimulating hormone (FSH) and luteinising hormone (LH)
  • serum testosterone
  • serum oestrogen
  • ultrasound pelvis
  • LHRH stimulation test
More 1st investigations to order

Investigations to consider

  • MRI brain
  • CT brain
  • 17-hydroxyprogesterone
  • urinary steroid profile
  • adrenocorticotropic hormone (ACTH) stimulation test
  • CT or MRI adrenals
  • ultrasound adrenals
  • bone scan/skeletal survey
  • other pituitary hormone investigations
  • genetic testing
  • thyroid function tests
More investigations to consider

Emerging tests

  • overnight gonadotrophin profile

Treatment algorithm


gonadotrophin-dependent precocious puberty (GDPP)

gonadotrophin-independent precocious puberty (GIPP)



Ameeta Mehta, MBBS, DCH, DNBE, MSc, MRCP, MD
Ameeta Mehta

Paediatric Endocrinologist




AM is an author of several articles cited within this topic.

Peter Hindmarsh, BSc, MD, FRCP, FRCPCH

Professor of Paediatric Endocrinology

University College London




PH is an author of several articles cited within this topic.

Peer reviewers

Malcolm Donaldson, MD, FRCP, FRCPCH, DCH

Senior Lecturer in Child Health

Department of Child Health

Royal Hospital for Sick Children




MD has received lecture fees and financial support from pharmaceutical companies (Pfizer, Novo Nordisk, Serono) who manufacture growth hormone and whose brands of growth hormone MD recommends. MD is also an author of articles cited in this topic.

Dianne Deplewski, MD

Assistant Professor of Pediatrics

University of Chicago




DD declares that she has no competing interests.

  • Precocious puberty images
  • Differentials

    • Premature thelarche
    • Premature adrenarche
    • Congenital adrenal hyperplasia (CAH)
    More Differentials
  • Guidelines

    • Evaluation and referral of children with signs of early puberty
    • Consensus statement on the use of gonadotropin-releasing hormone analogs in children
    More Guidelines
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