Precocious puberty

Last reviewed: 2 Sep 2023
Last updated: 23 May 2023



History and exam

Key diagnostic 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 tumors
  • cranial irradiation
  • McCune-Albright syndrome
  • gonadal tumors
  • 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

  • Tanner staging
  • measurement of testicular size
  • bone age assessment
  • basal follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
  • gonadotropin-releasing hormone (GnRH) stimulation test
  • serum testosterone
  • serum estrogen
  • ultrasound pelvis
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 gonadotropin profile

Treatment algorithm


central precocious puberty (CPP)

gonadotropin-independent precocious puberty (GIPP)



​Talat Mushtaq, ​BSc, MBCHB, MRCPCH, MD

Paediatric Endocrinology Consultant

Leeds Teaching Hospitals NHS Trust




TM has received support from Novo Nordisk and Pfizer to attend overseas conferences. He has also received honoraria from Kyowa Kirin for lectures and educational events.

​Sasha Howard, MBBS, MRCPCH, MSc, PhD

Senior Lecturer and Honorary Consultant in Paediatric Endocrinology

Queen Mary University of London

Barts Health NHS Trust




SH has received speaking honoraria from Sandoz and Novo Nordisk.


Dr Talat Mushtaq and Dr Sasha Howard would like to gratefully acknowledge Dr Ameeta Mehta and Professor Peter Hindmarsh, previous contributors to this topic.


AM and PH are authors of several references 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) that manufacture growth hormone and whose brands of growth hormone MD recommends. MD is also an author of articles cited in this topic.

Paul Kaplowitz, MD, PhD

Professor Emeritus

Division of Endocrinology

Children's National Hospital




PK declares that he has no competing interests.

  • Precocious puberty images
  • Differentials

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

    • GnRH analogue stimulation testing to investigate precocious puberty
    • Use of gonadotropin-releasing hormone analogs in children: update by an international consortium
    More Guidelines
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