Q. What investigations are helpful ?
A. Bone age is advanced in TPP and is extremely helpful at the time of initial diagnosis as well as on follow up. Pelvic sonography for uterine and ovarian size and morphology are necessary and also help in excluding a primary ovarian pathology. Bilateral enlargement of ovaries with small follicular cysts and enlargement of uterus favors HPG axis activation. CNS imaging is very valuable in excluding intracranial organic lesions and detecting hypothalamic hamartomas. Vaginal cytology shows marked estrogen effect in TPP. Hormonal evaluation includes estimation of sex steroids, serum estradiol (>10pg/ml) or testosterone (>0.2ng/ml) and gonadotropins (>1 IU/L) which may be in the pubertal range. LH, FSH response to GnRH stimulation test with a LH/FSH ratio exceeding 1, favors CPP.

Study of thyroid hormones, adrenal androgens and 17 - hydroxyprogesterone may be undertaken as indicated. ACTH stimulation and dexamethasone suppression tests may be required in girls with premature adrenarche to differentiate from primary adrenal disease such as congenital adrenal hyperplasia. Adrenal imaging be occasionally required to exclude virilizing adrenal tumor. Bilateral adrenal hyperplasia may be seen in cases with CAH.

Q. What are the goals of management in these children ?
A. The management is directed towards reversing and preventing further progression of puberty, arrest of skeletal maturation which compromises height potential and dealing with the emotional and psychologic problems which are frequently encountered. These children should be guarded against sexual abuse.