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Definition, etiology, and evaluation of precocious puberty

Jennifer Harrington, MBBS, PhD
Mark R Palmert, MD, PhD
Section Editors
Peter J Snyder, MD
William F Crowley, Jr, MD
Mitchell Geffner, MD
Deputy Editors
Alison G Hoppin, MD
Kathryn A Martin, MD


Precocious puberty is the onset of pubertal development at an age that is 2 to 2.5 standard deviations (SD) earlier than population norms. The cause of precocious puberty may range from a variant of normal development (eg, isolated premature adrenarche or isolated premature thelarche) to pathologic conditions with significant risk of morbidity and even death (eg, malignant germ-cell tumor and astrocytoma).

The clinician faced with a child who presents with early sexual development should consider the following questions:

Is the child too young to have reached the pubertal milestone in question? – To answer this question, the clinician needs to know the normal ages for pubertal milestones and how to separate normal from abnormal development.

What is causing the early sexual development? – To answer this question, the physician ascertains whether the sexual development is attributable to androgen and/or estrogen effects, and whether the source of sex hormone is centrally mediated through the hypothalamic-pituitary-gonadal axis, or from an autonomous peripheral origin, or has an exogenous basis.

Is therapy indicated, and, if so, what therapy?


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Literature review current through: Sep 2016. | This topic last updated: Mar 21, 2016.
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  1. Boepple PA, Crowley WF Jr. Precocious puberty. In: Reproductive Endocrinology, Surgery, and Technology, Adashi EY, Rock JA, Rosenwaks Z (Eds), Lippincott-Raven, Philadelphia 1996. Vol 1, p.989.
  2. Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child 1969; 44:291.
  3. Marshall WA, Tanner JM. Variations in the pattern of pubertal changes in boys. Arch Dis Child 1970; 45:13.
  4. Harlan WR, Harlan EA, Grillo GP. Secondary sex characteristics of girls 12 to 17 years of age: the U.S. Health Examination Survey. J Pediatr 1980; 96:1074.
  5. Harlan WR, Grillo GP, Cornoni-Huntley J, Leaverton PE. Secondary sex characteristics of boys 12 to 17 years of age: the U.S. Health Examination Survey. J Pediatr 1979; 95:293.
  6. Tanner JM, Davies PS. Clinical longitudinal standards for height and height velocity for North American children. J Pediatr 1985; 107:317.
  7. Sun SS, Schubert CM, Chumlea WC, et al. National estimates of the timing of sexual maturation and racial differences among US children. Pediatrics 2002; 110:911.
  8. Aksglaede L, Sørensen K, Petersen JH, et al. Recent decline in age at breast development: the Copenhagen Puberty Study. Pediatrics 2009; 123:e932.
  9. Herman-Giddens ME, Steffes J, Harris D, et al. Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics 2012; 130:e1058.
  10. Kuiri-Hänninen T, Sankilampi U, Dunkel L. Activation of the hypothalamic-pituitary-gonadal axis in infancy: minipuberty. Horm Res Paediatr 2014; 82:73.
  11. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network. Pediatrics 1997; 99:505.
  12. Teilmann G, Pedersen CB, Jensen TK, et al. Prevalence and incidence of precocious pubertal development in Denmark: an epidemiologic study based on national registries. Pediatrics 2005; 116:1323.
  13. Rosenfield RL, Lipton RB, Drum ML. Thelarche, pubarche, and menarche attainment in children with normal and elevated body mass index. Pediatrics 2009; 123:84.
  14. Kaplowitz P. Clinical characteristics of 104 children referred for evaluation of precocious puberty. J Clin Endocrinol Metab 2004; 89:3644.
  15. Kaplowitz P, Bloch C, Section on Endocrinology, American Academy of Pediatrics. Evaluation and Referral of Children With Signs of Early Puberty. Pediatrics 2016; 137.
  16. Kaplowitz PB, Oberfield SE. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. Pediatrics 1999; 104:936.
  17. Euling SY, Herman-Giddens ME, Lee PA, et al. Examination of US puberty-timing data from 1940 to 1994 for secular trends: panel findings. Pediatrics 2008; 121 Suppl 3:S172.
  18. Rosenfield RL, Bachrach LK, Chernausek SD, et al. Current age of onset of puberty. Pediatrics 2000; 106:622.
  19. Midyett LK, Moore WV, Jacobson JD. Are pubertal changes in girls before age 8 benign? Pediatrics 2003; 111:47.
  20. De Sanctis V, Corrias A, Rizzo V, et al. Etiology of central precocious puberty in males: the results of the Italian Study Group for Physiopathology of Puberty. J Pediatr Endocrinol Metab 2000; 13 Suppl 1:687.
  21. Choi KH, Chung SJ, Kang MJ, et al. Boys with precocious or early puberty: incidence of pathological brain magnetic resonance imaging findings and factors related to newly developed brain lesions. Ann Pediatr Endocrinol Metab 2013; 18:183.
  22. Mogensen SS, Aksglaede L, Mouritsen A, et al. Pathological and incidental findings on brain MRI in a single-center study of 229 consecutive girls with early or precocious puberty. PLoS One 2012; 7:e29829.
  23. Pedicelli S, Alessio P, Scirè G, et al. Routine screening by brain magnetic resonance imaging is not indicated in every girl with onset of puberty between the ages of 6 and 8 years. J Clin Endocrinol Metab 2014; 99:4455.
  24. Cisternino M, Arrigo T, Pasquino AM, et al. Etiology and age incidence of precocious puberty in girls: a multicentric study. J Pediatr Endocrinol Metab 2000; 13 Suppl 1:695.
  25. Striano S, Santulli L, Ianniciello M, et al. The gelastic seizures-hypothalamic hamartoma syndrome: facts, hypotheses, and perspectives. Epilepsy Behav 2012; 24:7.
  26. Jung H, Carmel P, Schwartz MS, et al. Some hypothalamic hamartomas contain transforming growth factor alpha, a puberty-inducing growth factor, but not luteinizing hormone-releasing hormone neurons. J Clin Endocrinol Metab 1999; 84:4695.
  27. Listernick R, Charrow J, Gutmann DH. Intracranial gliomas in neurofibromatosis type 1. Am J Med Genet 1999; 89:38.
  28. Ogilvy-Stuart AL, Clayton PE, Shalet SM. Cranial irradiation and early puberty. J Clin Endocrinol Metab 1994; 78:1282.
  29. Silveira LG, Noel SD, Silveira-Neto AP, et al. Mutations of the KISS1 gene in disorders of puberty. J Clin Endocrinol Metab 2010; 95:2276.
  30. Teles MG, Bianco SD, Brito VN, et al. A GPR54-activating mutation in a patient with central precocious puberty. N Engl J Med 2008; 358:709.
  31. Seminara SB, Messager S, Chatzidaki EE, et al. The GPR54 gene as a regulator of puberty. N Engl J Med 2003; 349:1614.
  32. Abreu AP, Dauber A, Macedo DB, et al. Central precocious puberty caused by mutations in the imprinted gene MKRN3. N Engl J Med 2013; 368:2467.
  33. Hagen CP, Sørensen K, Mieritz MG, et al. Circulating MKRN3 levels decline prior to pubertal onset and through puberty: a longitudinal study of healthy girls. J Clin Endocrinol Metab 2015; 100:1920.
  34. Macedo DB, Abreu AP, Reis AC, et al. Central precocious puberty that appears to be sporadic caused by paternally inherited mutations in the imprinted gene makorin ring finger 3. J Clin Endocrinol Metab 2014; 99:E1097.
  35. Pescovitz OH, Hench K, Green O, et al. Central precocious puberty complicating a virilizing adrenal tumor: treatment with a long-acting LHRH analog. J Pediatr 1985; 106:612.
  36. Pescovitz OH, Cassorla F, Comite F, et al. LHRH analog treatment of central precocious puberty complicating congenital adrenal hyperplasia. Ann N Y Acad Sci 1985; 458:174.
  37. Holland FJ, Kirsch SE, Selby R. Gonadotropin-independent precocious puberty ("testotoxicosis"): influence of maturational status on response to ketoconazole. J Clin Endocrinol Metab 1987; 64:328.
  38. Faggiano M, Criscuolo T, Perrone L, et al. Sexual precocity in a boy due to hypersecretion of LH and prolactin by a pituitary adenoma. Acta Endocrinol (Copenh) 1983; 102:167.
  39. Ambrosi B, Bassetti M, Ferrario R, et al. Precocious puberty in a boy with a PRL-, LH- and FSH-secreting pituitary tumour: hormonal and immunocytochemical studies. Acta Endocrinol (Copenh) 1990; 122:569.
  40. Papanikolaou A, Michala L. Autonomous Ovarian Cysts in Prepubertal Girls. How Aggressive Should We Be? A Review of the Literature. J Pediatr Adolesc Gynecol 2015; 28:292.
  41. Lack EE, Perez-Atayde AR, Murthy AS, et al. Granulosa theca cell tumors in premenarchal girls: a clinical and pathologic study of ten cases. Cancer 1981; 48:1846.
  42. Young RH, Dickersin GR, Scully RE. Juvenile granulosa cell tumor of the ovary. A clinicopathological analysis of 125 cases. Am J Surg Pathol 1984; 8:575.
  43. Arhan E, Cetinkaya E, Aycan Z, et al. A very rare cause of virilization in childhood: ovarian Leydig cell tumor. J Pediatr Endocrinol Metab 2008; 21:181.
  44. Urban MD, Lee PA, Plotnick LP, Migeon CJ. The diagnosis of Leydig cell tumors in childhood. Am J Dis Child 1978; 132:494.
  45. Henderson CG, Ahmed AA, Sesterhenn I, et al. Enucleation for prepubertal leydig cell tumor. J Urol 2006; 176:703.
  46. Englund AT, Geffner ME, Nagel RA, et al. Pediatric germ cell and human chorionic gonadotropin-producing tumors. Clinical and laboratory features. Am J Dis Child 1991; 145:1294.
  47. Shenker A, Laue L, Kosugi S, et al. A constitutively activating mutation of the luteinizing hormone receptor in familial male precocious puberty. Nature 1993; 365:652.
  48. Egli CA, Rosenthal SM, Grumbach MM, et al. Pituitary gonadotropin-independent male-limited autosomal dominant sexual precocity in nine generations: familial testotoxicosis. J Pediatr 1985; 106:33.
  49. Van Wyk JJ, Grumbach MM. Syndrome of precocious menstruation and galactorrhea in juvenile hypothyroidism: an example of hormonal overlap in pituitary feedback. J Pediatr 1960; 57:416.
  50. Castro-Magaña M, Angulo M, Cañas A, et al. Hypothalamic-pituitary gonadal axis in boys with primary hypothyroidism and macroorchidism. J Pediatr 1988; 112:397.
  51. Cabrera SM, DiMeglio LA, Eugster EA. Incidence and characteristics of pseudoprecocious puberty because of severe primary hypothyroidism. J Pediatr 2013; 162:637.
  52. Bhansali A, Kashyap A, Lodha S, et al. Isosexual precocity: uncommon presentation of a common disorder. Postgrad Med J 2000; 76:177.
  53. Anasti JN, Flack MR, Froehlich J, et al. A potential novel mechanism for precocious puberty in juvenile hypothyroidism. J Clin Endocrinol Metab 1995; 80:276.
  54. Franklin SL. Effects of unintentional exposure of children to compounded transdermal sex hormone therapy. Pediatr Endocrinol Rev 2011; 8:208.
  55. Food and Drug Administration safety communication, 7/29/10: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm220185.htm (Accessed on October 06, 2010).
  56. Henley DV, Lipson N, Korach KS, Bloch CA. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med 2007; 356:479.
  57. Henley DV, Korach KS. Physiological effects and mechanisms of action of endocrine disrupting chemicals that alter estrogen signaling. Hormones (Athens) 2010; 9:191.
  58. Partsch CJ, Sippell WG. Pathogenesis and epidemiology of precocious puberty. Effects of exogenous oestrogens. Hum Reprod Update 2001; 7:292.
  59. Fara GM, Del Corvo G, Bernuzzi S, et al. Epidemic of breast enlargement in an Italian school. Lancet 1979; 2:295.
  60. Sáenz de Rodríguez CA, Bongiovanni AM, Conde de Borrego L. An epidemic of precocious development in Puerto Rican children. J Pediatr 1985; 107:393.
  61. Kunz GJ, Klein KO, Clemons RD, et al. Virilization of young children after topical androgen use by their parents. Pediatrics 2004; 114:282.
  62. Martinez-Pajares JD, Diaz-Morales O, Ramos-Diaz JC, Gomez-Fernandez E. Peripheral precocious puberty due to inadvertent exposure to testosterone: case report and review of the literature. J Pediatr Endocrinol Metab 2012; 25:1007.
  63. Phornphutkul C, Okubo T, Wu K, et al. Aromatase p450 expression in a feminizing adrenal adenoma presenting as isosexual precocious puberty. J Clin Endocrinol Metab 2001; 86:649.
  64. Boyce AM, Collins MT. Fibrous Dysplasia/McCune-Albright Syndrome. In: GeneReviews® [Internet], Pagon RA, Adam MP, Ardinger HH, et al. (Eds), University of Washington, Seattle 2015. Available at: http://www.ncbi.nlm.nih.gov/books/NBK274564/ (Accessed on September 18, 2015).
  65. Frisch LS, Copeland KC, Boepple PA. Recurrent ovarian cysts in childhood: diagnosis of McCune-Albright syndrome by bone scan. Pediatrics 1992; 90:102.
  66. Nabhan ZM, West KW, Eugster EA. Oophorectomy in McCune-Albright syndrome: a case of mistaken identity. J Pediatr Surg 2007; 42:1578.
  67. de Sanctis C, Lala R, Matarazzo P, et al. McCune-Albright syndrome: a longitudinal clinical study of 32 patients. J Pediatr Endocrinol Metab 1999; 12:817.
  68. Haddad N, Eugster E. An update on the treatment of precocious puberty in McCune-Albright syndrome and testotoxicosis. J Pediatr Endocrinol Metab 2007; 20:653.
  69. Schmidt H, Kiess W. Secondary central precocious puberty in a girl with McCune-Albright syndrome responds to treatment with GnRH analogue. J Pediatr Endocrinol Metab 1998; 11:77.
  70. Boyce AM, Chong WH, Shawker TH, et al. Characterization and management of testicular pathology in McCune-Albright syndrome. J Clin Endocrinol Metab 2012; 97:E1782.
  71. Weinstein LS, Shenker A, Gejman PV, et al. Activating mutations of the stimulatory G protein in the McCune-Albright syndrome. N Engl J Med 1991; 325:1688.
  72. Shenker A, Weinstein LS, Moran A, et al. Severe endocrine and nonendocrine manifestations of the McCune-Albright syndrome associated with activating mutations of stimulatory G protein GS. J Pediatr 1993; 123:509.
  73. Lumbroso S, Paris F, Sultan C, European Collaborative Study. Activating Gsalpha mutations: analysis of 113 patients with signs of McCune-Albright syndrome--a European Collaborative Study. J Clin Endocrinol Metab 2004; 89:2107.
  74. Chanson P, Salenave S, Orcel P. McCune-Albright syndrome in adulthood. Pediatr Endocrinol Rev 2007; 4 Suppl 4:453.
  75. Schwindinger WF, Francomano CA, Levine MA. Identification of a mutation in the gene encoding the alpha subunit of the stimulatory G protein of adenylyl cyclase in McCune-Albright syndrome. Proc Natl Acad Sci U S A 1992; 89:5152.
  76. Grant DB, Martinez L. The McCune-Albright syndrome without typical skin pigmentation. Acta Paediatr Scand 1983; 72:477.
  77. Pasquino AM, Pucarelli I, Passeri F, et al. Progression of premature thelarche to central precocious puberty. J Pediatr 1995; 126:11.
  78. Zhu SY, Du ML, Huang TT. An analysis of predictive factors for the conversion from premature thelarche into complete central precocious puberty. J Pediatr Endocrinol Metab 2008; 21:533.
  79. de Vries L, Guz-Mark A, Lazar L, et al. Premature thelarche: age at presentation affects clinical course but not clinical characteristics or risk to progress to precocious puberty. J Pediatr 2010; 156:466.
  80. Crofton PM, Evans NE, Wardhaugh B, et al. Evidence for increased ovarian follicular activity in girls with premature thelarche. Clin Endocrinol (Oxf) 2005; 62:205.
  81. Zung A, Glaser T, Kerem Z, Zadik Z. Breast development in the first 2 years of life: an association with soy-based infant formulas. J Pediatr Gastroenterol Nutr 2008; 46:191.
  82. Mendez MA, Anthony MS, Arab L. Soy-based formulae and infant growth and development: a review. J Nutr 2002; 132:2127.
  83. Freni-Titulaer LW, Cordero JF, Haddock L, et al. Premature thelarche in Puerto Rico. A search for environmental factors. Am J Dis Child 1986; 140:1263.
  84. Madlon-Kay DJ. 'Witch's milk'. Galactorrhea in the newborn. Am J Dis Child 1986; 140:252.
  85. Nebesio TD, Eugster EA. Pubic hair of infancy: endocrinopathy or enigma? Pediatrics 2006; 117:951.
  86. Kaplowitz PB, Mehra R. Clinical characteristics of children referred for signs of early puberty before age 3. J Pediatr Endocrinol Metab 2015; 28:1139.
  87. Janus D, Wojcik M, Tyrawa K, Starzyk J. Transient isolated scrotal hair development in infancy. Clin Pediatr (Phila) 2013; 52:628.
  88. Kaplowitz P, Soldin SJ. Steroid profiles in serum by liquid chromatography-tandem mass spectrometry in infants with genital hair. J Pediatr Endocrinol Metab 2007; 20:597.
  89. Ejaz S, Lane A, Wilson T. Outcome of Isolated Premature Menarche: A Retrospective and Follow-Up Study. Horm Res Paediatr 2015; 84:217.
  90. Nella AA, Kaplowitz PB, Ramnitz MS, Nandagopal R. Benign vaginal bleeding in 24 prepubertal patients: clinical, biochemical and imaging features. J Pediatr Endocrinol Metab 2014; 27:821.
  91. Palmert MR, Malin HV, Boepple PA. Unsustained or slowly progressive puberty in young girls: initial presentation and long-term follow-up of 20 untreated patients. J Clin Endocrinol Metab 1999; 84:415.
  92. Lazar L, Pertzelan A, Weintrob N, et al. Sexual precocity in boys: accelerated versus slowly progressive puberty gonadotropin-suppressive therapy and final height. J Clin Endocrinol Metab 2001; 86:4127.
  93. Heller ME, Dewhurst J, Grant DB. Premature menarche without other evidence of precocious puberty. Arch Dis Child 1979; 54:472.
  94. Hill NC, Oppenheimer LW, Morton KE. The aetiology of vaginal bleeding in children. A 20-year review. Br J Obstet Gynaecol 1989; 96:467.
  95. Cabrera-Cantú F, Urrutia-Osorio M, Valdez-Arellano F, et al. Sertoli-Leydig cell tumor in a 12-year-old girl: a review article and case report. Arch Gynecol Obstet 2014; 290:791.
  96. Alikasifoglu A, Gonc EN, Akcoren Z, et al. Feminizing Sertoli cell tumor associated with Peutz-Jeghers syndrome. J Pediatr Endocrinol Metab 2002; 15:449.
  97. Papadimitriou A, Beri D, Tsialla A, et al. Early growth acceleration in girls with idiopathic precocious puberty. J Pediatr 2006; 149:43.
  98. Joustra SD, van der Plas EM, Goede J, et al. New reference charts for testicular volume in Dutch children and adolescents allow the calculation of standard deviation scores. Acta Paediatr 2015; 104:e271.
  99. DeSalvo DJ, Mehra R, Vaidyanathan P, Kaplowitz PB. In children with premature adrenarche, bone age advancement by 2 or more years is common and generally benign. J Pediatr Endocrinol Metab 2013; 26:215.
  100. Neely EK, Hintz RL, Wilson DM, et al. Normal ranges for immunochemiluminometric gonadotropin assays. J Pediatr 1995; 127:40.
  101. Harrington J, Palmert MR, Hamilton J. Use of local data to enhance uptake of published recommendations: an example from the diagnostic evaluation of precocious puberty. Arch Dis Child 2014; 99:15.
  102. Houk CP, Kunselman AR, Lee PA. Adequacy of a single unstimulated luteinizing hormone level to diagnose central precocious puberty in girls. Pediatrics 2009; 123:e1059.
  103. Bizzarri C, Spadoni GL, Bottaro G, et al. The response to gonadotropin releasing hormone (GnRH) stimulation test does not predict the progression to true precocious puberty in girls with onset of premature thelarche in the first three years of life. J Clin Endocrinol Metab 2014; 99:433.
  104. Bay K, Andersson AM, Skakkebaek NE. Estradiol levels in prepubertal boys and girls--analytical challenges. Int J Androl 2004; 27:266.
  105. Rosenfield RL, Bordini B, Yu C. Comparison of detection of normal puberty in girls by a hormonal sleep test and a gonadotropin-releasing hormone agonist test. J Clin Endocrinol Metab 2013; 98:1591.
  106. Lee PA, Gollenberg AL, Hediger ML, et al. Luteinizing hormone, testosterone and inhibin B levels in the peripubertal period and racial/ethnic differences among boys aged 6-11 years: analyses from NHANES III, 1988-1994. Clin Endocrinol (Oxf) 2010; 73:744.
  107. Carel JC, Eugster EA, Rogol A, et al. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics 2009; 123:e752.
  108. Houk CP, Kunselman AR, Lee PA. The diagnostic value of a brief GnRH analogue stimulation test in girls with central precocious puberty: a single 30-minute post-stimulation LH sample is adequate. J Pediatr Endocrinol Metab 2008; 21:1113.
  109. Kandemir N, Demirbilek H, Özön ZA, et al. GnRH stimulation test in precocious puberty: single sample is adequate for diagnosis and dose adjustment. J Clin Res Pediatr Endocrinol 2011; 3:12.
  110. Chi CH, Durham E, Neely EK. Pharmacodynamics of aqueous leuprolide acetate stimulation testing in girls: correlation between clinical diagnosis and time of peak luteinizing hormone level. J Pediatr 2012; 161:757.
  111. Carretto F, Salinas-Vert I, Granada-Yvern ML, et al. The usefulness of the leuprolide stimulation test as a diagnostic method of idiopathic central precocious puberty in girls. Horm Metab Res 2014; 46:959.
  112. Sathasivam A, Garibaldi L, Shapiro S, et al. Leuprolide stimulation testing for the evaluation of early female sexual maturation. Clin Endocrinol (Oxf) 2010; 73:375.
  113. Resende EA, Lara BH, Reis JD, et al. Assessment of basal and gonadotropin-releasing hormone-stimulated gonadotropins by immunochemiluminometric and immunofluorometric assays in normal children. J Clin Endocrinol Metab 2007; 92:1424.
  114. Oerter KE, Uriarte MM, Rose SR, et al. Gonadotropin secretory dynamics during puberty in normal girls and boys. J Clin Endocrinol Metab 1990; 71:1251.
  115. Rosenfield RL. Clinical review: Identifying children at risk for polycystic ovary syndrome. J Clin Endocrinol Metab 2007; 92:787.
  116. Livadas S, Dracopoulou M, Dastamani A, et al. The spectrum of clinical, hormonal and molecular findings in 280 individuals with nonclassical congenital adrenal hyperplasia caused by mutations of the CYP21A2 gene. Clin Endocrinol (Oxf) 2015; 82:543.
  117. Armengaud JB, Charkaluk ML, Trivin C, et al. Precocious pubarche: distinguishing late-onset congenital adrenal hyperplasia from premature adrenarche. J Clin Endocrinol Metab 2009; 94:2835.
  118. Chalumeau M, Chemaitilly W, Trivin C, et al. Central precocious puberty in girls: an evidence-based diagnosis tree to predict central nervous system abnormalities. Pediatrics 2002; 109:61.
  119. Eksioglu AS, Yilmaz S, Cetinkaya S, et al. Value of pelvic sonography in the diagnosis of various forms of precocious puberty in girls. J Clin Ultrasound 2013; 41:84.
  120. Sathasivam A, Rosenberg HK, Shapiro S, et al. Pelvic ultrasonography in the evaluation of central precocious puberty: comparison with leuprolide stimulation test. J Pediatr 2011; 159:490.
  121. de Vries L, Horev G, Schwartz M, Phillip M. Ultrasonographic and clinical parameters for early differentiation between precocious puberty and premature thelarche. Eur J Endocrinol 2006; 154:891.
  122. Badouraki M, Christoforidis A, Economou I, et al. Evaluation of pelvic ultrasonography in the diagnosis and differentiation of various forms of sexual precocity in girls. Ultrasound Obstet Gynecol 2008; 32:819.
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