about the type of precocious puberty; however, in general, suppressed FSH secretion in the presence of elevated sex steroids suggests the presence of PPP. Basal LH levels >0.6 IU/L have been used to rule out CPP, though with limited success. Therefore, in such cases, GnRH stimulation can be utilized to diagnose true CPP. A post-stimulation LH value of ≥5 IU/L after a 100-μg IV dose of GnRH is considered diagnostic for CPP in patients with pubertal signs.

Treatment [1, 2]

CPP

Long-acting GnRH-agonist (GnRH-a) is considered the gold standard for managing CPP. Administration of GnRH-a results in decreased FSH and LH levels, and consequently a signi cant decline in sex steroid levels. Occupation of GnRH receptors by long-acting GnRH-a administration results in desensitization and internalization of receptors, resulting in diminishing FSH and LH levels. Various formulations of long-acting GnRH-a are available, including intramuscular depot, subcutaneous injection, and subcutaneous implant. There is minimal agreement about the monitoring of hormonal parameters or ideal hormone levels during GnRH-a therapy. Thus, the overall goals of treatment are aimed toward the stabilization of pubertal progression, avoiding early menarche, decreasing premature advancement of bone age, and declining rapid increase in linear growth velocity. Studies have shown that girls who begin GnRH-a therapy before age 6 have the greatest bene t in terms of adult height, while those treated after age 8 have minimal bene t.

The most common side effects associated with GnRH-a treatment include headaches, hot fushes, and local injection-site reactions. Sterile abscesses may develop with intramuscular formulations or subcutaneous implants, limiting its ef cacy. Furthermore, fracture of subcutaneous implants may occur during extraction, necessitating ultrasound-guided removal of the fragments. Vaginal bleeding may occur after the rst dose of GnRH-a due to a transient increase in FSH, LH, and E2. Weight gain can also be a GnRH-a-associated side effect.

There is limited consensus about an optimal age to discontinue GnRH-a treatment. However, experts agree that it should be individualized to predicted height, synchronization of puberty with other sibling and/or peers, and the level of personal distress. Most often, treatment withdrawal is initiated at 12–12.5 years of bone age in girls. Menses spontaneously occur within 12 months of GnRH-a cessation.