A Practical and Integrative Approach to Differential Diagnosis Between Precocious Puberty and Premature Telarch: Newly Proposed Clinical and Laboratory Finding-Based Diagnostic Scoring in Precocious Puberty and Premature Telarch

Murat Karaoglan; Mehmet Keskin; Ayhan Ozkur; Ozlem Keskin

Background: Accurate and differential diagnosis of preococious puberty (PP) have some important challenges. Many parameters have used to diagnose pubertal diseases so far. However LH-RH stimulation test is considered as a gold standard procedure, ıt has some difficulties in practise.

Objective: We aimed to set a newly proposed clinical and laboratory finding-based diagnostic scoring in the differential diagnosis of preoccious puberty and premature telarch (PT).

Method: In this study, a total of 267 patients (164 PP; 103 PT) were enrolled in Paediatric Endocrinology Department of Medical Faculty of Gaziantep University. We accepted following including criteria: At least one of secondary sex characteristics is T2 or P2 according to Tanner scoring. We used basal LH 0.31 or peak LH of at least 5 IU/l and/or stimulated LH/FSH ratio of at least 0.31 as cutoff criteria for pubertal response during GnRH testing. We accepted following findings as pubertal signs: i) uterine length is 35 mm or longer; ii) ovarian volume is 1 ml or larger size; iii) bone age is more advanced than chronological age by 1 years or older; iv) oestradiol level is higher than 10 pg/ml.

Findings: We determined among all parameters what we can use in clinical scoring. (Nagelkerke) These parameters: i) age at diagnosis ii) BA-CA(year) iii) Estradiol level iv) uterine length (mm) v) Ovarian volume(cm³) vi) peak LH level. We determined scoring every single parameters and established two different scoring model: i) Model 1 (without LH-RH stimulation test); ii) Model 2 (including peak LH level). We have designed the total score respectively as 12 and 15 points in Models 1 and 2. For diagnosis of precocious puberty, we accepted above five points (>5 points) in Model 1 and above seven points (>7 points) in Model 2 (Table 2). The specificity of both models were statistically significant. Model 1(%88.4); model 2(%91.4).

Table 1 Cut off levels for PP and PT.
Variables (%)	Cut off	PP (n:164)	PT (n:103)
Age at diagnosis (year)	>6.5	142 (86.6)	44 (42.7)
	≤6.5	22 (13.4)	59 (57.3)
BA-CA (year)	>1.1	116 (70.7)	14 (13.6)
	≤1.1	48 (29.3)	89 (86.4)
Estrogen	>12	87 (53.0)	6 (5.8)
	≤12	77 (47)	97 (94.2)
Uterine length (mm)	>32	132 (80.5)	28 (27.2)
	≤32	32 (19.5)	75 (72.8)
Ovarian volume (cm³)	>1.09	126 (76.8)	27 (26.2)
	≤1.09	38 (23.2)	76 (73.8)
PLH	>4.37	109 (79.6)	19 (26)
	≤4.37	28 (20.4)
Significant at P<0.05. Nagelkerke R ²=0.77. Cox & Snell R ²=0.56.

Table 2 Scores for every single parameters (for abstract P3-1161).
	Model 1: Nagelkerke R²=0.77				Model 2: Nagelkerke: R²=0.81
Variables n (%)	β	Rounded score	Adjusted OR (95% Cl)	P	β		Adjusted OR lower	P
Age at diagnosis	3.02	3	20.4 (5.87-70.90)	0.001*	3.32	3	27.68 (5.87–141.93)	0.001*
BA-CA	2.15	2	8.61 (3.34-22.22)	0.001*	2.68	2.5	14.63 (95.87–70.90)	0.001*
Estrogen	3.63	3.5	37.64 (9.33-151.90)	0.001*	2.74	2.5	15.60 (2.83-85.800)	0.002*
Uterine length	1.89	2	6.65 (2.75–16.12)	0.001*	1.60	1.5	4.95 (1.61–13.17)	0.005*
Overian volume	1.54	1.5	4.64 (1.89–11.35)	0.001*	2.35	2	10.52 (2.97–37.27)	0.001*
pLH	–	–	–		3.51	3.5	33.52 (8.20–136.89)	0.001*
		Total=12				Total =15

Conclusion: Clinical and laboratory finding-based practical and integrative diagnostic scoring in the differential diagnosis of preoccious puberty) and premature telarch can be more logical and reasonable approach. We propose a newly scoring system which is used onset age, bone age-choronological age,uterine length, ovarian volume, estradiol in differential diagnosis of PP and PT. The newly proposed scoring system which allows to diagnose PP and PT without LH-RH stimulation test. This scoring model both eliminates disadvantages and provides applicaple to every society, standard and measurable approach.

ESPE Abstracts

P3-1161