ESPE Abstracts

Background: Mini-puberty is one of the most essential events of infancy, with intermittent alterations that relate to puberty presentations, and it is critical for sexual development in both sexes. It represents the maturation of sexual organs after activation of the hypothalamic-pituitary-gonadal (HPG) axis during the neonatal period, resulting in high gonadotropin and sex steroid levels; allows for the development of the genital organs and creates the basis for future fertility. It is usually self-limited occurring mainly in the first 3-6 months of life in both sexes. In premature females, rarely it may present in an exaggerated form and can be associated with pubertal characteristics, i.e. vaginal bleeding and breast development.

Clinical Data: Here, we present an extreme premature female, born at 27 weeks gestational age, birth weight of 600gram, who had a recurrent vaginal bleeding episodes and breast development at the age of 3 months (corrected gestational age of 40 +2 weeks) associated with increased levels of luteinizing and follicle-stimulating hormones (LH: 3.6, FSH: 11.3IU/L respectively) and significantly high luteinizing hormone-releasing hormone (LHRH) test results suggesting central precocious puberty (LH reaching 20.6IU/L, FSH: 38.4IU/L). Ultrasound was done and showed thick endometrium, with suspected ovarian cyst. Head MRI was normal, normal thyroid function tests, negative CEA, Alpha fetoprotein and βHCG levels. She was assessed to have exaggerated mini-puberty in preterm raising the question to treat or not to treat in these cases. She was observed over a period of time during which regression of secondary sexual characteristics has been observed and reduction in gonadotropin levels (LH & FSH) without initiating treatment.

Conclusion: Only a few cases of exaggerated mini-puberty presenting as vaginal bleeding have been reported in the literature. It is typically an asymptomatic temporary activation of the hypothalamus-pituitary-gonadal (HPG) axis. In premature newborns, it can be exaggerated with significant puberty changes in clinical, hormonal, and sonographic data. The severity and combination of puberty symptoms such as vaginal bleeding, breast development, extremely high levels of gonadotropins, and ovarian follicle size in premature newborns are not sufficient indications to initiate treatment. Mini-puberty of infants should be addressed in the differential diagnosis of females who present with vaginal bleeding within the first 6 months of life. We suggest that in such circumstances, cautious observation until full resolution is reasonable rather than immediate treatment with a gonadotropin-releasing hormone analog. To our knowledge, this is the first description of this disease in a Palestinian family.