ESPE Abstracts

Menarche is a late pubertal event that occurs at an average age of 12.4 years and follows on an average of 2.5 years after the onset of breast development. When it occurs before the age of 10 years, it is considered early menarche. Isolated premature menarche is defined as onset of vaginal bleeding in a prepubertal female, in the absence of appropriate secondary sexual characters or a known pathological cause. It can present with isolated or recurrent periodic episodes of bleeding and it is a diagnosis of exclusion, as underlying organic disorders must be ruled out. This entity is considered “incomplete precocious puberty”, analogous to premature thelarche and premature pubarche. The pathophysiology of this condition is not well understood and is hypothesised to be due to atypical sensitivity of the endometrium to very low prepubertal levels of oestrogens or due to Endocrine Disrupting Chemicals (EDCs). Data on this is scarce, but it has been observed that isolated premature menarche typically resolves after 1-3 episodes and therefore, in most cases, watchful waiting for clinical progression is considered appropriate. Further workup is deemed necessary when patients have persistent vaginal bleeding, to rule out true precocious puberty or other underlying pathology. Initial screening tests may include bone age, pelvic ultrasound, measurement of LH, FSH, Oestradiol, thyroid function tests and Dehydroepiandrosterone sulfate (DHEA-S). Here we report our experience at Hull University Teaching Hospital, UK, of management and outcomes of prepubertal cyclic vaginal bleeding through 4 cases. The age range of first episode of vaginal bleeding was between 6-8 years. Two patients had a family history of early menarche. All patients were prepubertal on examination and had a high BMI. All patients were investigated with bone age and pelvic ultrasound. All patients had a prepubertal uterine appearance. Bone age was slightly accelerated in two patients. Three patients had recurrent vaginal bleeding and therefore had blood tests, which were all unremarkable and confirmed prepubertal hormone levels. Two patients additionally had MRI head, which was unremarkable. Only one patient was managed with a gonadotropin releasing hormone (GnRH) agonist (Triptorelin), as bleeding was significantly affecting her psychologically. Bleeding stopped after the first injection and this treatment is ongoing. One patient had only one episode of menstrual-like vaginal bleed with subsequent resolution and hence discharged. One patient continued to have cyclical bleeding and was discharged after 10 years of age. Our fourth patient is still under follow up.