A 14-year-old girl is brought to the office by her mother for evaluation of lack of menstruation. The patient has no headaches, nipple discharge, or abdominal or pelvic pain. She takes a topical retinoid and an oral antibiotic for acne and was recently prescribed glasses for myopia. Her last office visit was 3 months ago for evaluation of gastroenteritis. Vaccinations are up to date, including human papillomavirus. Her mother has hypothyroidism; family history is otherwise unremarkable. The patient has 2 older sisters, both of whom underwent menarche at age 13. The patient is not sexually active and does not use tobacco, alcohol, or illicit drugs. Since her last appointment, height has increased from 152 cm (5 ft) to 155 cm (5 ft 1 in, 10th percentile) and weight is unchanged at 45.4 kg (100 lb, 15th percentile). Blood pressure is 118/72 mm Hg and pulse is 68/min. Physical examination shows nodulocystic acne on the face; the skin on the chest and back is clear. The thyroid is soft with no palpable nodules. Breast development is Tanner stage 4 and pubic hair is Tanner stage 3. Which of the following is the best next step in management of this patient?

Question

A 14-year-old girl is brought to the office by her mother for evaluation of lack of menstruation.  The patient has no headaches, nipple discharge, or abdominal or pelvic pain.  She takes a topical retinoid and an oral antibiotic for acne and was recently prescribed glasses for myopia.  Her last office visit was 3 months ago for evaluation of gastroenteritis.  Vaccinations are up to date, including human papillomavirus.  Her mother has hypothyroidism; family history is otherwise unremarkable.  The patient has 2 older sisters, both of whom underwent menarche at age 13.  The patient is not sexually active and does not use tobacco, alcohol, or illicit drugs.  Since her last appointment, height has increased from 152 cm (5 ft) to 155 cm (5 ft 1 in, 10th percentile) and weight is unchanged at 45.4 kg (100 lb, 15th percentile).  Blood pressure is 118/72 mm Hg and pulse is 68/min.  Physical examination shows nodulocystic acne on the face; the skin on the chest and back is clear.  The thyroid is soft with no palpable nodules.  Breast development is Tanner stage 4 and pubic hair is Tanner stage 3.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Normal pubertal development begins with the activation of the hypothalamic-pituitary-ovarian axis. Pulsatile secretion of gonadotropin-releasing hormone from the hypothalamus stimulates the release of FSH and LH from the anterior pituitary, activating the gonads to produce estrogen. hypothalamic-pituitary-ovarian axis Breast development (thelarche) is typically the first sign of puberty in girls and occurs at age 8-12 in response to rising estrogen levels. Pubic hair development (pubarche) usually follows thelarche but can occur first. The onset of menses (menarche) is expected around Tanner stage 4, approximately 2-2.5 years after initial breast bud development. The average age for menarche is 12.5; however, lack of menses is considered normal at age <15 if development of secondary sex characteristics has been appropriate. In the 6 months preceding menarche, girls experience a growth spurt, a peak in growth velocity. puberty in girls Tanner stage 4 This patient is age 14 with normal breast and pubic hair development. Given that she has grown 3 cm in the past 3 months, she is likely undergoing a pubertal growth spurt, and menarche is anticipated within the next 6 months. Appropriate management is to provide reassurance regarding her normal development and reevaluate if menarche does not occur by age 15. (Choice A) CT scan of the abdomen can evaluate for an androgen-secreting adrenal mass in patients with virilization (eg, clitoromegaly, premature pubarche). This patient has facial acne and pubic hair typical of normal adrenarche. (Choice B) Karyotype analysis is performed for amenorrhea in the setting of little or no breast development, a presentation concerning for Turner syndrome. Patients have primary ovarian insufficiency, resulting in a lack of estrogen and abnormal pubertal development. (Choices C, D, and F) Primary amenorrhea is the lack of menses without secondary sex characteristics at age >13 or with secondary sex characteristics at age >15. Evaluation includes a thyroid-stimulating hormone level to evaluate for hypothyroidism and a pelvic ultrasound to confirm the presence of a uterus and ovaries. MRI of the brain may be indicated in a patient who also has galactorrhea and an elevated prolactin level, a presentation suggestive of a prolactinoma. This patient does not have primary amenorrhea as she is age 14 with normal pubertal development. > > Educational objective: Breast development is typically the first manifestation of puberty and is followed by menarche within 2-2.5 years. Premenarchal patients age <15 with normal breast and pubic hair development require no further evaluation. References: Normal and abnormal puberty. (http://www.ncbi.nlm.nih.gov/pubmed/25905253)

A 14-Year-Old Girl Is Brought to the Office by Her