A 14-year-old girl is brought to the office by her mother due to "not yet reaching puberty." The mother reports that her daughter started to have breast development and wear a bra about 2 years ago. However, the patient has not had a growth spurt or reached menarche. Her mother is worried because the girl's 2 older sisters had their first menstrual periods at age 11 and are both over 172.7 cm (5 ft 8 in) tall. The mother states, "Nobody else in our family has been a 'late bloomer'." The patient has had increasing facial acne over the last year for which she uses an over-the-counter topical cream. She has no chronic medical conditions and has had no previous surgeries. The patient was born at term and met all developmental milestones. She recently started high school and is a member of the cheerleading squad. The patient is not sexually active and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/60 mm Hg and pulse is 68/min. Weight and height are at the 25th and 55th percentiles, respectively. Breast development is sexual maturity rating stage 3. The external genitalia are normal and pubic hair is Tanner stage 2. Skin examination reveals mild comedonal acne on the nose and forehead. 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 due to "not yet reaching puberty."  The mother reports that her daughter started to have breast development and wear a bra about 2 years ago.  However, the patient has not had a growth spurt or reached menarche.  Her mother is worried because the girl's 2 older sisters had their first menstrual periods at age 11 and are both over 172.7 cm (5 ft 8 in) tall.  The mother states, "Nobody else in our family has been a 'late bloomer'."  The patient has had increasing facial acne over the last year for which she uses an over-the-counter topical cream.  She has no chronic medical conditions and has had no previous surgeries.  The patient was born at term and met all developmental milestones.  She recently started high school and is a member of the cheerleading squad.  The patient is not sexually active and does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/60 mm Hg and pulse is 68/min.  Weight and height are at the 25th and 55th percentiles, respectively.  Breast development is sexual maturity rating stage 3.  The external genitalia are normal and pubic hair is Tanner stage 2.  Skin examination reveals mild comedonal acne on the nose and forehead.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Puberty is the process of achieving sexual maturity as a result of increasing levels of sex hormones. The hypothalamic-pituitary-ovarian axis is typically activated in early adolescence, causing a pulsatile secretion of hypothalamic GnRH to stimulate the release of FSH and LH and activate the ovaries to produce estrogen. This leads to a sequence of events beginning with breast development (thelarche) in girls age 8-12 and culminating in the onset of menses (menarche) 2-2.5 years later. hypothalamic-pituitary-ovarian axis The timing of menarche varies, but it is normal if menses occur by age 15 in girls with secondary sexual characteristics. This patient is age 14 with normal pubertal progression, including breast and pubic hair development. The mild facial acne is a sign of normal adrenarche that occurs during puberty. In addition, this patient has normal stature; growth spurts typically occur shortly before the onset of menses. Given these findings, reassurance and observation are indicated. However, this patient requires reevaluation if menarche does not occur by age 15. (Choice A) Constitutional delay of puberty, characterized by a delayed bone age, may be considered in girls age >12 with short stature and no breast development (first sign of puberty). This patient has a normal height and breast development; therefore, a bone age is not indicated. (Choices B and D) Pelvic ultrasound and a FSH level are ordered to evaluate for primary amenorrhea, the lack of menses at age >15 with secondary sexual characteristics (eg, breast development) or age >13 with no secondary sexual characteristics. (Choice C) Karyotype analysis is indicated to evaluate for Turner syndrome. Patients can present with primary amenorrhea; however, they typically have concomitant short stature (<3rd percentile) and little to no breast development. Educational objective: Puberty in girls typically begins with breast development and pubic hair growth, followed by menarche about 2-2.5 years later. A lack of menses at age <15 is normal if secondary sexual characteristics are present; reassurance and observation are indicated. 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