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Precocious puberty in girls
PRECOCIOUS PUBERTY IN GIRLS RANDOLPH
H. HoaE, M.D., F.A.C.S.,
RrcHMOND, VA.
(From the Department of Gynecology, llfi.Jdical College of Virginia)
HE constitutional type of precocious puberty is the most eommon type.1 Cases in which T the precocity is due to an ovarian tumor are less frequent, and the ovarian neoplasm in such cases is almost always a granulosa eel! tumor. In reviewing the literature L find only two cases in which what appeared to he a simplP eyst of the omry was thought to account for the precocity. One was a case reported by Lull,2 in which the lesion seemed to be a simple follicular cyst; the other ease was revorted by Mengert ," who Ktnted that the ovarian lesion may have been a follicular cyst. In the ease now reported below, a simple cyst of the ovary was present.
Case Report H. W., a Negro girl, was born on Jan. S, 19314 at full term with a normal delivery. She was thought to weigh 7 pounds at birth, was breast fed, walked at 9 months, and talked at 18 months. Dentition occurred at (i months. She had measles at 2 years, pertussis at 4 years, varicella at 5 yea1·s, and mumps at 6 years. 'l'here were four siblings. On May 26, 1937, when she was 6 years, 4 months olcl, she had vaginal bleeding for the first time. Three months before that she had had a vaginal discharge. Two months before the bleeding·, swelling of thf' brea~ts had been noted. The first episode of bleeding lasted four days. Bleeding subsequt>ntly recurred every twent.v-eight days, continuing to last four days each time, and was never wry free. However, for thre<' months before admission to the hospital she bled eontinuou~ly. Because of the bleeding she wa~ admittecl to the hospital on Aug. 29, 19:1R. At that time she was 7 years, 7 months old. She was well nourished, appeared in good health, and was large for her age. The breasts wPre preeociou~ly devPloped, and hair wa~ pre~ent on the mons pubis. There was a slight bloody rlischarge from the introitus. This orificf' was virginal. Rectal examination reveale!l an abnormal pelvis mass. An x-ray of the skull was normal. The sella turcica measured ll mm. in length and S mm. in height. Blood eount~ and urinalysis were normal. The \Vassermann rea<'tion was negatiw. The blood pressure was 100/50. The weight was 76 pounds, temperaturp 9R,6o F., pulse 110, ancl respirations 22. A preoperative diagnosis of preeoeious puberty, probahly tluP to a granulosa c·ell tumor of the ovary, was made. She was operated upon on ~ept. ti, JH:l)ol. An ovarian c•,yst rt>placecl the right ovary. It was thin·wallerl, fillea with thin fluid, and measured 10 rm. in cliameter. A right salpingo-oophorectomy was done. The appPnclix and n small left parovarian cyst were also removed. The tubes, uterus, and left ovary were recorded as being small. The right tube measured i by 0.4 ''Ill. The pathologist reported n corpus luteum cyst (Figs. 1 and 2). The patient's convalescence was uneventful. The follow-up was as follows: May 23, 1940 (aged 9 years): 'l'here was no bleeding since the operation. There were no complaints. A keloid of the scar was present. The hymen was intact. A normal infantile uterus was felt on rectal examination. The breasts were larger than normal for her age, and puhic hair was present, hut the development of both was less than prior to opera6on. Feb. 17, 1944 (aged 13 year~): Amenorrhea persisted until the age of 12 when menstruation occurred. She menstruated regularly every month since then, flowing five days. Moderate dysmenorrhea occurPd. The introitus was virginal. No abnormalities were found on rectal examination. 388
Volume 57 Number 2
PRECOCIOUS PUBERTY IN GIRLS
389
July 21, 1947 (aged 16¥.! years): The last menstrual period was April 6, 1947. Weight 116% pounds, height 60 inches, blood pressure 116/80. The uterus was soft and the size of a ten to twelve weeks' pregnancy.
On Dec, 30, 1947, this patient, lacking nine days of being 17 years old, entered St. Philip Hospital on the obstetrical service and was delivered at term on that day of her :first child. She was discharged from the hospital on Jan. 6, 1948.
F ig. 1.- Section of ovarian cyst in a case of precodous pubert y.
Fig. 2. -Precocious pu berty. Secti on uterine tube, ad ul t type.
Comments The precocious puberty in this case was obviously not due to a granulosa cell tumor, suspected preoperatively, nor was any true tumor of the ovary found. Nevertheless, consider· ing that a cyst with a diameter of 10 em. replaced the right ovary and that there was some regression of secondary sex characteristics postoperatively, it was regarded that this patient
HOGE
390
Am.]. Obst. & Gynec. February, 1949
had a form of precocious puberty due to the ovarian eyst. However, as this interpretation did not seem entirely satisfactory, Dr. Emil Novak was requested to give his views on the case. He reportss his belief that the ovarian condition was a cystic, hut normally functioning, corpus luteum, and that the ~a;;e is one of the constitutional type. He sugge>'ts that the subsequent amenorrhea was of the functional type whidt iB set>n not infrequently in normal girls in the pubertal or adolescent stage. Thus is reported a ease of ~exual preeocity as~oe.iated with an ovarian cy~t, but possihly of the constitutional type. It may be that Mengert 's and Lull's were similar to this case.
References 1. 2. 3. 4. 5.
Novak, E.: AM . .J. O:ssT. & GYNEC. 47: 20, 1944. Lull, C. B.: AM • .J. 0BST. & GYNEC. 41: 445, 1941. Mengert, W. F.: AM. J. 0BST. & GYNEC. 37: 485, 1939. Bureau of Vital Statistics, Richmond, Virginia. Novak, E.: Personal c-ommunication. 1200
EAST BROAD STREET
Hellma.D, L. M., and Vosburgh, G. R .. : Role of Transfusion in the Etiology .of Erythroblastosis, ,J. A. M.A. 136: 79, 1948. The authors wish to re-emphasize the fact that Rh compatibility should be determined for all women prior to transfusion and only Rh negative blood should be used in negative cases. They report cases of nine Rh-negative women who gave histories of previous blood transfusions and, as a result of the transfusions, the subsequent ehildbearing careers of these patients were gravely jeopardized. These nine women had had :five normal children prior to their transfusions but had only two normal infants thereafter. Both of these normal chil· dren botn after transfusion were Rh-negativl:', these women having heterozygous husbands. Wn,LTAM BERMAN'.
Aldrich, C. Anderson:
The Advisability of Breast Feeding, J. A. M. A. 135: 915, 1947.
Human milk still remains the best type of milk for young infants, although it probably is not always a complete food after the first few weeks. Breast milk has a definite preventive and therapeutic value. It is the safest milk for premature babies who are ma· ture enough to suckle at the breast. As a technique, breast feeding is probably the best method of providing gratification and a sense of security to the babies. But even in artificial feeding the mother can impart an adequate amount of that security in her manner of handling the infant. Contraindications include pathologic conditions in the breast or nipple and some disease processes in the mother. Minor objections to breast feeding can best be met during the antepartum care of the patient. WILLIAM BERMAN.
H. HoaE, M.D., F.A.C.S.,
RrcHMOND, VA.
(From the Department of Gynecology, llfi.Jdical College of Virginia)
HE constitutional type of precocious puberty is the most eommon type.1 Cases in which T the precocity is due to an ovarian tumor are less frequent, and the ovarian neoplasm in such cases is almost always a granulosa eel! tumor. In reviewing the literature L find only two cases in which what appeared to he a simplP eyst of the omry was thought to account for the precocity. One was a case reported by Lull,2 in which the lesion seemed to be a simple follicular cyst; the other ease was revorted by Mengert ," who Ktnted that the ovarian lesion may have been a follicular cyst. In the ease now reported below, a simple cyst of the ovary was present.
Case Report H. W., a Negro girl, was born on Jan. S, 19314 at full term with a normal delivery. She was thought to weigh 7 pounds at birth, was breast fed, walked at 9 months, and talked at 18 months. Dentition occurred at (i months. She had measles at 2 years, pertussis at 4 years, varicella at 5 yea1·s, and mumps at 6 years. 'l'here were four siblings. On May 26, 1937, when she was 6 years, 4 months olcl, she had vaginal bleeding for the first time. Three months before that she had had a vaginal discharge. Two months before the bleeding·, swelling of thf' brea~ts had been noted. The first episode of bleeding lasted four days. Bleeding subsequt>ntly recurred every twent.v-eight days, continuing to last four days each time, and was never wry free. However, for thre<' months before admission to the hospital she bled eontinuou~ly. Because of the bleeding she wa~ admittecl to the hospital on Aug. 29, 19:1R. At that time she was 7 years, 7 months old. She was well nourished, appeared in good health, and was large for her age. The breasts wPre preeociou~ly devPloped, and hair wa~ pre~ent on the mons pubis. There was a slight bloody rlischarge from the introitus. This orificf' was virginal. Rectal examination reveale!l an abnormal pelvis mass. An x-ray of the skull was normal. The sella turcica measured ll mm. in length and S mm. in height. Blood eount~ and urinalysis were normal. The \Vassermann rea<'tion was negatiw. The blood pressure was 100/50. The weight was 76 pounds, temperaturp 9R,6o F., pulse 110, ancl respirations 22. A preoperative diagnosis of preeoeious puberty, probahly tluP to a granulosa c·ell tumor of the ovary, was made. She was operated upon on ~ept. ti, JH:l)ol. An ovarian c•,yst rt>placecl the right ovary. It was thin·wallerl, fillea with thin fluid, and measured 10 rm. in cliameter. A right salpingo-oophorectomy was done. The appPnclix and n small left parovarian cyst were also removed. The tubes, uterus, and left ovary were recorded as being small. The right tube measured i by 0.4 ''Ill. The pathologist reported n corpus luteum cyst (Figs. 1 and 2). The patient's convalescence was uneventful. The follow-up was as follows: May 23, 1940 (aged 9 years): 'l'here was no bleeding since the operation. There were no complaints. A keloid of the scar was present. The hymen was intact. A normal infantile uterus was felt on rectal examination. The breasts were larger than normal for her age, and puhic hair was present, hut the development of both was less than prior to opera6on. Feb. 17, 1944 (aged 13 year~): Amenorrhea persisted until the age of 12 when menstruation occurred. She menstruated regularly every month since then, flowing five days. Moderate dysmenorrhea occurPd. The introitus was virginal. No abnormalities were found on rectal examination. 388
Volume 57 Number 2
PRECOCIOUS PUBERTY IN GIRLS
389
July 21, 1947 (aged 16¥.! years): The last menstrual period was April 6, 1947. Weight 116% pounds, height 60 inches, blood pressure 116/80. The uterus was soft and the size of a ten to twelve weeks' pregnancy.
On Dec, 30, 1947, this patient, lacking nine days of being 17 years old, entered St. Philip Hospital on the obstetrical service and was delivered at term on that day of her :first child. She was discharged from the hospital on Jan. 6, 1948.
F ig. 1.- Section of ovarian cyst in a case of precodous pubert y.
Fig. 2. -Precocious pu berty. Secti on uterine tube, ad ul t type.
Comments The precocious puberty in this case was obviously not due to a granulosa cell tumor, suspected preoperatively, nor was any true tumor of the ovary found. Nevertheless, consider· ing that a cyst with a diameter of 10 em. replaced the right ovary and that there was some regression of secondary sex characteristics postoperatively, it was regarded that this patient
HOGE
390
Am.]. Obst. & Gynec. February, 1949
had a form of precocious puberty due to the ovarian eyst. However, as this interpretation did not seem entirely satisfactory, Dr. Emil Novak was requested to give his views on the case. He reportss his belief that the ovarian condition was a cystic, hut normally functioning, corpus luteum, and that the ~a;;e is one of the constitutional type. He sugge>'ts that the subsequent amenorrhea was of the functional type whidt iB set>n not infrequently in normal girls in the pubertal or adolescent stage. Thus is reported a ease of ~exual preeocity as~oe.iated with an ovarian cy~t, but possihly of the constitutional type. It may be that Mengert 's and Lull's were similar to this case.
References 1. 2. 3. 4. 5.
Novak, E.: AM . .J. O:ssT. & GYNEC. 47: 20, 1944. Lull, C. B.: AM • .J. 0BST. & GYNEC. 41: 445, 1941. Mengert, W. F.: AM. J. 0BST. & GYNEC. 37: 485, 1939. Bureau of Vital Statistics, Richmond, Virginia. Novak, E.: Personal c-ommunication. 1200
EAST BROAD STREET
Hellma.D, L. M., and Vosburgh, G. R .. : Role of Transfusion in the Etiology .of Erythroblastosis, ,J. A. M.A. 136: 79, 1948. The authors wish to re-emphasize the fact that Rh compatibility should be determined for all women prior to transfusion and only Rh negative blood should be used in negative cases. They report cases of nine Rh-negative women who gave histories of previous blood transfusions and, as a result of the transfusions, the subsequent ehildbearing careers of these patients were gravely jeopardized. These nine women had had :five normal children prior to their transfusions but had only two normal infants thereafter. Both of these normal chil· dren botn after transfusion were Rh-negativl:', these women having heterozygous husbands. Wn,LTAM BERMAN'.
Aldrich, C. Anderson:
The Advisability of Breast Feeding, J. A. M. A. 135: 915, 1947.
Human milk still remains the best type of milk for young infants, although it probably is not always a complete food after the first few weeks. Breast milk has a definite preventive and therapeutic value. It is the safest milk for premature babies who are ma· ture enough to suckle at the breast. As a technique, breast feeding is probably the best method of providing gratification and a sense of security to the babies. But even in artificial feeding the mother can impart an adequate amount of that security in her manner of handling the infant. Contraindications include pathologic conditions in the breast or nipple and some disease processes in the mother. Minor objections to breast feeding can best be met during the antepartum care of the patient. WILLIAM BERMAN.