Precocious puberty — branching viva

Opening framework

My framework rests on one decision: who is driving the axis? Precocious puberty is secondary sexual characteristics before 8 years in girls and before 9 years in boys. If the hypothalamic–pituitary–gonadal axis is genuinely switched on, the process is central (GnRH-dependent), gonadotropins rise, and a GnRH analog will switch it back off. If a sex-steroid source is operating outside the axis, the process is peripheral (GnRH-independent), gonadotropins are suppressed, and a GnRH analog is useless. I confirm with a bone age and a basal-then-stimulated gonadotropin panel, I image the brain in every boy and in girls under 6 years, and I match the treatment to the driver. The two preventable harms are a short adult stature from unchecked sex steroids and a missed central nervous system lesion. ^{[1] [2]}