USMLE® Step 1 style questions USMLE
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A 6-year-old girl comes to the office for a routine examination. She was born at 37 weeks' gestation by vaginal delivery without complication. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 13/min, and her blood pressure is 97/58 mm Hg. Physical examination shows Tanner stage 3 breast development. A radiograph of the wrist is obtained and shows a bone age of 10 years. A leuprolide stimulation test shows no luteinizing hormone response. Which of the following is the most appropriate next step in the diagnosis of this patient?
Contributors:Sam Gillespie, BSc
Puberty is the time in an individual’s life when they physically become sexually mature and able to have children.
Precocious refers to puberty occurring at an earlier age than the average age among an individual’s peers.
Generally, puberty is considered precocious if it begins before the age of 8 in females and the age of 9 in males.
The hypothalamic-pituitary-gonadal axis is a system of hormone signaling between the hypothalamus, pituitary gland, and gonads, either the testes or ovaries, to control sexual development and reproduction.
Gonadotropin-releasing hormone is released by the hypothalamus into the hypophyseal portal system, which is a network of capillaries connecting the hypothalamus to the hypophysis, or pituitary.
When gonadotropin-releasing hormone reach the pituitary gland, it stimulates cells in the anterior pituitary, called gonadotrophs, to release gonadotropin hormones: luteinizing hormone and follicle-stimulating hormone into the blood.
These gonadotropin hormones then stimulate the gonads to produce specific steroids, sex hormones.
In addition, the Sertoli cells of the testes respond to follicle-stimulating hormone by producing more sperm.
The major sex specific hormones in women are estrogen and progesterone, and they are produced by the ovarian follicles that are scattered on the ovaries.
Each ovarian follicle is made up of a ring of granulosa and theca cells surrounding a primary oocyte at its core.
Beginning at puberty, theca cells respond to luteinizing hormone by producing androstenedione, an androgen.
Then, the granulosa cells respond to follicle stimulating hormone by converting the androstenedione into estrogen and progesterone.
The increased production of sex hormones drives the development of primary and secondary sex characteristic observed during puberty.
Primary sex characteristics refers to the genitals, organs directly involved in sexual reproduction.
Secondary sex characteristics refers to any sex-specific physical characteristic that is not directly involved or necessary in sexual reproduction, like pubic hair and breasts, in females.
The Tanner scale centers on two, independent criteria: the appearance of pubic hair in both sexes; and the increase in testicular volume and penile size and length in males, and breast development in females.
There are five stages: In stage 1, the prepubertal stage, no pubic hair is present in either sex. Males have a small penis and testes. Females have a flat-chest.
In stage 2, pubic hair appears; there is a measurable enlargement of the testes; and breast buds appear.
In stage 3, pubic hair becomes coarser; the penis begins to enlarge in both size and length; and breast mounds form.