Female Pelvis: Precocious Puberty—Primary Amenorrhea

Part of the Medical Radiology book series (MEDRAD)


Puberty is induced by the activation of the hypothalamic gonadotropin-releasing hormone pulse generator. Puberty is defined by the age of menarche, pubertal onset by the development of breast buds. Menarche usually occurs 2–5 years after budding. Pelvic ultrasound is both simple and effective in pediatrics to assess the pubertal status and to contribute to the etiological workup of prepubertal bleeding and primary amenorrhea. Apart from isolated premature thelarche and isolated premature pubarche where pelvic ultrasound displays normal prepubertal features, pubertal precocities encompass the central precocious puberties (gonadotropin-dependent) and the peripheral precocious puberties (gonadotropin-independent) which are distinctive both on imaging and biology. Conversely pubertal delay and primary amenorrhea may be linked to numerous causes: uterine and ovarian sonographic characteristics allow for the rapid recognition of Turner syndrome, müllerian duct anomalies, abnormal sex differentiation, or ovarian tumors. Magnetic Resonance Imaging (MRI) is clearly indicated in Müllerian duct aplasia, in central precocious puberty and in the workup of hypothalamo–pituitary-related primary amenorrhea.


Turner Syndrome Precocious Puberty Gonadal Dysgenesis Central Precocious Puberty Primary Amenorrhea 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Doctor Garel expresses his deep gratitude to Ms Ginette Bleau for her expertise, availability, patience, and kindness in editing this chapter.


  1. Acién P, Acién MI (2011) The history of female genital tract malformation classifications and proposal of an updated system. Hum Reprod Update 17:693–705PubMedCrossRefGoogle Scholar
  2. Albanese G, Russ P, Schlaff WD (2011) Magnetic resonance imaging of Mullerian duct anomalies. Postgrad Obstet Gynecol 31:1–8Google Scholar
  3. Ambrosino MM, Hernanz-Schulman M, Genieser NB, Sklar CA, Fefferman NR, David R (1994) Monitoring of girls undergoing medical therapy for isosexual precocious puberty. J Ultrasound Med 13:501–508PubMedGoogle Scholar
  4. Badouraki M, Christoforidis A, Economou I, Dimitriadis AS, Katzos G (2008a) Sonographic assessment of uterine and ovarian development in normal girls aged 1–12 years. J Clin Ultrasound 36:539–544PubMedCrossRefGoogle Scholar
  5. Badouraki M, Christoforidis A, Economou I, Dimitriadis AS, Katzos G (2008b) Evaluation of pelvic ultrasonography in the diagnosis and differentiation of various forms of sexual precocity in girls. Ultrasound Obstet Gynecol 32:819–827PubMedCrossRefGoogle Scholar
  6. Battaglia C, Regnani G, Mancini F, Iughetti L, Venturoli S, Flamigni C (2002) Pelvic sonography and uterine artery color Doppler analysis in the diagnosis of female precocious puberty. Ultrasound Obstet Gynecol 19:386–391PubMedCrossRefGoogle Scholar
  7. Battaglia C, Mancini F, Regnani G, Persico N, Iughetti L, De Aloysio D (2003) Pelvic ultrasound and color Doppler findings in different isosexual precocities. Ultrasound Obstet Gynecol 22:277–283PubMedCrossRefGoogle Scholar
  8. Bermejo C, Ten Martínez P, Cantarero R, Diaz D, Pérez Pedregosa J, Barrón E, Labrador E, Ruiz López L (2010) Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 35:593–601PubMedCrossRefGoogle Scholar
  9. Breech LL, Laufer MR (2009) Müllerian anomalies. Obstet Gynecol Clin North Am 36:47–68PubMedCrossRefGoogle Scholar
  10. Bridges NA, Cooke A, Healy MJ, Hindmarsh PC, Brook CG (1993) Standards for ovarian volume in childhood and puberty. Fertil Steril 60:456–460PubMedGoogle Scholar
  11. Buzi F, Pilotta A, Dordoni D, Lombardi A, Zaglio S, Adlard P (1998) Pelvic ultrasonography in normal girls and in girls with pubertal precocity. Acta Paediatr 87:1138–1145PubMedCrossRefGoogle Scholar
  12. Caspi B, Zalel Y, Katz Z, Appelman Z, Insler V (1995) The role of sonography in the detection of vaginal foreign bodies in young girls: the bladder indentation sign. Pediatr Radiol 25(Suppl 1):S60–S61PubMedGoogle Scholar
  13. Chalumeau M, Chemaitilly W, Trivin C, Adan L, Bréart G, Brauner R (2002) Central precocious puberty in girls: an evidence-based diagnosis tree to predict central nervous system abnormalities. Pediatrics 109:61–67PubMedCrossRefGoogle Scholar
  14. Cisternino M, Arrigo T, Pasquino AM, Tinelli C, Antoniazzi F, Beduschi L, Bindi G, Borrelli P, De Sanctis V, Farello G, Galluzzi F, Gargantini L, Lo Presti D, Sposito M, Tató L (2000) Etiology and age incidence of precocious puberty in girls: a multicentric study. J Pediatr Endocrinol Metab 13(Suppl 1):695–701PubMedGoogle Scholar
  15. Cleemann L, Holm K, Fallentin E, Skouby SO, Smedegaard H, Møller N, Borch-Christensen H, Jeppesen EM, Wieslander SB, Andersson AM, Cohen A, Højbjerg Gravholt C (2011) Uterus and ovaries in girls and young women with Turner syndrome evaluated by ultrasound and magnetic resonance imaging. Clin Endocrinol (Oxf) 74:756–761CrossRefGoogle Scholar
  16. Cohen HL, Tice HM, Mandel FS (1990) Ovarian volumes measured by US: bigger than we think. Radiology 177:189–192PubMedGoogle Scholar
  17. Cohen HL, Eisenbert P, Mandel F, Haller JO (1992) Ovarian cysts are common in premenarchal girls: a sonographic study of 101 children 2–12 years old. AJR Am J Roentgenol 159:89–91PubMedGoogle Scholar
  18. Cohen HL, Shapiro MA, Mandel FS, Shapiro ML (1993) Normal ovaries in neonates and infants: a sonographic study of 77 patients 1 day–24 months old. AJR Am J Roentgenol 160:583–586PubMedGoogle Scholar
  19. Comstock CH, Boal DK (1984) Pelvic US of the pediatric patient. Semin Ultrasound CT MR 5:54–67Google Scholar
  20. de Vries L, Phillip M (2011a) Role of pelvic ultrasound in girls with precocious puberty. Horm Res Paediatr 75:148–152PubMedCrossRefGoogle Scholar
  21. de Vries L, Phillip M (2011b) Pelvic ultrasound examination in girls with precocious puberty is a useful adjunct in gonadotrophin-releasing hormone analogue therapy monitoring. Clin Endocrinol (Oxf) 75:372–377CrossRefGoogle Scholar
  22. de Vries L, Horev G, Schwartz M, Phillip M (2006) Ultrasonographic and clinical parameters for early differentiation between precocious puberty and premature thelarche. Eur J Endocrinol 154:891–898PubMedCrossRefGoogle Scholar
  23. Ferreira EC, Brito CC, Domingues RC, Bernardes M, Marchiori E, Gasparetto EL (2010) Whole-body MR imaging for the evaluation of McCune–Albright syndrome. 31:706–710Google Scholar
  24. Garel L, Dubois J, Grignon A, Filiatrault D, Van Vliet G (2001) US of the pediatric female pelvis: a clinical perspective. RadioGraphics 21:1393–1407PubMedGoogle Scholar
  25. Griffin IJ, Cole TJ, Duncan KA, Hollman AS, Donaldson MD (1995a) Pelvic ultrasound measurements in normal girls. Acta Paediatr 84:536–543PubMedCrossRefGoogle Scholar
  26. Griffin IJ, Cole TJ, Duncan KA, Hollman AS, Donaldson MD (1995b) Pelvic ultrasound findings in different forms of sexual precocity. Acta Paediatr 84:544–549PubMedCrossRefGoogle Scholar
  27. Grimbizis GF, Campo R (2010) Congenital malformations of the female genital tract: the need for a new classification system. Fertil Steril 94:401–407PubMedCrossRefGoogle Scholar
  28. Haber HP, Mayer EI (1994) Ultrasound evaluation of uterine and ovarian size from birth to puberty. Pediatr Radiol 24:11–13PubMedCrossRefGoogle Scholar
  29. Haber HP, Wollmann HA, Ranke MB (1995) Pelvic ultrasonography: early differentiation between isolated premature thelarche and central precocious puberty. Eur J Pediatr 154:182–186PubMedCrossRefGoogle Scholar
  30. Herter LD, Golendziner E, Flores JA, Becker E Jr, Spritzer PM (2002a) Ovarian and uterine sonography in healthy girls between 1 and 13 years old: correlation of findings with age and pubertal status. AJR Am J Roentgenol 178:1531–1536PubMedGoogle Scholar
  31. Herter LD, Golendziner E, Flores JA, Moretto M, Di Domenico K, Becker E Jr, Spritzer PM (2002b) Ovarian and uterine findings in pelvic sonography: comparison between prepubertal girls, girls with isolated thelarche, and girls with central precocious puberty. J Ultrasound Med 21:1237–1246PubMedGoogle Scholar
  32. Holm K, Laursen EM, Brocks V, Müeller J (1995) Pubertal maturation of the internal genitalia: an ultrasound evaluation of 166 healthy girls. Ultrasound Obstet Gynecol 6:175–181PubMedCrossRefGoogle Scholar
  33. Ivarsson SA, Nilsson KO, Persson PH (1983) Ultrasonography of the pelvic organs in prepubertal and postpubertal girls. Arch Dis Child 58:352–354PubMedCrossRefGoogle Scholar
  34. Jensen AM, Brocks V, Holm K, Laursen EM, Müller J (1998) Central precocious puberty in girls: internal genitalia before, during, and after treatment with long-acting gonadotropin-releasing hormone analogues. J Pediatr 132:105–108PubMedCrossRefGoogle Scholar
  35. Junqueira BL, Allen LM, Spitzer RF, Lucco KL, Babyn PS, Doria AS (2009) Müllerian duct anomalies and mimics in children and adolescents: correlative intraoperative assessment with clinical imaging. Radiographics 29:1085–1103PubMedCrossRefGoogle Scholar
  36. Kalfa N, Philibert P, Patte C, Thibaud E, Pienkowski C, Ecochard A, Boizet-Bonhoure B, Fellous M, Sultan C (2009) Juvenile granulosa-cell tumor: clinical and molecular expression. Gynecol Obstet Fertil 37:33–44PubMedCrossRefGoogle Scholar
  37. Khadilkar VV, Khadilkar AV, Kinare AS, Tapasvi HS, Deshpande SS, Maskati GB (2006) Ovarian and uterine ultrasonography in healthy girls between birth to 18 hears. Indian Pediatr 43:625–630PubMedGoogle Scholar
  38. King LR, Siegel MJ, Solomon AL (1993) Usefulness of ovarian volume and cysts in female isosexual precocious puberty. J Ultrasound Med 12:577–581PubMedGoogle Scholar
  39. Lee PA (2003) Puberty and its disorders. In: Lifshitz F (ed) Pediatric endocrinology, 4th edn. Marcel Dekker, New York, pp 211–238Google Scholar
  40. Lippe BM, Sample WF (1978) Pelvic ultrasonography in pediatric and adolescent endocrine disorders. J Pediatr 29:897–902Google Scholar
  41. Lumbroso S, Paris F, Sultan C; European Collaborative Study (2004) Activating Gsalpha mutations: analysis of 113 patients with signs of McCune–Albright syndrome—a European Collaborative Study. J Clin Endocrinol Metab 89:2107–2113CrossRefGoogle Scholar
  42. Marcal L, Nothaft MA, Coelho F, Volpato R, Iyer R (2011) Mullerian duct anomalies: MR imaging. Abdom Imaging 36:756–764PubMedCrossRefGoogle Scholar
  43. Martins WP, Nastri CO (2009) Ultrasonographic measurement of ovarian volume in the diagnosis of central precocious puberty. Ultrasound Obstet Gynecol 34:484–485PubMedCrossRefGoogle Scholar
  44. Massarano AA, Adams JA, Preece MA, Brook CG (1989) Ovarian ultrasound appearances in Turner syndrome. J Pediatr 114(4 Pt 1):568–573PubMedGoogle Scholar
  45. Mosfeldt Laursen E, Holm K, Brocks V, Jarden M, Müller J (1996) Doppler assessement of flow velocity in the uterine artery during pubertal maturation. Ultrasound Obstet Gynecol 8:341–345CrossRefGoogle Scholar
  46. Mueller GC, Hussain HK, Smith YR, Quint EH, Carlos RC, Johnson TD, DeLancey JO (2007) Müllerian duct anomalies: comparison of MRI diagnosis and clinical diagnosis. AJR Am J Roentgenol 189:1294–1302PubMedCrossRefGoogle Scholar
  47. Nussbaum AR, Sanders RC, Jones MD (1986) Neonatal uterine morphology as seen on real-time US. Radiology 160:641–643PubMedGoogle Scholar
  48. Oppelt P, Renner SP, Kellermann A, Brucker S, Hauser GA, Ludwig KS, Strissel PL, Strick R, Wallwiener D, Beckmann MW (2006) Clinical aspects of Mayer–Rokitansky–Kuester–Hauser syndrome: recommendations for clinical diagnosis and staging. Hum Reprod 21:792–797PubMedCrossRefGoogle Scholar
  49. Orbak Z, Sağsöz N, Alp H, Tan H, Yildirim H, Kaya D (1998) Pelvic ultrasound measurements in normal girls: relation to puberty and sex hormone concentration. J Pediatr Endocrinol Metab 11:525–530PubMedGoogle Scholar
  50. Orsini LF, Salardi S, Pilu G, Bovicelli L, Cacciari E (1984) Pelvic organs in premenarcheal girls: real-time ultrasonography. Radiology 153:113–116PubMedGoogle Scholar
  51. Pompili G, Munari A, Franceschelli G, Flor N, Meroni R, Frontino G, Fedele L, Cornalba G (2009) Magnetic resonance imaging in the preoperative assessment of Mayer–Rokitansky–Kuster–Hauser syndrome. Radiol Med 114:811–826PubMedCrossRefGoogle Scholar
  52. Razzghy-Azar M, Ghasemi F, Hallaji F, Ghasemi A, Ghasemi M (2010) Sonographic measurement of uterus and ovaries in premenarcheal healthy girls between 6 and 13 years old: correlation with age and pubertal status. J Clin Ultrasound 39:64–73CrossRefGoogle Scholar
  53. Rosenberg HK (2009) Sonography of the pelvis in patients with primary amenorrhea. Endocrinol Metab Clin North Am 38:739–760PubMedCrossRefGoogle Scholar
  54. Salardi S, Orsini LF, Cacciari E, Bovicelli L, Tassoni P, Reggiani A (1985) Pelvic ultrasonography in premenarcheal girls: relation to puberty and sex hormone concentrations. Arch Dis Child 60:120–125PubMedCrossRefGoogle Scholar
  55. Salardi S, Orsini LF, Cacciari E, Partesotti S, Brondelli L, Cicognani A, Frejaville E, Pluchinotta V, Tonioli S, Bovicelli L (1988) Pelvic ultrasonography in girls with precocious puberty, congenital adrenal hyperplasia, obesity, or hirsutism. J Pediatr 112:880–887PubMedCrossRefGoogle Scholar
  56. Sample WF, Lippe BM, Gyepes MT (1977) Gray-scale ultrasonography of the normal female pelvis. Radiology 125:477–483PubMedGoogle Scholar
  57. Sathasivam A, Rosenbert HK, Shapiro S, Wang H, Rapaport R (2011) Pelvic ultrasonography in the evaluation of central precocious puberty: comparison with leuprolide stimulation test. J Pediatr 159:490–495PubMedCrossRefGoogle Scholar
  58. Schoenfeld A, Ovadia Y, Laron Z (1990) US observations in girls with central precocious puberty before and during therapy with GnRH analogue. Adolesc Pediatr Gynecol 3:31–37Google Scholar
  59. Scully RE (1988) Juvenile granulosa cell tumor. Pediatr Pathol 8:423–427PubMedCrossRefGoogle Scholar
  60. Shawker TH, Comite F, Rieth KG, Dwyer AJ, Cutler GB Jr, Loriaux DL (1984) Ultrasound evaluation of female isosexual precocious puberty. J Ultrasound Med 3:309–316PubMedGoogle Scholar
  61. Spevak MR, Cohen HL (2002) Ultrasonography of the adolescent female pelvis. Ultrasound Q 18:275–288PubMedCrossRefGoogle Scholar
  62. Stanhope R, Adams J, Jacobs HS, Brook CG (1985) Ovarian ultrasound assessment in normal children, idiopathic precocious puberty, and during low dose pulsatile gonadotrophin releasing hormone treatment of hypogonadotrophic hypogonadism. Arch Dis Child 60:116–119PubMedCrossRefGoogle Scholar
  63. Stanhope R, Abdulwahid NA, Adams J, Brook CG (1986) Studies of gonadotrophin pulsatility and pelvic ultrasound examinations distinguish between isolated premature thelarche and central precocious puberty. Eur J Pediatr 145:190–194PubMedCrossRefGoogle Scholar
  64. States LJ, Bellah RD (1996) Imaging of the pediatric female pelvis. Semin Roentgenol 31:312–329PubMedCrossRefGoogle Scholar
  65. Stranzinger E, Strouse PJ (2008) Ultrasound of the pediatric female pelvis. Semin Ultrasound CT MR 29:98–113PubMedCrossRefGoogle Scholar
  66. Teele RL, Share JC (1992) Ultrasonography of the female pelvis in childhood and adolescence. Radiol Clin North Am 30:743–758PubMedGoogle Scholar
  67. Troiano RN, McCarthy SM (2004) Mullerian duct anomalies: imaging and clinical issues. Radiology 233:19–34PubMedCrossRefGoogle Scholar
  68. Vallerie AM, Breech LL (2010) Update in Müllerian anomalies: diagnosis, management, and outcomes. Curr Opin Obstet Gynecol 22:381–387 Google Scholar
  69. Ziereisen F, Heinrichs C, Dufour D, Saerens M, Avni EF (2001) The role of Doppler evaluation of the uterine artery in girls around puberty. Pediatr Radiol 31:712–719PubMedCrossRefGoogle Scholar
  70. Ziereisen F, Guissard G, Damry N, Avni EF (2005) Sonographic imaging of the paediatric female pelvis. Eur Radiol 15:1296–1309PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg  2012

Authors and Affiliations

  1. 1.Department of Medical ImagingCHU Sainte-JustineMontrealCanada
  2. 2.Department of Radiology, Faculty of MedicineUniversity of MontrealQuebecCanada

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