During the past decade, it has become clear that precocious puberty is a complex disorder with multiple pathophysiologic causes. Although gonadotropin-releasing hormone (GnRH)-dependent mechanisms account for the vast majority of precocious puberty in girls, GnRH-independent processes play an important role in a minority of patients. The recent availability of specific therapies for both GnRH-dependent and GnRH-independent precocious puberty has made it increasingly important for pediatricians to distinguish between these two subsets.1,2 Although most patients with precocious puberty neatly fall into one or the other subset, a significant minority of patients may present a diagnostic challenge even after an extensive evaluation is undertaken.

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