Diagnostic Value of Pelvic and Transperineal Ultrasound in Girls with Central Precocious Puberty

Diagnostic Value of Pelvic and Transperineal Ultrasound in Girls with Central Precocious Puberty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Diagnostic Value of Pelvic and Transperineal Ultrasound in Girls with Central Precocious Puberty Sepideh Rahmati¹, Minasadat Mohajerzadeh², Maloud Saffari Rad³, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8220014/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Central precocious puberty (CPP) requires early and accurate diagnosis to prevent adverse physical and psychological consequences. Although the GnRH stimulation test is the diagnostic gold standard, it is invasive, time-consuming, and not readily available in all settings. Pelvic ultrasonography offers a practical non-invasive adjunct, but sonographic criteria vary considerably across populations. Moreover, estrogen-related changes in the vaginal mucosa—despite their diagnostic potential—have been largely overlooked. This study uniquely incorporates transperineal ultrasonography to measure vaginal mucosal and muscular thickness as novel markers for CPP. Methods: In this case–control study conducted from 2021 to 2023, 32 girls with CPP and 32 age-matched controls (all under 8 years) underwent transabdominal pelvic ultrasonography to assess uterine and ovarian dimensions, and transperineal ultrasound to measure vaginal mucosal and wall muscle thickness. Baseline characteristics were compared using Chi-square and Mann–Whitney U tests. ROC curve analysis was performed to determine optimal diagnostic cut-off values. Results: Girls with CPP showed significantly higher uterine length and uterine volume compared with controls. Vaginal mucosal thickness measured via transperineal ultrasound was also significantly increased in the CPP group, highlighting its diagnostic potential. ROC analysis identified uterine length (AUC = 0.747; 26.5 mm) as the strongest discriminator, followed by uterine volume (AUC = 0.734), right ovary width (AUC = 0.724), and right ovary volume (AUC = 0.723). Conclusions: Both transabdominal and transperineal ultrasonography provide valuable non-invasive tools for evaluating girls suspected of CPP. The introduction of vaginal mucosal assessment via transperineal imaging represents a novel diagnostic approach that may improve early identification of CPP, particularly in settings with limited access to GnRH testing. Larger population-based studies are recommended to refine ultrasonographic cut-off values. Figures Figure 1 Introduction Central precocious puberty (CPP) is defined as the onset of secondary sexual characteristics in girls before the age of 8 years, resulting from the premature activation of the hypothalamic-pituitary-gonadal (HPG) axis [1]. This condition poses significant challenges, including reduced final adult height due to premature epiphyseal fusion, psychological distress, and potential long-term health risks such as an increased susceptibility to metabolic syndrome and hormone-sensitive cancers [2, 3]. The timely and accurate diagnosis of CPP is therefore paramount to initiating appropriate treatment with GnRH agonists, which can effectively halt pubertal progression and ameliorate these adverse outcomes. The current diagnostic gold standard for CPP is the gonadotropin-releasing hormone (GnRH) stimulation test, which measures the pituitary response of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) [4]. Despite its diagnostic accuracy, the GnRH test is fraught with limitations. It is an invasive procedure requiring serial blood draws, is time-consuming (taking several hours), costly, and not readily available in all clinical settings [5]. These drawbacks highlight an urgent need for reliable, accessible, and non-invasive adjunctive tools to aid in the initial evaluation and triage of patients suspected of having CPP. Pelvic ultrasonography has emerged as a promising, non-invasive, and cost-effective modality for assessing pubertal status. It provides direct anatomical visualization of the uterus and ovaries, which are primary target organs for estrogen. In girls with CPP, rising estrogen levels lead to measurable changes in pelvic structures, including an increase in uterine volume and length, ovarian volume, and the presence of endometrial lining [6, 7]. Numerous studies have sought to establish sonographic criteria for differentiating CPP from premature thelarche (PT) or prepubertal states. For instance: Calcaterra et al. (2020) demonstrated that a model combining basal LH levels and pelvic ultrasound parameters (uterine length > 3.5 cm, transverse diameter > 1.5 cm, ovarian volume > 2 ml) had a sensitivity and specificity of 85% for identifying rapidly progressive CPP, suggesting its utility in selecting patients for the GnRH test [8]. Lee et al. (2016) identified uterine volume as a key discriminator, proposing a cutoff of > 3.4 ml to differentiate CPP from PT, although they found other parameters less useful [9]. Wen et al. (2018) concluded that pelvic ultrasound is a valuable tool for diagnosing and differentiating various forms of precocious puberty, with parameters like cervical thickness and endometrial thickness being particularly discriminative in specific age groups [10]. Yuan et al. (2020) developed a diagnostic model based on transrectal pelvic ultrasound and basal gonadotropin levels, achieving a sensitivity of 84.9% and specificity of 86.2% for idiopathic CPP [11]. However, the literature is marked by a lack of consensus. The proposed sonographic cut-off values vary considerably across different studies and populations [9, 12]. This heterogeneity can be attributed to factors such as ethnic and geographic variations in pubertal timing, differences in ultrasound techniques (transabdominal vs. transrectal), and small sample sizes in some studies. Furthermore, while most research has focused on uterine and ovarian morphology, the potential diagnostic value of assessing estrogen-induced changes in the vaginal tissue has been largely overlooked. The vaginal mucosa undergoes significant histological changes during puberty, becoming thicker and more glycogen-rich under the influence of estrogen [13, 14]. Transperineal ultrasonography offers a unique, non-invasive window to quantify these changes by measuring the thickness of the vaginal mucosa and the underlying myometrium. To the best of our knowledge, the combined use of standard pelvic ultrasonography with transperineal assessment of vaginal parameters has not been systematically investigated for the diagnosis of CPP. Therefore, this study was designed to comprehensively evaluate the diagnostic value of a wide range of sonographic parameters—including those of the uterus, ovaries, and, innovatively, the vaginal mucosa obtained via transperineal ultrasound—in girls with CPP compared to age-matched prepubertal controls. Our primary aim was to identify the most accurate sonographic criteria and to establish population-specific cut-off values that can serve as a reliable, non-invasive tool for the diagnosis of central precocious puberty in girls. Methods and Material This case-control study was conducted from 2021 to 2023. The case group included 32 girls under 8 years of age who were referred by their parents to the pediatric endocrinology clinic in Bojnurd due to the appearance of secondary sexual characteristics (pubic hair growth and breast enlargement), as well as girls under 8 who were referred for other reasons such as growth assessment, thyroid issues, and obesity, in whom precocious puberty was detected during examination. Height, weight, BMI, and Tanner stage were assessed, and then they were referred to the project's radiologist. The required sample size for the study was determined using a proportion estimation formula, considering sensitivity = 0.86 and specificity = 0.80 from previous studies, precision = 0.10, and a type I error of 0.05%, resulting in 32 participants per group. The control group also consisted of 32 girls under 8 years of age who visited the pediatric endocrinology clinic for check-ups or other reasons and had no signs of precocious puberty. Additionally, by referring to kindergartens and elementary schools, girls aged 6 to 8 years who showed no clinical signs of precocious puberty upon examination by an endocrinologist were referred to the project's radiologist. Cases whose pelvic and breast ultrasound parameters fell within the pubertal range according to similar studies were excluded from the control group. All participants in both groups underwent transabdominal pelvic ultrasound (using a Samsung WS80 device with a curve probe and frequency of 1–7 MHz) with a full bladder. The length, width, height, and volume of the uterus and ovaries were measured. Additionally, transperineal ultrasound (using a Samsung WS80 device with a linear probe and frequency of 3–12 MHz) was used to measure the thickness of the vaginal mucosa and the thickness of the vaginal wall muscle. The obtained measurements of the uterus and ovaries from the case group were then compared with those of the control group (girls under 8 years without secondary sexual characteristics, with similar age range, BMI, and nutritional status). After data collection and necessary controls, the information was entered into a computer and analyzed using SPSS software version 24. Descriptive statistics such as percentage, ratio, mean, and standard deviation were used, along with appropriate statistical tests like Chi-square and Fisher's exact tests (for qualitative variables) and Mann-Whitney U test (for quantitative variables). The results were analyzed with a 95% confidence level. Additionally, Receiver Operating Characteristic (ROC) curves were used to determine the best cut-off points, and the sensitivity and specificity of each point were calculated. Results The study sample consisted of 64 girls under 8 years of age, with 32 girls showing signs of puberty as the case group and 32 girls without secondary sexual characteristics as the control group. Table 1 compares baseline information (qualitative variables) between the case and control groups using Chi-square and Fisher's exact tests. The results showed no statistically significant differences between the two groups in terms of maternal education (p=1), paternal education (p=0.13), maternal occupation (p=0.27), paternal occupation (p=0.8), term birth (p=0.69), type of delivery (p=0.3), exposure to age-inappropriate media (p=0.5), history of specific diseases (adrenal and thyroid diseases, and birth defects) (p=0.5), soy consumption (p=0.69), and peanut consumption (p=0.74). A statistically significant difference was found in dairy consumption (p=0.016), which was higher in the control group than in the case group. An inverse relationship was observed between dairy consumption and precocious puberty in the studied sample. Table 1. Personal Information (Qualitative Variables) of Case and Control Groups Variable Category Case Group Frequency (%) Control Group Frequency (%) p-value Maternal Education High School Diploma or Less 11 (34.4%) 11 (34.4%) 1 University Education 21 (65.6%) 21 (65.6%) Paternal Education High School Diploma or Less 17 (53.1%) 11 (34.4%) 0.13 University Education 15 (46.9%) 21 (65.6%) Maternal Occupation Homemaker 25 (78.1%) 21 (65.6%) 0.27 Employed 7 (21.9%) 11 (34.4%) Paternal Occupation Self-Employed 15 (46.9%) 14 (43.8%) 0.8 Employee 17 (53.1%) 18 (56.3%)* Dairy Consumption <3 Units/Day 29 (90.6%) 21 (65.6%) 0.016 ≥3 Units/Day 3 (9.4%) 11 (34.4%) Soy Consumption <500 g 30 (93.8%) 30 (93.8%) 0.69 ≥500 g 2 (6.3%) 2 (6.3%) Peanut Consumption <500 g 30 (93.8%) 25 (78.1%) 0.74 ≥500 g 2 (6.3%) 7 (21.9%) Preterm Birth Yes 2 (6.3%) 2 (6.3%) 0.69 No 30 (93.8%) 30 (93.8%) Type of Delivery Cesarean 10 (31.3%) 14 (43.8%) 0.3 Vaginal 22 (68.8%) 18 (56.3%) Exposure to Age-Inappropriate Media Yes 1 (3.1%) 0 (0%) 0.5 No 31 (96.9%) 32 (100%) History of Specific Past Diseases Yes 0 (0%) 1 (3.1%) 0.5 No 32 (100%) 31 (96.9%) Note: *p-value <0.05 indicates statistical significance (bolded).* Chi-square test was used for analysis. Table 2. Quantitative Information of Case and Control Groups Variable Case Group Mean (SD) Control Group Mean (SD) p-value Age (years) 7.17 (0.82) 6.86 (0.86) 0.12 Number of children in family 2.00 (0.56) 1.94 (0.43) 0.63 Birth order 1.53 (0.62) 1.50 (0.56) 0.90 Maternal age at puberty (years) 12.75 (1.21) 12.63 (1.07) 0.86 Birth weight (grams) 3244.70 (362.28) 3290.70 (273.06) 0.94 Birth length (cm) 50.81 (1.59) 51.27 (1.80) 0.31 Birth head circumference (cm) 34.86 (0.81) 34.94 (0.77) 0.79 Current weight (kg) 25.83 (6.60) 24.71 (6.60) 0.33 Current height (cm) 125.30 (10.93) 124.67 (7.74) 0.51 BMI (kg/m²) 16.26 (2.67) 15.87 (3.58) 0.16 Paternal height (cm) 173.69 (5.78) 176.06 (7.27) 0.94 Maternal height (cm) 158.41 (5.43) 161.06 (6.08) 0.56 Analysis performed using the Mann-Whitney U Test . *All p-values > 0.05 indicate no statistically significant differences between the two groups for any of these quantitative variables.* Table 2 compares quantitative variables between the two groups using the Mann-Whitney U test. No statistically significant differences were found between the two groups in terms of maternal age at puberty (p=1), birth weight (p=1), birth length (p=1), birth head circumference (p=1), current weight (p=1), current height (p=1), BMI (p=1), paternal height (p=1), and maternal height (p=1). Table 3. Ultrasound Measurement Criteria in Case and Control Groups Variable Case Group Mean (SD) Control Group Mean (SD) p-value Uterine Length (mm) 31.46 (8.77) 26.28 (2.96) 0.001 Uterine Height (mm) 7.60 (4.94) 5.13 (1.92) 0.003 Uterine Width (mm) 11.44 (6.70) 8.10 (3.05) 0.004 Uterine Volume (cm³) 2.93 (8.31) 0.71 (0.59) 0.01 Right Ovary Length (mm) 24.28 (5.44) 20.06 (5.05) 0.03 Right Ovary Height (mm) 10.25 (2.97) 8.29 (2.53) <0.001 Right Ovary Width (mm) 13.22 (3.20) 34.94 (0.77)* 0.002 Left Ovary Length (mm) 23.37 (5.05) 20.03 (4.83) 0.012 Left Ovary Height (mm) 10.53 (3.52) 8.32 (1.88) 0.003 Left Ovary Width (mm) 11.92 (3.46) 10.57 (3.09) 0.041 Left Ovary Volume (cm³) 2.01 (1.60) 1.15 (0.88) <0.001 Endometrial Thickness (mm) 0.81 (1.98) 0.06 (0.25) 0.001 Cervical Length (mm) 14.31 (3.08) 14.53 (3.04) 0.823 Uterine Body Length (mm) 16.44 (8.38) 12.31 (2.92) 0.004 Uterine Body-to-Cervix Ratio 1.19 (0.62) 0.89 (0.33) 0.031 Anteroposterior Cervical Diameter (mm) 6.90 (2.82) 5.68 (1.05) 0.003 Vaginal Mucosa Thickness (mm) 0.89 (0.32) 0.68 (0.26) 0.006 Vaginal Wall Muscle Thickness (mm) 1.16 (0.40) 1.10 (0.34) 0.647 Vaginal Mucosa-to-Muscle Thickness Ratio 0.81 (0.30) 0.64 (0.25) 0.317 Note: The value "34.94 (0.77)" for Right Ovary Width in the Control Group appears inconsistent with other ovarian measurements and may represent a data entry error. This value is more characteristic of head circumference measurements than ovarian width. Bold p-values indicate statistically significant differences (p < 0.05) Analysis performed using the Mann-Whitney U Test Table 3 compares pelvic and transperineal ultrasound criteria between the case and control groups. The results showed significant differences in all ultrasound criteria between the two groups, except for cervical length (p=0.823), vaginal wall muscle thickness (p=0.647), and the ratio of vaginal mucosa thickness to muscle thickness (p=0.317), which showed no significant differences. To evaluate the overall diagnostic value of ultrasonographic parameters for differentiating precocious puberty from normal and to determine the optimal positive cut-off point for each diagnostic ultrasound parameter, Receiver Operating Characteristic (ROC) curve analysis was employed. The Area Under the Curve (AUC) represents the overall accuracy of each test. Among the parameters, uterine length was identified as the best predictor (AUC = 0.747), followed by uterine volume (AUC = 0.734), right ovarian width (AUC = 0.724), and right ovarian volume (AUC = 0.723). For uterine length, a cut-off value of 26.5 mm yielded a sensitivity of 78% and a specificity of 68%. At 27.5 mm, the sensitivity and specificity were both 68%, while at 28.5 mm, the sensitivity was 56% with a specificity of 81%. Since ultrasound is primarily used as a screening tool where high sensitivity is prioritized over specificity, the value of 26.5 mm was selected as the optimal cut-off for uterine length to distinguish precocious puberty from normal. For uterine volume, a cut-off of 0.60 mL demonstrated a sensitivity of 75% and a specificity of 68%. At 0.63 mL, the sensitivity was 71% with a specificity of 71%. Consequently, 0.60 mL was determined to be the suitable cut-off value for uterine volume in predicting central precocious puberty in girls. Regarding right ovarian width, a cut-off of 11.5 mm resulted in a sensitivity of 65% and a specificity of 62%. At 12.5 mm, the sensitivity was 62% with a specificity of 81%. Thus, 11.5 mm was chosen as the appropriate cut-off for right ovarian width to predict central precocious puberty. For right ovarian volume, a cut-off of 1.09 mL provided a sensitivity of 71% and a specificity of 56%. At 1.15 mL, the sensitivity was 62% with a specificity of 65%, and at 1.22 mL, the sensitivity was 56% with a specificity of 68%. Therefore, 1.09 mL was established as the optimal cut-off for right ovarian volume to differentiate precocious puberty from normal. Table 4. Results of ROC Curve Analysis Variable Area Under Curve (AUC) Measured Value Lower Bound Upper Bound Sensitivity Specificity Uterine Length (mm) 0.747 26.5 0.626 0.867 69% 69% 27.5 28.5 Uterine Volume (cm³) 0.734 0.60 0.608 0.859 71% 71% 0.63 0.67 Right Ovary Width (mm) 0.724 11.5 0.599 0.848 65% 62% 12.5 Right Ovary Volume (cm³) 0.723 1.09 0.599 0.848 62% 65% 1.15 1.22 Table 4: Results of ROC Curve Analysis for Diagnostic Parameters of Central Precocious Puberty Variable Area Under Curve (AUC) Cut-off Value Lower Bound Upper Bound Sensitivity Specificity Uterine Length (mm) 0.747 26.5 0.626 0.867 78% 68% 27.5 68% 68% 28.5 56% 81% Uterine Volume (cm³) 0.734 0.60 0.608 0.859 75% 68% 0.63 71% 71% 0.67 68% 71% Right Ovarian Width (mm) 0.724 11.5 0.599 0.848 65% 62% 12.5 62% 81% Right Ovarian Volume (cm³) 0.723 1.09 0.599 0.848 71% 56% 1.15 62% 65% 1.22 Discussion In 2019, Calcaterra et al. conducted a study in Italy on 177 girls with precocious puberty. They suggested that a diagnostic model incorporating at least three hormonal and ultrasonographic criteria (including LH level, estradiol level, uterine length, uterine width, and ovarian volume) could be effective in selecting patients who require a GnRH stimulation test for diagnosing precocious puberty. Similarly, our study identifies ultrasonography as a useful auxiliary diagnostic method for precocious puberty in girls, with uterine length determined to be the best ultrasonographic parameter (13). Yuan et al. (2020) developed a diagnostic model based on basal serum LH levels and transrectal ultrasonographic parameters. Our study also supports the use of ultrasonography as a beneficial auxiliary diagnostic tool for precocious puberty in girls (11). In a 2018 study by Wan et al. on 47 girls with Central Precocious Puberty (CPP), pelvic ultrasonography was proposed as a suitable method for diagnosing CPP in girls, which corroborates the findings of our present study (10). Lee et al. (2016) reported that uterine volume was greater in girls with CPP compared to those with premature thelarche, while other parameters showed no significant difference between the two groups. In our study, uterine volume was also identified as the second most suitable parameter for predicting CPP (12). Kaplowitz et al. (2016) indicated that pelvic ultrasonography can be effective in diagnosing CPP in girls, as increased ovarian and uterine volumes are key diagnostic factors. This finding aligns with our study (24). A 2011 study in Turkey by Ilmaz et al. on 125 girls with precocious puberty reported that nearly all pelvic ultrasonographic parameters were significantly increased in girls under 8 years with precocious puberty compared to both the control group and girls with premature thelarche. This consistency strengthens our own findings (21). In his research, Haber identified uterine volume as a diagnostic criterion for precocious puberty with 100% sensitivity and specificity. Our study also recognized uterine volume as the second most suitable parameter, albeit with a sensitivity of 75% and specificity of 68% (22). Zarei et al. (2023) conducted a study in Tehran (2015–2019) involving 183 participants. They reported significant differences in most ultrasonographic parameters in girls with CPP, except for the anteroposterior diameter of the cervix and ovarian volume. They identified uterine volume as the best predictive parameter, followed by uterine width and the fundus-to-cervix ratio, for predicting CPP. They also endorsed pelvic ultrasonography as a useful auxiliary method, noting that the optimal diagnostic criteria and cut-off values may vary based on ethnicity and study type. Our study similarly found uterine volume to be the second-best predictive parameter. However, in contrast to Zarei et al.'s findings which showed no statistically significant difference in ovarian volume, our study identified right ovarian volume as the fourth diagnostic parameter for precocious puberty (26). A 2018 study by Kharoshi et al. in Mashad on 15 girls with CPP suggested that the best criteria for diagnosing CPP were right ovarian volume (cut-off 1.35 ml), followed by uterine volume (cut-off 1.65 ml), and then uterine length (cut-off 31.5 mm). Our study determined the best ultrasonographic criteria to be uterine length (cut-off 26.5 mm), followed by uterine volume (cut-off 0.6 ml), right ovarian width (cut-off 11.5 mm), and then right ovarian volume (cut-off 1.09 ml). This shows notable similarity in the identified best parameters and the obtained cut-off values, despite slight variations (20). Sathasivam et al. (2011), in a study based on pelvic ultrasonography of 50 girls aged 3.1–9.5 years, concluded that ultrasonography alone is not a suitable method for diagnosing precocious puberty in girls. They recommended that ultrasonographic criteria should be used alongside laboratory criteria for diagnosis (23). Conclusion Precocious puberty can have significant physical and psychological consequences. However, timely diagnosis and treatment can prevent these adverse outcomes. Currently, the GnRH stimulation test is the standard diagnostic test for CPP. Considering its limitations and invasive nature, transabdominal and transperineal ultrasonography can be considered as non-invasive, cost-effective, and auxiliary methods for diagnosing precocious puberty in girls. Recommendations: There is currently no universally agreed-upon value for ultrasonographic measurements in diagnosing precocious puberty in girls. This may be due to different measurement techniques and variations in study populations. Furthermore, ethnicity and geographical characteristics might influence these criteria. These issues highlight the importance of conducting further research with larger sample sizes, including within our own country, to establish precise ultrasonographic criteria with appropriate cut-off values for diagnosing precocious puberty in girls. Very limited research has been conducted in this field in our country, making this study one of the pioneering investigations in this area nationally. It is also recommended that measurements using the transperineal ultrasonography method be further investigated with larger sample sizes and in more studies. Abbreviations CPP Central Precocious Puberty US Ultrasound Declarations Acknowledgment: Ethics approval and consent to participate Ethics approval was obtained from the IRB of [IR.NKUMS.REC.1400.167], approval number [4000181]. Written informed consent was obtained from parents or legal guardians. Consent for publication Not applicable Funding The authors declare that no funding was received for this study. Ethics approval and consent to participate Ethics approval was obtained from the Institutional Review Board (IRB) of North Khorasan University of Medical Sciences (IR.NKUMS.REC.1400.167), approval number 4000181. This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the parents or legal guardians of all participants. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors declare that no funding was received for this study. Authors’ contributions Sepideh Rahmati contributed to the study design, data collection, data analysis, and manuscript drafting. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all participants and their parents or legal guardians for their cooperation in this study. This article is derived from the research project of Dr. Sepideh Rahmati. I extend my sincere gratitude and appreciation to the esteemed professors, Dr. Maulood Safari Rad and Dr. Minasadat Mohajerzadeh, for their valuable guidance and support. References Yildiz AE, Elhan AH, Fitoz S. Prevalence and sonographic features of ectopic thyroidal thymus in children: A retrospective analysis. Journal of Clinical Ultrasound . 2018;46(6):375-379. Heras V, Castellano JM, Fernandois D, Velasco I, Rodríguez-Vazquez E, Roa J, et al. Central Ceramide Signaling Mediates Obesity-Induced Precocious Puberty. Cell Metabolism . 2020;32(6):951-966.e8. Harroud A, Morris JA, Forgetta V, Mitchell R, Smith GD, Sawcer SJ, et al. Effect of age at puberty on risk of multiple sclerosis: A mendelian randomization study. 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Badouraki M, Christoforidis A, Economou I, Dimitriadis AS, Katzos G. Evaluation of pelvic ultrasonography in the diagnosis and differentiation of various forms of sexual precocity in girls. Ultrasound in Obstetrics & Gynecology . 2008;32(6):819-827. Zarei E, Rakhshankhah N, Khodadost M, Abouie A, Mohammadnejad K, Vafadar M. Effectiveness of Pelvic Ultrasonography in the Diagnosis of Central Precocious Puberty and Its Differentiation from Similar Conditions. Iranian Journal of Radiology . 2022;19(4):e129295 Additional Declarations No competing interests reported. Supplementary Files file.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 13 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers invited by journal 30 Jan, 2026 Editor assigned by journal 27 Jan, 2026 Editor invited by journal 16 Dec, 2025 Submission checks completed at journal 12 Dec, 2025 First submitted to journal 12 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8220014","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583115447,"identity":"becc81db-66a0-49e0-82ca-1e2900fe2c5b","order_by":0,"name":"Sepideh Rahmati¹","email":"data:image/png;base64,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","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sepideh","middleName":"","lastName":"Rahmati¹","suffix":""},{"id":583115448,"identity":"ab6d8920-24a8-429f-a3fb-683822069d77","order_by":1,"name":"Minasadat Mohajerzadeh²","email":"","orcid":"","institution":"North Khorasan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Minasadat","middleName":"","lastName":"Mohajerzadeh²","suffix":""},{"id":583115449,"identity":"12d966a4-2c9e-44fd-b13d-d9c80fef8f82","order_by":2,"name":"Maloud Saffari Rad³","email":"","orcid":"","institution":"North Khorasan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Maloud","middleName":"Saffari","lastName":"Rad³","suffix":""},{"id":583115450,"identity":"3eab7446-3c63-4157-8600-fa20af9acb41","order_by":3,"name":"Hassan saadati","email":"","orcid":"","institution":"North Khorasan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hassan","middleName":"","lastName":"saadati","suffix":""},{"id":583115451,"identity":"7b132bb8-72a2-4600-8dc2-83d864668abc","order_by":4,"name":"Sara Rahmati","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Rahmati","suffix":""}],"badges":[],"createdAt":"2025-11-27 09:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8220014/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8220014/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101789857,"identity":"915165cd-12fd-4366-b7ba-7e5e17be4294","added_by":"auto","created_at":"2026-02-03 16:02:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80741,"visible":true,"origin":"","legend":"\u003cp\u003eROC curves for uterine length, uterine volume, right ovary width, and right ovary volume\u003c/p\u003e\n\u003cp\u003ea)ROC curve for uterine length criterion\u003c/p\u003e\n\u003cp\u003eb)ROC curve for uterine volume criterion\u003c/p\u003e\n\u003cp\u003ec)ROC curve for right ovary width criterion\u003c/p\u003e\n\u003cp\u003ed)ROC curve for right ovary volume criterion\u003c/p\u003e","description":"","filename":"file.png","url":"https://assets-eu.researchsquare.com/files/rs-8220014/v1/34eb35e5d09c62cde2a44454.png"},{"id":101789909,"identity":"cfe722e8-00dd-4abf-a835-85dceff04880","added_by":"auto","created_at":"2026-02-03 16:02:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1667800,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8220014/v1/362da42a-cb2b-4957-a8fc-9f8283fa74d1.pdf"},{"id":101789858,"identity":"808098b0-c905-4fdf-90cf-e8b729bd4364","added_by":"auto","created_at":"2026-02-03 16:02:25","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":101156,"visible":true,"origin":"","legend":"","description":"","filename":"file.docx","url":"https://assets-eu.researchsquare.com/files/rs-8220014/v1/026d953f11f32375828375d9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Value of Pelvic and Transperineal Ultrasound in Girls with Central Precocious Puberty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCentral precocious puberty (CPP) is defined as the onset of secondary sexual characteristics in girls before the age of 8 years, resulting from the premature activation of the hypothalamic-pituitary-gonadal (HPG) axis [1]. This condition poses significant challenges, including reduced final adult height due to premature epiphyseal fusion, psychological distress, and potential long-term health risks such as an increased susceptibility to metabolic syndrome and hormone-sensitive cancers [2, 3]. The timely and accurate diagnosis of CPP is therefore paramount to initiating appropriate treatment with GnRH agonists, which can effectively halt pubertal progression and ameliorate these adverse outcomes.\u003c/p\u003e \u003cp\u003eThe current diagnostic gold standard for CPP is the gonadotropin-releasing hormone (GnRH) stimulation test, which measures the pituitary response of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) [4]. Despite its diagnostic accuracy, the GnRH test is fraught with limitations. It is an invasive procedure requiring serial blood draws, is time-consuming (taking several hours), costly, and not readily available in all clinical settings [5]. These drawbacks highlight an urgent need for reliable, accessible, and non-invasive adjunctive tools to aid in the initial evaluation and triage of patients suspected of having CPP.\u003c/p\u003e \u003cp\u003ePelvic ultrasonography has emerged as a promising, non-invasive, and cost-effective modality for assessing pubertal status. It provides direct anatomical visualization of the uterus and ovaries, which are primary target organs for estrogen. In girls with CPP, rising estrogen levels lead to measurable changes in pelvic structures, including an increase in uterine volume and length, ovarian volume, and the presence of endometrial lining [6, 7]. Numerous studies have sought to establish sonographic criteria for differentiating CPP from premature thelarche (PT) or prepubertal states. For instance:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCalcaterra et al. (2020)\u003c/b\u003e demonstrated that a model combining basal LH levels and pelvic ultrasound parameters (uterine length\u0026thinsp;\u0026gt;\u0026thinsp;3.5 cm, transverse diameter\u0026thinsp;\u0026gt;\u0026thinsp;1.5 cm, ovarian volume\u0026thinsp;\u0026gt;\u0026thinsp;2 ml) had a sensitivity and specificity of 85% for identifying rapidly progressive CPP, suggesting its utility in selecting patients for the GnRH test [8].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eLee et al. (2016)\u003c/b\u003e identified uterine volume as a key discriminator, proposing a cutoff of \u0026gt;\u0026thinsp;3.4 ml to differentiate CPP from PT, although they found other parameters less useful [9].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eWen et al. (2018)\u003c/b\u003e concluded that pelvic ultrasound is a valuable tool for diagnosing and differentiating various forms of precocious puberty, with parameters like cervical thickness and endometrial thickness being particularly discriminative in specific age groups [10].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eYuan et al. (2020)\u003c/b\u003e developed a diagnostic model based on transrectal pelvic ultrasound and basal gonadotropin levels, achieving a sensitivity of 84.9% and specificity of 86.2% for idiopathic CPP [11].\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eHowever, the literature is marked by a lack of consensus. The proposed sonographic cut-off values vary considerably across different studies and populations [9, 12]. This heterogeneity can be attributed to factors such as ethnic and geographic variations in pubertal timing, differences in ultrasound techniques (transabdominal vs. transrectal), and small sample sizes in some studies. Furthermore, while most research has focused on uterine and ovarian morphology, the potential diagnostic value of assessing estrogen-induced changes in the vaginal tissue has been largely overlooked.\u003c/p\u003e \u003cp\u003eThe vaginal mucosa undergoes significant histological changes during puberty, becoming thicker and more glycogen-rich under the influence of estrogen [13, 14]. Transperineal ultrasonography offers a unique, non-invasive window to quantify these changes by measuring the thickness of the vaginal mucosa and the underlying myometrium. To the best of our knowledge, the combined use of standard pelvic ultrasonography with transperineal assessment of vaginal parameters has not been systematically investigated for the diagnosis of CPP.\u003c/p\u003e \u003cp\u003eTherefore, this study was designed to comprehensively evaluate the diagnostic value of a wide range of sonographic parameters\u0026mdash;including those of the uterus, ovaries, and, innovatively, the vaginal mucosa obtained via transperineal ultrasound\u0026mdash;in girls with CPP compared to age-matched prepubertal controls. Our primary aim was to identify the most accurate sonographic criteria and to establish population-specific cut-off values that can serve as a reliable, non-invasive tool for the diagnosis of central precocious puberty in girls.\u003c/p\u003e"},{"header":"Methods and Material","content":"\u003cp\u003eThis case-control study was conducted from 2021 to 2023. The case group included 32 girls under 8 years of age who were referred by their parents to the pediatric endocrinology clinic in Bojnurd due to the appearance of secondary sexual characteristics (pubic hair growth and breast enlargement), as well as girls under 8 who were referred for other reasons such as growth assessment, thyroid issues, and obesity, in whom precocious puberty was detected during examination. Height, weight, BMI, and Tanner stage were assessed, and then they were referred to the project's radiologist. The required sample size for the study was determined using a proportion estimation formula, considering sensitivity\u0026thinsp;=\u0026thinsp;0.86 and specificity\u0026thinsp;=\u0026thinsp;0.80 from previous studies, precision\u0026thinsp;=\u0026thinsp;0.10, and a type I error of 0.05%, resulting in 32 participants per group.\u003c/p\u003e \u003cp\u003eThe control group also consisted of 32 girls under 8 years of age who visited the pediatric endocrinology clinic for check-ups or other reasons and had no signs of precocious puberty. Additionally, by referring to kindergartens and elementary schools, girls aged 6 to 8 years who showed no clinical signs of precocious puberty upon examination by an endocrinologist were referred to the project's radiologist. Cases whose pelvic and breast ultrasound parameters fell within the pubertal range according to similar studies were excluded from the control group.\u003c/p\u003e \u003cp\u003eAll participants in both groups underwent transabdominal pelvic ultrasound (using a Samsung WS80 device with a curve probe and frequency of 1\u0026ndash;7 MHz) with a full bladder. The length, width, height, and volume of the uterus and ovaries were measured. Additionally, transperineal ultrasound (using a Samsung WS80 device with a linear probe and frequency of 3\u0026ndash;12 MHz) was used to measure the thickness of the vaginal mucosa and the thickness of the vaginal wall muscle. The obtained measurements of the uterus and ovaries from the case group were then compared with those of the control group (girls under 8 years without secondary sexual characteristics, with similar age range, BMI, and nutritional status).\u003c/p\u003e \u003cp\u003eAfter data collection and necessary controls, the information was entered into a computer and analyzed using SPSS software version 24. Descriptive statistics such as percentage, ratio, mean, and standard deviation were used, along with appropriate statistical tests like Chi-square and Fisher's exact tests (for qualitative variables) and Mann-Whitney U test (for quantitative variables). The results were analyzed with a 95% confidence level. Additionally, Receiver Operating Characteristic (ROC) curves were used to determine the best cut-off points, and the sensitivity and specificity of each point were calculated.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study sample consisted of 64 girls under 8 years of age, with 32 girls showing signs of puberty as the case group and 32 girls without secondary sexual characteristics as the control group.\u003c/p\u003e\n\u003cp\u003eTable 1 compares baseline information (qualitative variables) between the case and control groups using Chi-square and Fisher\u0026apos;s exact tests. The results showed no statistically significant differences between the two groups in terms of maternal education (p=1), paternal education (p=0.13), maternal occupation (p=0.27), paternal occupation (p=0.8), term birth (p=0.69), type of delivery (p=0.3), exposure to age-inappropriate media (p=0.5), history of specific diseases (adrenal and thyroid diseases, and birth defects) (p=0.5), soy consumption (p=0.69), and peanut consumption (p=0.74). A statistically significant difference was found in dairy consumption (p=0.016), which was higher in the control group than in the case group. An inverse relationship was observed between dairy consumption and precocious puberty in the studied sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Personal Information (Qualitative Variables) of Case and Control Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"627\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCase Group Frequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group Frequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh School Diploma or Less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUniversity Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (65.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (65.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePaternal Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh School Diploma or Less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (53.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUniversity Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (46.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (65.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Occupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHomemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (78.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (65.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePaternal Occupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSelf-Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (46.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEmployee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (53.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (56.3%)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDairy Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;3 Units/Day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 (90.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (65.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;3 Units/Day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSoy Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;500 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;500 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePeanut Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;500 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (78.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;500 g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePreterm Birth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eType of Delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCesarean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVaginal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (68.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (56.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eExposure to Age-Inappropriate Media\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (96.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Specific Past Diseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (96.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e*p-value \u0026lt;0.05 indicates statistical significance (bolded).*\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChi-square test\u003c/strong\u003e was used for analysis.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Quantitative Information of Case and Control Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCase Group Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.17 (0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.86 (0.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of children in family\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00 (0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.94 (0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBirth order\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.53 (0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.50 (0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age at puberty (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.75 (1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.63 (1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight (grams)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3244.70 (362.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3290.70 (273.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBirth length (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.81 (1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51.27 (1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBirth head circumference (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.86 (0.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.94 (0.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent weight (kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.83 (6.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.71 (6.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent height (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e125.30 (10.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e124.67 (7.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.26 (2.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.87 (3.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePaternal height (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e173.69 (5.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e176.06 (7.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal height (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e158.41 (5.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e161.06 (6.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAnalysis performed using the \u003cstrong\u003eMann-Whitney U Test\u003c/strong\u003e.\u003c/em\u003e\u003cbr\u003e\u0026nbsp;*All p-values \u0026gt; 0.05 indicate no statistically significant differences between the two groups for any of these quantitative variables.*\u003c/p\u003e\n\u003cp\u003eTable 2 compares quantitative variables between the two groups using the Mann-Whitney U test. No statistically significant differences were found between the two groups in terms of maternal age at puberty (p=1), birth weight (p=1), birth length (p=1), birth head circumference (p=1), current weight (p=1), current height (p=1), BMI (p=1), paternal height (p=1), and maternal height (p=1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Ultrasound Measurement Criteria in Case and Control Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCase Group Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.46 (8.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.28 (2.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Height (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.60 (4.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.13 (1.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Width (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.44 (6.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.10 (3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Volume (cm\u0026sup3;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.93 (8.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.71 (0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovary Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.28 (5.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.06 (5.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovary Height (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.25 (2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.29 (2.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovary Width (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.22 (3.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.94 (0.77)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ovary Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.37 (5.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.03 (4.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ovary Height (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.53 (3.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.32 (1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ovary Width (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.92 (3.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.57 (3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.041\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ovary Volume (cm\u0026sup3;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.01 (1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.15 (0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEndometrial Thickness (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.81 (1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.06 (0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCervical Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.31 (3.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.53 (3.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Body Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.44 (8.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.31 (2.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Body-to-Cervix Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.19 (0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.89 (0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAnteroposterior Cervical Diameter (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.90 (2.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.68 (1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal Mucosa Thickness (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.89 (0.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.68 (0.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal Wall Muscle Thickness (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.16 (0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.10 (0.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal Mucosa-to-Muscle Thickness Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.81 (0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.64 (0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cem\u003eThe value \u0026quot;34.94 (0.77)\u0026quot; for Right Ovary Width in the Control Group appears inconsistent with other ovarian measurements and may represent a data entry error. This value is more characteristic of head circumference measurements than ovarian width.\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBold p-values\u003c/strong\u003e indicate statistically significant differences (p \u0026lt; 0.05)\u003c/li\u003e\n \u003cli\u003eAnalysis performed using the \u003cstrong\u003eMann-Whitney U Test\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTable 3 compares pelvic and transperineal ultrasound criteria between the case and control groups. The results showed significant differences in all ultrasound criteria between the two groups, except for cervical length (p=0.823), vaginal wall muscle thickness (p=0.647), and the ratio of vaginal mucosa thickness to muscle thickness (p=0.317), which showed no significant differences.\u003c/p\u003e\n\u003cp\u003eTo evaluate the overall diagnostic value of ultrasonographic parameters for differentiating precocious puberty from normal and to determine the optimal positive cut-off point for each diagnostic ultrasound parameter, Receiver Operating Characteristic (ROC) curve analysis was employed. The Area Under the Curve (AUC) represents the overall accuracy of each test.\u003c/p\u003e\n\u003cp\u003eAmong the parameters, uterine length was identified as the best predictor (AUC = 0.747), followed by uterine volume (AUC = 0.734), right ovarian width (AUC = 0.724), and right ovarian volume (AUC = 0.723).\u003c/p\u003e\n\u003cp\u003eFor uterine length, a cut-off value of 26.5 mm yielded a sensitivity of 78% and a specificity of 68%. At 27.5 mm, the sensitivity and specificity were both 68%, while at 28.5 mm, the sensitivity was 56% with a specificity of 81%. Since ultrasound is primarily used as a screening tool where high sensitivity is prioritized over specificity, the value of 26.5 mm was selected as the optimal cut-off for uterine length to distinguish precocious puberty from normal.\u003c/p\u003e\n\u003cp\u003eFor uterine volume, a cut-off of 0.60 mL demonstrated a sensitivity of 75% and a specificity of 68%. At 0.63 mL, the sensitivity was 71% with a specificity of 71%. Consequently, 0.60 mL was determined to be the suitable cut-off value for uterine volume in predicting central precocious puberty in girls.\u003c/p\u003e\n\u003cp\u003eRegarding right ovarian width, a cut-off of 11.5 mm resulted in a sensitivity of 65% and a specificity of 62%. At 12.5 mm, the sensitivity was 62% with a specificity of 81%. Thus, 11.5 mm was chosen as the appropriate cut-off for right ovarian width to predict central precocious puberty.\u003c/p\u003e\n\u003cp\u003eFor right ovarian volume, a cut-off of 1.09 mL provided a sensitivity of 71% and a specificity of 56%. At 1.15 mL, the sensitivity was 62% with a specificity of 65%, and at 1.22 mL, the sensitivity was 56% with a specificity of 68%. Therefore, 1.09 mL was established as the optimal cut-off for right ovarian volume to differentiate precocious puberty from normal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Results of ROC Curve Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eArea Under Curve (AUC)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMeasured Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLower Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUpper Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.747\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Volume (cm\u0026sup3;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.608\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovary Width (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovary Volume (cm\u0026sup3;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Results of ROC Curve Analysis for Diagnostic Parameters of Central Precocious Puberty\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eArea Under Curve (AUC)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCut-off Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLower Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUpper Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.747\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e78%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUterine Volume (cm\u0026sup3;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.608\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovarian Width (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ovarian Volume (cm\u0026sup3;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn 2019, Calcaterra et al. conducted a study in Italy on 177 girls with precocious puberty. They suggested that a diagnostic model incorporating at least three hormonal and ultrasonographic criteria (including LH level, estradiol level, uterine length, uterine width, and ovarian volume) could be effective in selecting patients who require a GnRH stimulation test for diagnosing precocious puberty. Similarly, our study identifies ultrasonography as a useful auxiliary diagnostic method for precocious puberty in girls, with uterine length determined to be the best ultrasonographic parameter (13).\u003c/p\u003e \u003cp\u003eYuan et al. (2020) developed a diagnostic model based on basal serum LH levels and transrectal ultrasonographic parameters. Our study also supports the use of ultrasonography as a beneficial auxiliary diagnostic tool for precocious puberty in girls (11).\u003c/p\u003e \u003cp\u003eIn a 2018 study by Wan et al. on 47 girls with Central Precocious Puberty (CPP), pelvic ultrasonography was proposed as a suitable method for diagnosing CPP in girls, which corroborates the findings of our present study (10).\u003c/p\u003e \u003cp\u003eLee et al. (2016) reported that uterine volume was greater in girls with CPP compared to those with premature thelarche, while other parameters showed no significant difference between the two groups. In our study, uterine volume was also identified as the second most suitable parameter for predicting CPP (12).\u003c/p\u003e \u003cp\u003eKaplowitz et al. (2016) indicated that pelvic ultrasonography can be effective in diagnosing CPP in girls, as increased ovarian and uterine volumes are key diagnostic factors. This finding aligns with our study (24).\u003c/p\u003e \u003cp\u003eA 2011 study in Turkey by Ilmaz et al. on 125 girls with precocious puberty reported that nearly all pelvic ultrasonographic parameters were significantly increased in girls under 8 years with precocious puberty compared to both the control group and girls with premature thelarche. This consistency strengthens our own findings (21).\u003c/p\u003e \u003cp\u003eIn his research, Haber identified uterine volume as a diagnostic criterion for precocious puberty with 100% sensitivity and specificity. Our study also recognized uterine volume as the second most suitable parameter, albeit with a sensitivity of 75% and specificity of 68% (22).\u003c/p\u003e \u003cp\u003eZarei et al. (2023) conducted a study in Tehran (2015\u0026ndash;2019) involving 183 participants. They reported significant differences in most ultrasonographic parameters in girls with CPP, except for the anteroposterior diameter of the cervix and ovarian volume. They identified uterine volume as the best predictive parameter, followed by uterine width and the fundus-to-cervix ratio, for predicting CPP. They also endorsed pelvic ultrasonography as a useful auxiliary method, noting that the optimal diagnostic criteria and cut-off values may vary based on ethnicity and study type. Our study similarly found uterine volume to be the second-best predictive parameter. However, in contrast to Zarei et al.'s findings which showed no statistically significant difference in ovarian volume, our study identified right ovarian volume as the fourth diagnostic parameter for precocious puberty (26).\u003c/p\u003e \u003cp\u003eA 2018 study by Kharoshi et al. in Mashad on 15 girls with CPP suggested that the best criteria for diagnosing CPP were right ovarian volume (cut-off 1.35 ml), followed by uterine volume (cut-off 1.65 ml), and then uterine length (cut-off 31.5 mm). Our study determined the best ultrasonographic criteria to be uterine length (cut-off 26.5 mm), followed by uterine volume (cut-off 0.6 ml), right ovarian width (cut-off 11.5 mm), and then right ovarian volume (cut-off 1.09 ml). This shows notable similarity in the identified best parameters and the obtained cut-off values, despite slight variations (20).\u003c/p\u003e \u003cp\u003eSathasivam et al. (2011), in a study based on pelvic ultrasonography of 50 girls aged 3.1\u0026ndash;9.5 years, concluded that ultrasonography alone is not a suitable method for diagnosing precocious puberty in girls. They recommended that ultrasonographic criteria should be used alongside laboratory criteria for diagnosis (23).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePrecocious puberty can have significant physical and psychological consequences. However, timely diagnosis and treatment can prevent these adverse outcomes. Currently, the GnRH stimulation test is the standard diagnostic test for CPP. Considering its limitations and invasive nature, transabdominal and transperineal ultrasonography can be considered as non-invasive, cost-effective, and auxiliary methods for diagnosing precocious puberty in girls.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations:\u003c/h2\u003e \u003cp\u003eThere is currently no universally agreed-upon value for ultrasonographic measurements in diagnosing precocious puberty in girls. This may be due to different measurement techniques and variations in study populations. Furthermore, ethnicity and geographical characteristics might influence these criteria. These issues highlight the importance of conducting further research with larger sample sizes, including within our own country, to establish precise ultrasonographic criteria with appropriate cut-off values for diagnosing precocious puberty in girls. Very limited research has been conducted in this field in our country, making this study one of the pioneering investigations in this area nationally. It is also recommended that measurements using the transperineal ultrasonography method be further investigated with larger sample sizes and in more studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral Precocious Puberty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003eAcknowledgment:\u003c/h3\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the IRB of [IR.NKUMS.REC.1400.167], approval number [4000181]. Written informed consent was obtained from parents or legal guardians.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThe authors declare that no funding was received for this study.\u003c/p\u003e\n\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eEthics approval was obtained from the Institutional Review Board (IRB) of North Khorasan University of Medical Sciences (IR.NKUMS.REC.1400.167), approval number 4000181. This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the parents or legal guardians of all participants.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThe authors declare that no funding was received for this study.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eSepideh Rahmati contributed to the study design, data collection, data analysis, and manuscript drafting. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors would like to thank all participants and their parents or legal guardians for their cooperation in this study.\u003c/p\u003e\n\u003cp\u003eThis article is derived from the research project of Dr. Sepideh Rahmati. I extend my sincere gratitude and appreciation to the esteemed professors, Dr. Maulood Safari Rad and Dr. Minasadat Mohajerzadeh, for their valuable guidance and support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eYildiz AE, Elhan AH, Fitoz S. Prevalence and sonographic features of ectopic thyroidal thymus in children: A retrospective analysis. \u003cem\u003eJournal of Clinical Ultrasound\u003c/em\u003e. 2018;46(6):375-379.\u003c/li\u003e\n \u003cli\u003eHeras V, Castellano JM, Fernandois D, Velasco I, Rodr\u0026iacute;guez-Vazquez E, Roa J, et al. Central Ceramide Signaling Mediates Obesity-Induced Precocious Puberty. \u003cem\u003eCell Metabolism\u003c/em\u003e. 2020;32(6):951-966.e8.\u003c/li\u003e\n \u003cli\u003eHarroud A, Morris JA, Forgetta V, Mitchell R, Smith GD, Sawcer SJ, et al. Effect of age at puberty on risk of multiple sclerosis: A mendelian randomization study. \u003cem\u003eNeurology\u003c/em\u003e. 2019;92(16):e1803-e1810.\u003c/li\u003e\n \u003cli\u003eRazzaghy-Azar M, Moghimi A, Sadigh N, Montazer M, Golnari P, Zahedi-Shoolami L, et al. Age of puberty in Iranian girls living in Tehran. \u003cem\u003eAnnals of Human Biology\u003c/em\u003e. 2006;33(5-6):628-633.\u003c/li\u003e\n \u003cli\u003eKashani HH, Kavosh MS, Keshteli AH, Montazer M, Rostampour N, Kelishadi R, et al. Age of puberty in a representative sample of Iranian girls. \u003cem\u003eWorld Journal of Pediatrics\u003c/em\u003e. 2009;5(2):132-135.\u003c/li\u003e\n \u003cli\u003eKlein KO. Precocious puberty: who has it? Who should be treated? \u003cem\u003eThe Journal of Clinical Endocrinology \u0026amp; Metabolism\u003c/em\u003e. 1999;84(2):411-414.\u003c/li\u003e\n \u003cli\u003eMinelli C, van der Plaat DA, Leynaert B, Granell R, Amaral AFS, Pereira M, et al. Age at puberty and risk of asthma: A Mendelian randomisation study. \u003cem\u003ePLoS Medicine\u003c/em\u003e. 2018;15(8):e1002634.\u003c/li\u003e\n \u003cli\u003eAb Rahim SN, Omar J, Ismail TST. Gonadotropin-releasing hormone stimulation test and diagnostic cutoff in precocious puberty: a mini review. \u003cem\u003eAnnals of Pediatric Endocrinology \u0026amp; Metabolism\u003c/em\u003e. 2020;25(3):152-155.\u003c/li\u003e\n \u003cli\u003eMuratoğlu Şahin N, Uğraş Dikmen A, \u0026Ccedil;etinkaya S, Aycan Z. Subnormal Growth Velocity and Related Factors During GnRH Analog Therapy for Idiopathic Central Precocious Puberty. \u003cem\u003eJournal of Clinical Research in Pediatric Endocrinology\u003c/em\u003e. 2018;10(3):239-246.\u003c/li\u003e\n \u003cli\u003eWen X, Wen D, Zhang H, Zhang H, Yang Y. Observational study pelvic ultrasound a useful tool in the diagnosis and differentiation of precocious puberty in Chinese girls. \u003cem\u003eMedicine\u003c/em\u003e. 2018;97(10):e0092.\u003c/li\u003e\n \u003cli\u003eYuan B, Pi YL, Zhang YN, Xing P, Chong HM, Zhang HF. A diagnostic model of idiopathic central precocious puberty based on transrectal pelvic ultrasound and basal gonadotropin levels. \u003cem\u003eThe Journal of International Medical Research\u003c/em\u003e. 2020;48(8):300060520935278.\u003c/li\u003e\n \u003cli\u003eLee SH, Joo EY, Lee JE, Jun YH, Kim MY. The Diagnostic Value of Pelvic Ultrasound in Girls with Central Precocious Puberty. \u003cem\u003eChonnam Medical Journal\u003c/em\u003e. 2016;52(1):70-74.\u003c/li\u003e\n \u003cli\u003eCalcaterra V, Klersy C, Vinci F, Regalbuto C, Dobbiani G, Montalbano C, et al. Rapid progressive central precocious puberty: diagnostic and predictive value of basal sex hormone levels and pelvic ultrasound. \u003cem\u003eJournal of Pediatric Endocrinology \u0026amp; Metabolism\u003c/em\u003e. 2020;33(6):785-791.\u003c/li\u003e\n \u003cli\u003eFarage M, Maibach H. Lifetime changes in the vulva and vagina. \u003cem\u003eArchives of Gynecology and Obstetrics\u003c/em\u003e. 2006;273(4):195-202.\u003c/li\u003e\n \u003cli\u003eFarage MA, Maibach HI. Morphology and physiological changes of genital skin and mucosa. \u003cem\u003eCurrent Problems in Dermatology\u003c/em\u003e. 2011;40:9-19.\u003c/li\u003e\n \u003cli\u003eGangat M, Radovick S. Precocious puberty. \u003cem\u003eMinerva Pediatrica\u003c/em\u003e. 2020;72(6):491-500.\u003c/li\u003e\n \u003cli\u003eChang SSY, Nagarajan N, Tan JMC. Premature thelarche in an infant girl with failure to thrive related to dietary soy exposure. \u003cem\u003eBMJ Case Reports\u003c/em\u003e. 2021;14(3):e239818.\u003c/li\u003e\n \u003cli\u003eKota AS, Ejaz S. Precocious Puberty. \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL): StatPearls Publishing; 2021.\u003c/li\u003e\n \u003cli\u003eDe Sanctis V, Elhakim IZ, Soliman AT, Elsedfy H, Elalaily R, Millimaggi G. Methods for Rating Sexual Development in Girls. \u003cem\u003ePediatric Endocrinology Reviews\u003c/em\u003e. 2016;14(1):27-32.\u003c/li\u003e\n \u003cli\u003eKhoroushi F, Davoudi Y, Eshraghi P, Salehi M. Diagnostic value of pelvic sonography criteria in diagnosis of girls\u0026apos; precocious puberty in Mashhad. \u003cem\u003eThe Iranian Journal of Obstetrics, Gynecology and Infertility\u003c/em\u003e. 2019;22(3):8-15.\u003c/li\u003e\n \u003cli\u003eEksioglu AS, Yilmaz S, Cetinkaya S, Cinar G, Yildiz YT, Aycan Z. Value of pelvic sonography in the diagnosis of various forms of precocious puberty in girls. \u003cem\u003eJournal of Clinical Ultrasound\u003c/em\u003e. 2013;41(2):84-93.\u003c/li\u003e\n \u003cli\u003eHaber HP, Wollmann HA, Ranke MB. Pelvic ultrasonography: early differentiation between isolated premature thelarche and central precocious puberty. \u003cem\u003eEuropean Journal of Pediatrics\u003c/em\u003e. 1995;154(3):182-186.\u003c/li\u003e\n \u003cli\u003eSathasivam A, Rosenberg HK, Shapiro S, Wang H, Rapaport R. Pelvic ultrasonography in the evaluation of central precocious puberty: comparison with leuprolide stimulation test. \u003cem\u003eThe Journal of Pediatrics\u003c/em\u003e. 2011;159(3):490-495.\u003c/li\u003e\n \u003cli\u003eKaplowitz P, Bloch C. Evaluation and Referral of Children With Signs of Early Puberty. \u003cem\u003ePediatrics\u003c/em\u003e. 2016;137(1):e20153732.\u003c/li\u003e\n \u003cli\u003eBadouraki M, Christoforidis A, Economou I, Dimitriadis AS, Katzos G. Evaluation of pelvic ultrasonography in the diagnosis and differentiation of various forms of sexual precocity in girls. \u003cem\u003eUltrasound in Obstetrics \u0026amp; Gynecology\u003c/em\u003e. 2008;32(6):819-827.\u003c/li\u003e\n \u003cli\u003eZarei E, Rakhshankhah N, Khodadost M, Abouie A, Mohammadnejad K, Vafadar M. Effectiveness of Pelvic Ultrasonography in the Diagnosis of Central Precocious Puberty and Its Differentiation from Similar Conditions. \u003cem\u003eIranian Journal of Radiology\u003c/em\u003e. 2022;19(4):e129295\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8220014/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8220014/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eCentral precocious puberty (CPP) requires early and accurate diagnosis to prevent adverse physical and psychological consequences. Although the GnRH stimulation test is the diagnostic gold standard, it is invasive, time-consuming, and not readily available in all settings. Pelvic ultrasonography offers a practical non-invasive adjunct, but sonographic criteria vary considerably across populations. Moreover, estrogen-related changes in the vaginal mucosa\u0026mdash;despite their diagnostic potential\u0026mdash;have been largely overlooked. This study uniquely incorporates \u003cb\u003etransperineal ultrasonography\u003c/b\u003e to measure vaginal mucosal and muscular thickness as novel markers for CPP.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eIn this case\u0026ndash;control study conducted from 2021 to 2023, 32 girls with CPP and 32 age-matched controls (all under 8 years) underwent transabdominal pelvic ultrasonography to assess uterine and ovarian dimensions, and \u003cb\u003etransperineal ultrasound\u003c/b\u003e to measure vaginal mucosal and wall muscle thickness. Baseline characteristics were compared using Chi-square and Mann\u0026ndash;Whitney U tests. ROC curve analysis was performed to determine optimal diagnostic cut-off values.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eGirls with CPP showed significantly higher uterine length and uterine volume compared with controls. \u003cb\u003eVaginal mucosal thickness measured via transperineal ultrasound\u003c/b\u003e was also significantly increased in the CPP group, highlighting its diagnostic potential. ROC analysis identified uterine length (AUC\u0026thinsp;=\u0026thinsp;0.747; 26.5 mm) as the strongest discriminator, followed by uterine volume (AUC\u0026thinsp;=\u0026thinsp;0.734), right ovary width (AUC\u0026thinsp;=\u0026thinsp;0.724), and right ovary volume (AUC\u0026thinsp;=\u0026thinsp;0.723).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eBoth transabdominal and transperineal ultrasonography provide valuable non-invasive tools for evaluating girls suspected of CPP. \u003cb\u003eThe introduction of vaginal mucosal assessment via transperineal imaging represents a novel diagnostic approach\u003c/b\u003e that may improve early identification of CPP, particularly in settings with limited access to GnRH testing. Larger population-based studies are recommended to refine ultrasonographic cut-off values.\u003c/p\u003e","manuscriptTitle":"Diagnostic Value of Pelvic and Transperineal Ultrasound in Girls with Central Precocious Puberty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 16:02:20","doi":"10.21203/rs.3.rs-8220014/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-13T12:21:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202938608884068135803297233381951564255","date":"2026-02-04T08:29:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-30T14:35:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T09:30:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-16T05:55:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-12T18:31:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-12T18:26:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"74d99931-4c0c-4b69-84e5-7851b21fc65e","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T16:02:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 16:02:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8220014","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8220014","identity":"rs-8220014","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}