Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • nil

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Women's and Children's Health Network

Category 1 - appointment clinically indicated within 30 days

  • early onset of breast development in girls less than 6 years of age
  • early onset of testicular enlargement in boys less than 9 years of age

Category 2 — appointment clinically indicated within 90 days

  • breast development in girls between 6 to 8 years of age
  • early onset of pubic hair development in girls less than 8 years or boys less than 9 years of age
  • delayed puberty

Category 3 — appointment clinically indicated within 365 days

  • nil

For information on referral forms and how to import them, please view general referral information.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • identifies as Aboriginal and/or Torres Strait Islander
  • identify within your referral if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf
  • interpreter requirements


  • past medical/surgical history, including:
    • age of onset of breast development
    • age of onset of pubic hair development
    • age of menarche
    • is puberty absent or stalled?
    • medical conditions or treatments causing delayed growth and puberty
    • history of pituitary or gonadal problems
  • family history, including parents’ heights and pubertal timing
  • current medications and dosages
  • allergies and sensitivities
  • onset, duration, and progression of symptoms
  • management history including treatments trialled/implemented prior to referral


  • examination findings, including Tanner staging
  • height/weight/body mass index (BMI)


  • bone age X-ray
  • luteinizing hormone (LH)
  • follicle-stimulating hormone (FSH)
Testosterone (boys) or oestradiol (girls)

If breast development:

  • LH
  • FSH
  • oestradiol

If increase in testicular size:

  • LH
  • FSH
  • testosterone

If increase in pubic hair:

  • early morning 17 hydroxyprogesterone (17-OHP)
  • dehydroepiandrosterone sulfate (DHEAS)
  • testosterone

Clinical management advice

Breast and pelvic ultrasounds are not helpful for diagnosis in adolescence.

The onset of puberty usually occurs between 8 and 13 years in girls and between 9 and 14 years in boys. Girls reach menarche 2 to3 years after the onset of puberty. Full pubertal development occurs over 4 to 5 years.

Early puberty is defined as breast or pubic hair development before the age of 8 years in girls and testicular enlargement (testes > 4ml in volume) and pubic hair before the age of 9 years in boys. It is often associated with a rapid tempo of pubertal progression and increased height velocity.

Delayed puberty is defined as no breast development by age 13 years or no menstrual periods by age 16 years in girls and no testicular enlargement (testes < 4ml in volume) by age 14 years in boys.

General information

Contact Women’s and Children’s Hospital (WCH) endocrinology on-call on (08) 8161 7000 for advice or to escalate and discuss any clinical concerns.

Recent pathology results will be required prior to outpatient appointment. Consider providing repeat pathology form to patient at time of referral.

Patients who have previously been seen by a specialist are encouraged to be referred back to their care for further review if required.

Referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but may not fit the criteria provided, you are encouraged to contact the specialist team to discuss your concerns.

Clinical resources

Consumer resources