During the first 2 years of life, high levels of gonadotropins intermittently to adult values have several roles in sexual development such as brain muscularization, longitudinal good testicular function (spermatogenesis), penile and testicular size, prostate growth in men and uterine and breast enlarge in girls and sebaceous gland, acne development and transient pubic hairs in both sexes [5, 16, 17]. In premature infants exaggerated mini puberty state are observed with severe puberty exchange in clinical, laboratory and ultrasonography data.
Serum levels of gonadotropins especially FSH in preterm infants are higher and more extended than term newborns particularly in girls. In both sex LH level ordinarily decrease by 6–9 months of age, but in premature infants is longer than one year [4, 6].
In the patient of this study periodic vaginal bleeding was seen same as Ivana, Gisselle, Bethany and Maria study [6, 15, 18]. That is not conventional event in mini puberty state in term infants. This undesirable state in the premature infants is not necessarily needs to use GnRH agonist. Although Gisselle  start leuprolide injections every 28 day and discontinued it at age of 2 as same as the Aefke study. However, after disconnection of hormonal therapy any signs of puberty did not develop and the initial diagnosis of central precocious puberty (CPP) was incorrect. 
Patient in this study has pubic hairs, Same selim study  and unlike Gisselle  and Maria study . This symptom is consequent on gonadal and adrenals androgens secretion concomitant with the LH changes in the mini-Puberty .
By regression of puberty symptoms in the patient of this study during 12 months of monitoring, these were seen Respectively; disappearance of pubarche hair then stop vaginal bleeding after 4 months and complete evanesce of breast bud at 8th month of follow up.
The complete regression of puberty symptoms in our patient continue about 1 year due to severity of the prim presentation, although in the other studies have been reported from 2 weeks to 10 months due to less severity such as edema of the labia major. [13, 18, 19, 20,]
Altogether the severity of prematurity is not necessarily associated with the severity and variety of puberty presentations and the duration of symptoms.
Most of the patients in similar articles also had long-term hospitalizations because of bronchopulmonary dysplasia, recurrent prematurity apnea, primary pulmonary hypertension, and patent ductus arteriosus, retinopathy of prematurity and even intracranial hemorrhage which all problems are the causes of inflammatory mechanisms in the body. [13, 15, 18, 20]
Synchronization of reduction in sex hormones and inflammatory markers (ferritin) may indicate that inflammatory process is an irritant marker for exaggerated puberty during infancy period (see the table). Likewise, in current study case, gradual regression of puberty symptoms concomitant to recovery of BPD symptoms and decrease to discontinuous of oxygen demand are observed.
The levels of hormones mentioned in several studies did not necessarily coincide with the severity of clinical symptoms and indicates other effective factors such as the method and accuracy of laboratory tests, different sensitivity of the receptors in the sexual organs in the patients, Medications (drugs used) and inflammatory factors due to the severity of chronic and systemic diseases. (see table 2)
There is not any cut of point in gonadotropins and sex hormones serum levels to distinguish mini puberty from central precocious puberty due to serious etiology such as tumors that needs GnRH agonist to be assessed. Thus Serum levels of gonadotropins and sex hormones are higher in premature infants than normal term infants with mini puberty.
Ultrasound data showed in mini puberty ovaries maturation are dominant to uterine size. In the patient of this study ovarian follicle size was over 10 mm is the opposite of selim study  and similar sedin, Ivana, mosallanejad, Gisselle, and Maria studies. [13,15,1819,20]
Despite the decrease of the sex hormone levels and reduction of uterine size and ovaries volume, follicles with the size of 9 mm are observed in sonography which shows the development process and atrophy of the follicles that is not necessarily related to puberty improvement, like Sedin’s Study  result that can be remained till the age of 2.
In Sedin’s Study multiple ovarian cysts with an average diameter of 21 mm are found. In 50% of the cases reduction in the cysts are observed in the first month and in 25% of the cases in the second month. Also may persist at longer than three months in 10% of the cases .
If the cysts don't get smaller without clinical reduction, medroxyprogesterone acetate can be prescribed to decreasing the synthesis of ovarian estradiol .
However, it should be noted if regression of clinical symptoms are seen, medical treatment is not necessary because the enlargement and shrinkage of the follicles are seen naturally up to the age of 2. In Sedin’s study Medroxyprogesterone has been suggested for treatment with estradiol above 2000 pmo/L (radioimmunoassay), which is not recommended because the fluctuating estradiol levels during the first 2 years of life is proportional to the change in the size of the follicles. 
Although treatment with medroxyprogesterone causes a faster reduction in estradiol levels, but the important sexual development roles of hormonal changes during the mini-puberty period, definitely minimal therapeutic intervention during this particular period is recommended. 
To prevent torsion, aspiration drainage is recommended in cysts that are larger than 4–5 cm . However, the normal pathology of a 4 cm multiloculated cyst ovary in Sedin’s patient who has undergone unilateral oophorectomy and then observation of enlarged ovarian cysts in the opposite ovaries which have been treated with medroxyprogesterone for some time, shows that should be avoided hasty surgery. Because the main pathology is not in the ovaries but it is caused by exaggerated increase in the secretion of gonadotropins during mini puberty due to prematurity, temporarily. So it is better to use exaggerated mini puberty word instead ovarian hyperstimulation syndrome in preterm infants . Brain MRI with attention to Hypothalamus and pituitary is recommended to rule out the brain insult (tumor or anatomic disorders).
One of the premature infants in Sedin’s study had no clinical signs of puberty. Only periodical tests showed increased levels of estradiol serum and about 10-mm ovarian follicles till the age of 15 months which indicates the dynamic process of mini puberty even without clinical presentations. In a more comprehensive plane, with periodic monitoring such as hormonal testing, uterine and ovarian ultrasound findings, and attention to the clinical changes, it is possible to get a better understanding of the pattern of mini-pubertal changes and their importance in this critical period of life in the VLBW premature infants. .
It is recommended that after completing the evaluation of serious etiology for precocious puberty in preterm infancies, with careful monitoring, patients return to the pre-pubertal stage gradually, without any extra hormonal treatments.