Early Puberty

1. Why do some bloom early?

The problem of early blooming is called precocious puberty. If the girls show signs of puberty before the age of 8 years and if the boys before the age of 9 years then it is called precocious puberty.

2. What are the types of precocious puberty?

We divide this into four categories.

  • Central (complete or true) isosexual precocious puberty
  • Incomplete isosexual precocious puberty
  • Sexual precocity due to gonadotropin or sex steroid exposure
  • Variation in pubertal development

3. What could be the causes of the central precocious puberty?

Usually in girls the cause is unknown when it is called idiopathic. However it could be familial also. But in boys intracranial pathology like tumors, hydrocephalus, trauma, cranial irradiation are more common than idiopathic or familial cause.

4. What are the causes of incomplete isosexual precocious puberty in boys?

  1. Gonadotropin secreting tumors
  2. Autonomous androgen secretion

5. What are the causes of incomplete isosexual precocious puberty in girls?

  • Follicular cysts
  • Granulosa or theca cell tumors
  • Adrenal rest tissue
  • Estrogen administration from outside
  • Hypothyroidism
  • McCune – Albert syndrome

6. What are the variations in pubertal development?

They are of three different types. They actually do not denote precocious puberty and hence can be considered as normal variations only. They are premature thelarche (early breast enlargement without other signs), premature menarche (early periods without other signs) and premature adrenarche (early development of pubic and arm pit hair without other signs).

7. What are the implications of precocious puberty?

Precocious puberty is associated with both psychological and physiological implications. Psychologically the child is too young to adjust to the new situation. Physiologically it has a bearing on the ultimate height reached by the child. Although puberty is associated with initial growth spurt it ultimately causes early fusion of the bones thus reducing the final height.

8. How it is identified?

The doctor identifies the condition by the physical examination of the child where he notices the signs of puberty and then asks for the appropriate investigations.

9. What are those investigations?

He orders for the certain hormone tests by which one comes to know the blood levels of the hormones concerned with puberty are elevated or not. After that a stimulation test called GnRH stimulation test is performed. In this test the hypothalamic hormone GnRH is given and then the pituitary hormones are measured at 30 & 60 minutes. Seeing the pattern of these hormones one can diagnose precocious puberty. MRI scan of the brain and the adrenals are also requested in order to look at the structural lesions of these glands.

10. Is there any need to treat these patients?

Yes. This is because if this condition is left untreated then the final height of the child is compromised. Secondly there are psychological implications for the child as the child is not ready psychologically to accept the new situation.

11. What is the treatment for central precocious puberty?

Leuprorelin acetate 3.5mg given intra muscular every month suppresses pituitary FSH/LH secretion and hence stops the march of puberty.

12. How long these need to be given?

They need to be given at least until the normal age of puberty i.e. 10-12 years in girls and 12 years in boys.

13. Is there any problem in using this drug on long term basis?

No. Some may develop allergic reactions and some other may develop reduction in bone mineral density and hence increased dietary calcium supplementation may be necessary.

14. Will the puberty restart after stopping these drugs at the appropriate age?

Yes. It restarts once these drugs are stopped.

15. How to treat incomplete precocious puberty?

Treating the root cause like removal of the tumor causing the precocious puberty is the solution for this problem.

16. Do we have to treat premature thelarche, adrenacrche and menarche?

No, these treatments are not required as first two are self limiting conditions and the for the last none is required.

This article is prepared by Dr Rajiv Joshi
(rajeev_jsh@yahoo.co.in) and Dr A Bhattacharyya