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Precocious pubertyBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/precocious-puberty/DS00883
Precocious puberty is when someone's body begins changing from a child into an adult too soon. The process of changing from a child into an adult is known as puberty, and puberty that begins before age 8 for girls and before age 9 for boys is considered precocious puberty.
Puberty includes rapid growth of bones and muscles, changes in body shape and size, and development of the body's ability to reproduce.
The cause of precocious puberty often can't be found. Rarely, conditions such as infections, hormone disorders, tumors, brain abnormalities or injuries may cause precocious puberty. Treatment for precocious puberty typically includes medication to delay further development.
Signs and symptoms of precocious puberty include development of the following before age 8 in girls and before age 9 in boys.
Precocious puberty symptoms in girls include:
- Breast growth
- First period (menstruation)
Precocious puberty symptoms in boys include:
- Enlarged testicles and penis
- Facial hair (usually grows first on the upper lip)
- Deepening voice
Precocious puberty symptoms that can occur in boys or girls include:
- Pubic or underarm hair
- Rapid growth
- Adult body odor
When to see a doctor
Make an appointment with your child's doctor for an evaluation if your child has any of the signs or symptoms of precocious puberty.
To understand what causes precocious puberty in some children, it's helpful to know what causes puberty to begin. A number of steps must occur before puberty begins. This process involves the following steps:
- The brain starts the process. Part of the brain makes a hormone called gonadotropin-releasing hormone (Gn-RH).
- The pituitary gland releases more hormones. Gn-RH causes the pituitary gland — a small bean-shaped gland at the base of your brain — to release two more hormones. The hormones are called luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
- Sex hormones are produced. LH and FSH cause the ovaries to produce hormones involved in the growth and development of female sexual characteristics (estrogen) and the testicles to produce hormones responsible for the growth and development of male sexual characteristics (testosterone). The body will also begin to make estrogen and testosterone.
- Physical changes occur. The production of estrogen and testosterone causes the physical changes of puberty.
The reason this process begins early in some children depends on the type of precocious puberty they have: central precocious puberty or peripheral precocious puberty.
Central precocious puberty
There's usually no identifiable cause for this type of precocious puberty.
In central precocious puberty, the puberty process starts too soon. Although they begin earlier than they should, the pattern and timing of the steps in the process are otherwise normal. For the majority of children with this condition, there's no underlying medical problem and no identifiable reason for the early puberty.
In rare cases, the following may cause central precocious puberty:
- A tumor in the brain or spinal cord (central nervous system)
- A defect in the brain present at birth, such as excess fluid buildup (hydrocephalus) or a noncancerous tumor (hamartoma)
- Radiation to the brain or spinal cord
- Injury to the brain or spinal cord
- McCune-Albright syndrome — a genetic disease that affects bones and skin color and causes hormonal problems
- Congenital adrenal hyperplasia — a group of inherited disorders involving abnormal hormone production by the adrenal glands
- Hypothyroidism — a condition in which the thyroid gland doesn't produce enough hormones
Peripheral precocious puberty
Estrogen or testosterone in your child's body causes this type of precocious puberty.
Peripheral precocious puberty, which is less common than central precocious puberty, happens without involvement of a hormone in your brain (Gn-RH) that normally triggers the start of puberty. Instead, the cause is release of estrogen or testosterone into the body because of problems with the ovaries, testicles, adrenal glands or pituitary gland.
In both girls and boys, the following may lead to peripheral precocious puberty:
- A tumor in the adrenal glands or in the pituitary gland that secretes estrogen or testosterone
- McCune-Albright syndrome, a rare disorder that also affects the skin and bone
- Exposure to external sources of estrogen or testosterone, such as creams or ointments
In girls, peripheral precocious puberty may also be associated with:
- Ovarian cysts
- Ovarian tumors
In boys, peripheral precocious puberty may also be caused by:
- A tumor in the cells that make sperm (germ cells) or in the cells that make testosterone (Leydig cells)
- Gene mutation — a rare disorder called familial gonadotropin-independent sexual precocity, which is caused by a defect in a gene, can result in the early production of testosterone in boys, usually between ages 1 and 4.
Factors that increase a child's risk of precocious puberty include:
- Being a girl. Girls are much more likely to develop precocious puberty.
- Being African-American. Precocious puberty affects African-Americans more often than children of other races.
- Being obese. If your child is significantly overweight, he or she has a higher risk of developing precocious puberty.
- Being exposed to sex hormones. Coming in contact with an estrogen or testosterone cream or ointment, or other substances that contain these hormones (such as an adult's medication or dietary supplements), can increase your child's risk of developing precocious puberty.
- Having other medical conditions. Precocious puberty may be a complication of McCune-Albright syndrome or congenital adrenal hyperplasia — conditions that involve abnormal production of the male hormones (androgens). In rare cases, precocious puberty may also be associated with hypothyroidism.
Possible complications of precocious puberty include:
- Short height. Children with precocious puberty may grow quickly at first and be tall, compared with their peers. But, because their bones mature more quickly than normal, they often stop growing earlier than usual. This can cause them to be shorter than average as adults. Early treatment of precocious puberty, especially when it occurs in very young children, can help them grow taller than they would without treatment.
- Social and emotional problems. Girls and boys who begin puberty long before their peers may be extremely self-conscious about the changes occurring in their bodies. This may affect self-esteem and increase the risk of depression or substance abuse.
Preparing for your appointment
You're likely to start by seeing your child's pediatrician or a family doctor. However, in some cases when you call to set up an appointment, you may be referred immediately to a doctor who specializes in the treatment of hormone-related conditions in children (pediatric endocrinologist).
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your child's doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance, such as restrict your child's diet.
- Write down your child's symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, as well as any vitamins or supplements, that your child is taking.
- Make a list of family members' heights, especially if any of them are short as adults.
- Write down your family medical history, and note if any family members have had precocious puberty or endocrine problems.
- Bring a copy of your child's growth curve record if you are visiting a new doctor who doesn't have access to your child's medical record.
- Write down questions to ask your child's doctor.
Your time with the doctor is limited, so preparing a list of questions in advance will help you make the most of your time together. List your questions from most important to least important in case time runs out. For precocious puberty, some basic questions to ask your doctor include:
- What is likely causing my child's symptoms or condition?
- Are there other possible causes for my child's symptoms or condition?
- What kinds of tests does my child need?
- Is this condition likely temporary or chronic?
- What's the best treatment?
- What are the alternatives to the primary approach that you're suggesting?
- My child has other health conditions. How can we best manage them together?
- Are there any restrictions that my child needs to follow?
- Should my child see a specialist? What will that cost, and will my insurance cover seeing a specialist?
- Is there a generic alternative to the medicine you're prescribing?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask about:
- Your family medical history, in particular, family members' heights and any history of endocrine disorders or tumors
- The age at which puberty began for siblings and parents
- Family racial composition
Tests and diagnosis
To diagnose precocious puberty, the doctor will:
- Review your child's and your family's medical history
- Do a physical exam
- Run blood tests to measure hormone levels
X-rays of your child's hand and wrist also are important for diagnosing precocious puberty. These X-rays can help the doctor determine your child's bone age, which shows if the bones are growing too quickly.
Determining the type of precocious puberty
Your child's doctor will also need to find out which type of precocious puberty your child has. To do so, he or she will perform a test called a gonadotropin-releasing hormone (Gn-RH) stimulation test, and then take a blood sample. In children with central precocious puberty, this hormone will cause other hormone levels to rise. In children with peripheral precocious puberty, other hormone levels stay the same.
Additional testing for central precocious puberty
- Magnetic resonance imaging (MRI). A brain MRI is usually done for children who have central precocious puberty to see if any brain abnormalities are causing the early start of puberty.
- Thyroid testing. The doctor may also test your child's thyroid if he or she shows any signs of slow thyroid function (hypothyroidism), such as fatigue, sluggishness, increased sensitivity to cold, constipation, a drop in school performance or pale, dry skin.
Additional testing for peripheral precocious puberty
Other tests also are necessary for children with peripheral precocious puberty to find the cause of their condition. For example, the doctor may run additional blood tests to check other hormone levels or, in girls, he or she may do an ultrasound to check for an ovarian cyst or tumor.
Treatments and drugs
Treatment for precocious puberty depends on the cause.
Treating central precocious puberty
Most children with central precocious puberty, in which there's no underlying medical condition, can be effectively treated with medication. This treatment, called Gn-RH analogue therapy, usually includes a monthly injection of a medication, such as leuprolide (Lupron Depot), which delays further development. The child continues to receive this medication until he or she reaches the normal age of puberty. Once he or she stops receiving the medication, the process of puberty begins again.
Treating an underlying medical condition
If another medical condition is causing your child's precocious puberty, treatment of that condition is necessary to stop the progress of puberty. For example, if a child has a tumor that's producing hormones and causing precocious puberty, puberty usually will stop when the tumor is surgically removed.
Coping and support
Children who begin puberty early may feel different from their peers, which can cause social and emotional problems such as low self-esteem, depression and substance abuse. As a parent, you also may have trouble dealing with your child's early development.
If you, your child or other members of your family are having difficulty coping, seek counseling. Psychological counseling can help your family better understand and handle the emotions, issues and challenges that accompany precocious puberty. If you have questions or would like guidance on how to find a qualified counselor, talk with a member of your health care team.
Some of the risk factors for precocious puberty, such as sex and race, can't be avoided. But, there are things you can do to reduce your child's chances of developing precocious puberty, including:
- Keeping your child away from external sources of estrogen and testosterone — prescription medications for adults in the house or dietary supplements containing estrogen or testosterone, for example.
- Encouraging your child to maintain a healthy weight.
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