A 9-year-old Caucasian female came to clinic for her health supervision visit. Her mother is concerned because she noticed breast budding within the last month and is worried that her daughter “is developing too early.” She nor her daughter have noticed any axillary or pubic hair. They denied any unusual growth spurt or body odor. Her menses have not started, and she has not had any abnormal vaginal discharge. The past medical history and review of systems are negative. The family history shows that her mother and mother’s sister had menarche at age 11. Her father had his growth spurt around age 13-14 but the mother is not sure about the timing.
The pertinent physical exam shows a healthy female with normal vital signs. She is 28 kilograms (25-50%) and 140 cm (75%) and has grown 2.5 kilograms and 6 cm over the past year. Her skin examination shows two 0.5 cm cafe-au-lait spots. She is Tanner stage II for breast, and Tanner I for pubic hair. She has no axillary hair. The rest of her examination is normal. The diagnosis of normal pubertal changes was made. The patient and mother were counseled that this was normal, particularly as the mother and aunt appeared to have a similar pubertal pattern. However, the mother was counseled that if her daughter were to experience rapid changes going through puberty to recontact the office. Patient handouts including an information prescription for appropriate Internet resources for the daughter’s age were given.
During normal pubertal development “[h]igh-amplitude pulses of [gonadotropin releasing hormone] cause pulsatile increases in the pituitary gonadotropin-luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Increased LH levels stimulate production of sex steroids by testicular Leydig cells or ovarian granulosa cells. Pubertal levels of androgens or estrogens cause the physical changes of puberty….” These include growth spurt, breast budding, public and axillary hair, and penile and testicular enlargement. Production of ovarian follicular maturation and spermatogenesis also occurs.
Normal female puberty (mean age in years)
- Thelarche (breast budding caused by estrogens) is age 9 years
- Adrenarche (pubic hair caused by androgens) is age 10 years for Caucasian and age 9 years for African American girls.
- Menarche is age 12.8 years for Caucasian and 12.2 for African American girls.
Thelarche may be unilateral or bilateral. Most Caucasian girls begin puberty with thelarche (20%) and most African American girls begin with adrenarche. Average amount of time from thelarche to menarche is 2.5 years.
Definitions of what determines the age of diagnosis for precocious puberty have decreased recently:
- Basically any changes below age 8 should be concerning
- African American = adrenarche or thelarche < 6 years
- Caucasian = adrenarche or thelarche < 7 years
- Caucasian = adrenarche and thelarche < 8 years
Precocious puberty in girls is a problem that can lead to short stature, early sexuality, difficulty with menstrual hygiene and problems with being different from their peers. Children should be referred for precocious puberty evaluation when the diagnosis is made and/or if they have rapidly progressive puberty, predicted short stature compared to mid-parental height, bone age advanced 2 years or more, neurological symptoms or history of unusual symptoms or signs. unusual symptoms or signs.
Causes of precocious puberty include:
- Central (gonadotropins cause early maturation of the entire hypothalamic-pituitary-gonadal axis)
- Idiopathic (95% of cases)
- Tumors (primary or metastatic, benign or malignant)
- Damage – trauma, encephalitis
- Peripheral (gonadotropins are not the cause)
- Ovarian cysts
- Ovarian or adrenal tumors producing hormones
- Hypothyroidism (severe)
- McCune-Albright syndrome
- Toxins – environment, ingestion, topical
Evaluation of precocious puberty usually includes:
- Random LH is considered the best screening test for central precocious puberty as the prepubertal (low) and pubertal (higher) levels are basically distinct from one another and do not overlap.
- Random FSH is not helpful to determine precocious puberty, but it can be useful if a gonadotropin-releasing hormone study is being performed.
- Estrogen levels are not as consistent an indicator of puberty for girls as testosterone is for boys.
- DHEA is the preferred androgen steroid to measure and is usually elevated in girls and boys with precocious puberty.
- Thyroid testing is usually not indicated unless other symptoms are present.
- Pelvic ultrasound is indicated if peripheral precocious puberty is being considered but not for central.
- Head imaging may be considered especially in very young children as the incidence of a tumor is higher.
Treatment for precocious puberty usually consists of lutenizing hormone releasing hormone and gonadotropin releasing hormone agonists.
Questions for Further Discussion
1. What is the normal pubertal progression for boys?
2. At what ages is puberty considered delayed for girls and boys?
- Symptom/Presentation: Growth Problems | Health Maintenance and Disease Prevention | Precocious Puberty
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings Network. Pediatrics.1997;99:505-512.
Adams Hillard PJ. Menstruation in young girls: a clinical perspective. Obstet Gynecol. 2002 Apr;99(4):655-62.
Kaplowitz PB, Precocious Puberty. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/924002-overview (rev. 3/29/2010, cited 5/19/10).
Ryan G. Problems with menarche: When the First Period Comes Early or Late. Carver College of Medicine Pediatric Symposium Presentation. 10/4/08.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital