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| Precocious Puberty can occur in girls as well as boys. If not detected and treated early, such children can have serious physical and psychological problems. |
Arpita
[name changed] came to my clinic with her mother. She was eight and a half year
old and clearly in distress. Her parents were panicked as Arpita had her first
periods at such a tender age. Precocious Puberty is a hormonal disorder in
children where the pubertal changes happen early. As per the definition, the puberty is called precocious [early] if the
pubertal changes [breast development] in girls starts before 8 years or the
testis/penis enlarges in boys before 9 years of age. It may be accompanied
by development of pubic/ body hair and change in the body odour.
Normal Puberty:
Puberty,
is caused by sex steroids that are produced in the gonads [Ovaries in girls and
testis in the boys]. The timing of puberty is largely determined by genes and
the environment. The signal for producing these steroids originates from the
hypothalamus [a part of brain]. Hypothalamus and gonads are active at birth,
but it goes off to sleep for almost 10-12 years till the right time for puberty
is there. Hypothalamus receives cues from environment and the body fat; and
when the time is right, between 10-13 years it starts producing weak signals.
These signals stimulate pituitary gland to produce hormones. These hormones
become more active as the signal goes from weak to strong with time. Gonads
[Testes/ Ovaries] respond to these hormones and start producing sex steroids
[Testosterone/ Estrogen]. Sex steroids act on sex organs. In girls, the usual
pattern is enlargement of breasts, followed by appearance of pubic hair and in
the last, menses. Boys have enlargement of testes, followed by enlargement of
penis, appearance of pubic hair and sperm production. Both boys and girls grow
rapidly during the pubertal age and gain almost 25 percent of their final
height during puberty. Girls have their puberty earlier and stop growing
earlier than boys.
Precocious Puberty: Causes
Puberty
can start early when either the brain signals early or the gonads become active
even without the signal. Adrenal gland may cause early development of
underarm/pubic hair.
In girls,
most of the times, the cause for early puberty is not found. Such condition is
called as ‘Idiopathic’. Where in boys, most of the cases have underlying brain,
testicular or adrenal problem. Various disorders of brain [Tumour/ Infection/
Trauma/ Radiation/ Surgery] can make this signal appear early. Exposure to
various medicines, skin creams or pesticides may also cause pubertal changes in
children. Sometimes the pubertal changes start early but do not progress to
full-blown puberty. Early puberty may run in families.
What are the dangers of early
puberty?
As the
puberty starts, the bones grow and mature faster. During early puberty, these
kids appear taller than their peers as the peers have not yet entered puberty.
But as the puberty advances, the bones stop growing early and the final height
of such children is often severely compromised. Such children end up being
short. There is also psychological impact on the children such as school
absenteeism and feeling embarrassed. Such children are at high risk for getting
sexual exposure and abuse due to their physical maturity. The underlying causes
such as brain tumour need urgent attention and treatment.
Can early puberty be treated?
It is
necessary to investigate the cause of this early puberty. Some blood tests help
in knowing if the puberty has started from the brain, adrenals or the gonads.
An X-ray of the wrist tells us about the accelerated growth and the potential
for final height. Only a rough prediction can be made about the final height in
such cases by looking at wrist x-ray.
Most of
the cases in girls are treatable with monthly/ three monthly injections of
Leuprolide. Boys may need further investigations like MRI brain and adrenal
hormone testing. Treatment in boys mainly depends on the underlying cause. The
puberty is usually delayed by the medications till the child is old and mature
enough to handle the pubertal changes. The treatment halts the puberty and
allows bones to grow for more time, thus helping to grow to a normal height.
Is it safe to halt the puberty by
medications in such cases?
The
medications [Leuprolide] are temporarily delaying the puberty. Puberty usually re-starts
within 6-18 months of stopping the treatment. Occasionally some patients may
have allergy/ pain, otherwise the drug is safe. Rarely patients can have
abscess at the injection site. Patients on treatment need to consume calcium
[Milk, Ragi, Lentils] as the bone keep growing for longer periods at slow pace.
Summary:
Puberty is said to be early if it
starts in girls below 8 and boys below 9 years of age. Early puberty may have
psychologic effects on children. These children are tall in early stages but
their bones stop growing early and they remain short as Adults. Problems in the
brain, pituitary, adrenals, gonads [testes/ovary] and some drugs/chemicals can
cause this problem. Most of these problems are treatable. The purpose of
treatment is to achieve normal height and to delay the puberty till the child
is mature enough to manage it.
Dr.Tushar
Godbole
Pediatric
Endocrinolgist
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