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Obstetrics

Precocious or Early Puberty Development

Puberty is a phase of rapid growth and development that involves physical growth and sexual maturation, along with psychological and social development. The normal age of puberty in girls is 8-12 years whereas in boys it is 10-14 years. Precocious puberty refers to early puberty.

The signs of precocious puberty in girls include:

  • Breast development
  • Menstrual cycle
  • Appearance of underarm and pubic hair
  • Rapid growth such as increase in height
  • Acne

The signs of precocious puberty in boys include:

  • Deepening of voice
  • Appearance of underarm, chest, facial and pubic hair
  • Rapid growth such as increase in height
  • Enlarged penis and testes
  • Acne

Generally puberty is a result of increased hormonal levels in the body, stimulated by the hypothalamic-pituitary-gonadal axis. This stimulation triggers the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). In response to GnRH, the pituitary gland starts releasing luteinizing hormone (LH), which induces the special cells present in the testes and ovaries to produce sex hormones, i.e. testosterone and oestrogen respectively. The increased levels of the specific sex hormones are responsible for the development of secondary sexual characteristics.

Based on the cause of increased hormonal secretion, precocious puberty can be categorized as:

  • Central precocious puberty (CPP)- involves central nervous system i.e. brain and spinal cord
  • Peripheral precocious puberty (PPP)- involves organs other than brain and spinal cord

Causes

In central precocious puberty, underlying causes responsible for precocious puberty remain unidentified. The majority of patients, suffering from this condition, are medically fit, without any identifiable cause for early puberty. In rare cases, central precocious puberty may be secondary to any of the following conditions:

  • Tumour, either in the brain or spinal cord i.e. central nervous system
  • Inborn brain defect such as excessive fluid (hydrocephalus)or noncancerous tumour (hamartoma)
  • Exposure of the brain or spinal cord to harmful radiations
  • Trauma or injury to the brain or spinal cord
  • McCune-Albright syndrome- a genetic disease that affects bones and skin colour; resulting in hormonal disorders
  • Hypothyroidism- a condition characterized by decreased hormonal secretion by the thyroid gland
  • Congenital adrenal hyperplasia- an inherited disorder characterized by dysfunctioning of the adrenal glands

Peripheral precocious puberty (PPP) is a less common condition, in which the Gn-RH is not involved in triggering early puberty. In PPP there is an increased level of sex hormones, i.e. testosterone and oestrogen, secondary to:

  • Tumour in the adrenal or pituitary gland
  • McCune-Albright syndrome
  • Use of creams or ointments containing ingredient which may metabolize to oestrogen or testosterone
  • Ovarian cysts and ovarian tumours (girls)
  • Tumour in the germ cell i.e. leydig cells that produces testosterone (boys)
  • Gene mutation- defect in the gene that produces testosterone in 1-4 year old boys

Complications

The possible complications of precocious puberty are as follows:

  • Short height: due to early release of the hormones the growth plate fuses and further growth stops
  • Social and emotional problems: early puberty generates depression, loss of self-esteem and substance abuse

Diagnosis

The diagnosis of precocious puberty involves physical examination, family history and medical history of the child. The bone growth can be assessed by X-rays of the wrist bone, for evaluation of normal growth. Gn-RH Stimulation test is recommended for determining the type of precocious puberty. The additional tests that may be employed for testing CPP include MRI scan of the brain and thyroid testing, whereas for PPP additional tests may include certain blood tests and ultrasound for detecting ovarian cysts or tumours.

Treatment

The treatment of central precocious puberty involves certain medications, called Gn-RH analogue therapy, that delay the onset of puberty. In peripheral precocious puberty the underlying medical condition causing puberty also needs to be treated. The treatment may include surgical removal of the tumour, which is causing precocious puberty.

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