Precocious Puberty: Signs, Symptoms, Diagnosis & Treatment

Puberty is a developmental stage that marks the transition from childhood to adulthood (1). Girls reach puberty between the ages of eight and thirteen, whereas boys reach puberty between nine and fourteen years (2). Precocious puberty or early puberty occurs when a girl reaches puberty before eight years and a boy before nine years (3). It is more common in girls than boys (4).

The most common cause of early puberty is an acceleration in the normal physiological process. In some cases, though, it may indicate an underlying health concern. Therefore, parents must be aware of the indications and symptoms of early puberty.

Read on to learn about the signs and symptoms of premature puberty, how to diagnose it, and what treatment options are available.

Signs and Symptoms Of Precocious Puberty

The development of secondary sexual characteristics is the most common symptom of early puberty. A child may experience the following symptoms that are almost the same as the signs of regular puberty (3)(4)(5).

Signs of early puberty in girls and boys

• Increase in height (growth spurt) faster than peers

• Development of pubic, underarm, and facial hair

• Development of acne

• Increased moodiness

• Increased aggression

• Voice change

Signs of early puberty in girls

• Breast growth and development

• Ovulation

• Early menstruation or vaginal bleeding

Signs of early puberty in boys

• Increase in the muscle mass

• Deepening of the voice

• Enlargement of the penis and testicles

• Spontaneous erections or ejaculations

• Production of sperm

The development of adult-like body odor is another symptom of early puberty in girls and boys. Most children with precocious puberty grow quickly, and then their growth ceases before they reach their full genetic height potential.

Causes Of Precocious Puberty

Let’s understand these causes of precocious puberty based on the different types of the condition (3) (6) (7) (8):

1. Central precocious puberty (CPP): CPP, also known as gonadotropin-dependent puberty, occurs when the brain causes a premature secretion of gonadotropins, triggering early puberty. Gonadotropins are hormones released by the master gland or pituitary gland to signal sex hormone release from ovaries in girls and testicles in boys. The cause for CPP is often unidentifiable. However, in some cases, the following may trigger precocious puberty:

• Abnormality of the pituitary gland or hypothalamus, the portion of the brain that controls the pituitary

• Congenital disabilities, such as excess fluid build-up (hydrocephalus)

• Exposure of the brain or spinal cord to radiation

• Injury to the brain or spinal cord

• Problem with the thyroid gland, such as hypothyroidism (underactive thyroid gland)

CPP is the most common type of precocious puberty, and it is known to affect more girls than boys.

2. Peripheral precocious puberty (PPP): PPP, also known as gonadotrophin-independent puberty, is a rare puberty type where the sex glands, such as the ovaries in girls and testes in boys, start working earlier than they would typically do. This early functioning of the glands could happen due to

• Tumor in the adrenal gland or pituitary gland.

• Tumor in the germ cells (cells that make sperm) or Leydig cells (cells that produce testosterone)

• Cysts or tumors in the ovaries in girls or testicles in boys

3. Premature adrenarche: Premature adrenarche refers to when the adrenal glands produce weak male hormones (adrenal androgens) earlier than normal. Due to early hormone production, the child may develop secondary sexual characteristics such as pubic hair and body odor before eight years of age.

4. Premature thelarche: In some cases, girls between birth to eight years may show breast development. This condition is known as premature thelarche. Premature thelarche usually disappears as the child grows, and even if it persists, it doesn’t cause any physical changes.

Both premature adrenarche and premature thelarche are not causes for concerns, and hence, require no treatment.

Trigger Factors For Precocious Puberty

The following are some risk factors for precocious puberty in children (9) (10).

1. Gender: Girls are more likely to develop precocious puberty than boys. In girls, 90 to 95% of precocious puberty cases occur with no known cause. On the other hand, boys usually have an underlying cause that is detectable (4).

2. Ethnicity: A study suggests that African-American girls have some early breast and pubic hair development than white or Hispanic girls, and the chance increases if the girl is obese (11) (12). Clinical studies establishing the effect of ethnicity on puberty in boys/males are scarce.

3. Obesity: A 2017 cross-sectional study has shown that early pubertal development is positively associated with obesity. The study also highlights that the risk of early puberty is higher in girls than boys (13).

4. Family history or genetics: A child born into a family with a history of early puberty is more likely to develop the disorder than other children. Research shows that the MKRN3 gene causes the child to inherit the mutation from their father (14).

5. Other medical conditions: Congenital disabilities, such as adrenal hyperplasia and certain rare genetic syndromes, such as McCune-Albright syndrome, can increase a child’s risk of developing precocious puberty.

6. Estrogen or androgen exposure: A child is at a higher risk of developing precocious puberty when exposed to products containing estrogen or testosterone. Certain creams, ointments, medications, and supplements can contain these sex hormones.

7. Radiation exposure: The chance of developing precocious puberty increases if a child is exposed to radiation. A child undergoing radiation therapy for treating leukemia or tumors can get exposed to radiation, raising their risk of precocious puberty.

Consult a doctor promptly if your child has any of the risk factors mentioned above, along with symptoms of early puberty.

Diagnosis Of Precocious Puberty

A doctor will examine the child and take a note of their symptoms. They will also enquire about the child and their family’s medical history. Based on the suggestive findings, they may perform or order the following tests (4) (5) (15).

1. Physical examination: A pediatrician will thoroughly examine the child and look for the growth of pubic hair and breasts in girls and an increase in the size of the testicles and penis in boys. They will then compare their findings against the Tanner scale, a five-point scale that helps determine the extent of puberty development in children.

2. Blood tests: Blood tests help determine the hormone levels of a child. The different hormones that the doctor will check are

• Luteinizing hormone (LH)

• Follicle-stimulating hormone (FSH)

• Estradiol, a form of estrogen

• Testosterone

• Thyroid hormones

Further, the doctor may also do a gonadotropin-stimulating hormone (GnRH) test to determine how well the pituitary works.

3. GnRH test: Apart from checking the pituitary function, this hormone test helps determine the type of precocious puberty. In this test, a child is injected with gonadotropin-releasing hormone (GnRH).

4. X-ray: An x-ray, a non-invasive and safe test, may be done to determine the child’s bone age, which will help determine how fast the child is maturing. Usually, a doctor performs a single x-ray on the child’s hand and wrist. If a child’s bone age (as per the x-ray) is older than their birth age, it indicates early bone maturation.

5. Ultrasound (sonography): Ultrasound is most commonly done in children with peripheral precocious puberty. This test creates images of the blood vessels, tissues, and organs, to examine and locate abnormalities such as cysts and tumors in the adrenal glands, ovaries, and testes.

6. Magnetic resonance imaging (MRI): An MRI may also be done to detect the abnormalities in the brain and pituitary gland.

A timely diagnosis of precocious puberty is necessary for prompt management of the condition.

Possible Outcomes Of Precocious Puberty

Precocious puberty can lead to complications, such as (16) :

1. Short stature: Precocious puberty can make a child grow quickly for the first few years, and then their growth can stop earlier than their peers. Early cessation of vertical growth happens in precocious puberty because the child’s bones mature more quickly than average, leading to short stature. Prompt treatment of precocious puberty in young children can help them attain the maximum possible adult height.

2. Socio-emotional issues: Puberty brings about tremendous physical, physiological, and emotional changes in a child. These changes can impact a child more deeply when puberty sets in earlier than The sense of being different can make a child feel embarrassed and highly self-conscious. As a result, such children may avoid social interaction, gradually slipping into isolation. Coupled with hormonal changes, they may experience erratic mood swings and increased aggressiveness, increasing their risk of depression or substance abuse.

3. Sexual problems: Precocious puberty brings about early sexual changes in a child. These changes may make a child indulge in sexual activities early. However, this isn’t a pattern that every child follows. So, parents mustn’t be worried. Instead, they should talk to their child openly and explain to them about precocious puberty and the sexual changes they are experiencing.

Moreover, a child with early puberty may feel stressed and confused, which can affect their academic performance. Therefore, taking timely and prompt action is vital.

Treatment For Precocious Puberty

The doctor may follow a “wait and watch” approach if precocious puberty progresses slowly. They may also do this if the child has developed the early puberty closer to average pubertal age. In these cases, the doctor monitors the child’s growth and development for several months without any medications.

In other cases, the treatment will depend on the precocious puberty type and the underlying cause (if known). The main aim of the treatment is to treat the underlying course (3) (4).

Treating central precocious puberty

The basic treatment modality involves stopping gonadotrophin secretion. Here, the child gets a synthetic luteinizing hormone-releasing hormone (LHRH) injection. This injection halts the sexual maturation of the child by ceasing the gonadotrophin release from the pituitary gland.

The child gets the LHRH injection on a regular basis, giving a sustained hormone release for a year. This treatment, in most cases, continues until the average pubertal age.

Once the medication stops, the child progresses through puberty normally, although they may grow and develop faster than average. Also, they may experience short-term side effects, such as pain or irritation at the injection site.

Treating peripheral precocious puberty

The treatment for PPP depends on the cause of excess estrogen or androgen production. Depending on the specific reasons, such as tumor or cyst development, the treatment options may include :

• Removing the tumor or the cyst.

• Blocking the actions of estrogen or androgen on the body.

• Treating hypothyroidism with thyroid hormone replacement therapy.

Is Precocious Puberty Preventable?

Preventing precocious puberty isn’t possible. However, you can take prompt steps to manage it and help your child grow and develop without any physical or mental concerns. Here are a few ways in which you can help your child.

1. Treat your child like a normal child. It will help them overcome the sense of being different from others and boost their self-esteem and confidence. To do this, explain to your child that puberty is a normal physiological process that everyone experiences at different times. For some, it may start early, and for others, late. But, eventually, it’s a common phenomenon that everyone experiences. Let them know that there’s nothing awkward about early puberty changes.

2. Listen to them patiently. Children may have concerns, and they may want to share their experiences. So, talk to them and answer their queries empathetically. Precocious puberty causes early sexual maturation. So, the child may develop sexual desires earlier than their peers. If that’s the case with your child, talk to them openly and set clear boundaries.

3. Explain to them the condition in detail. It will help the child know what is happening and what they can do to manage it. For instance, if a girl child develops her breasts or starts her periods early, explain the changes that are happening and teach them ways to maintain personal hygiene during periods.

4. Work on risk factors. For instance, estrogen or progesterone-containing medications, creams, ointments, and dietary supplements can expose your child to these hormones. So keep your child away from such products. Likewise, encourage your child to maintain a healthy weight. Since obesity is a risk factor for precocious puberty, maintaining a healthy weight may help lower the risk to some extent.

5. Involve your child in positive activities such as arts and crafts, dance, music, and sports. It will help them channelize their energies in a positive direction. Also, interacting with children of similar interest give their self-esteem and confidence a boost.

6. Seek prompt medical help if the child is hesitant to open up to you or shows signs of extreme distress that you can’t handle. Talking to a counselor can help a child vent out. Besides, the counselor can teach the child coping skills and techniques to help manage their situation better.

References

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Reviewer

Dr. Supriya MahajanDNB, PDCC

   

Dr. Supriya Mahajan is a pediatrician and pediatric hepatologist with 16 years of experience. She completed her MBBS from Shyam Shah Medical College and diploma from the National Board of Education, New Delhi. She went on to gain specialization in the gut and liver-related diseases in children from the Institute of Liver and Biliary Sciences and MRCPCH 1, 2 from the Royal College of Pediatrics and Child Health (RCPCH), UK.

Read full bio of Dr. Supriya Mahajan