thelarche
is the appearance of breast tissue
Usually the first and most obvious sign of early puberty
Adrenarche
is the activation of the adrenal cortex for the production of adrenal androgens, and typically occurs before the onset of puberty.
Pubic and axillary hair may appear before, at about the same time, or well after the appearance of breast tissue
menarche
is the age of onset of the first menstrual period – later in puberty
Pubarche
is the appearance of pubic hair, but sometimes used interchangeably with adrenarche
race and pubertal timing
African American girls begin puberty earlier than Caucasian girls
measurement of male genitalia
: early sign of puberty: testicular length is more than 2.5 cm or testicular volume (with Prader orchidometer beads) is 4 mL or more
when does puberty begin?
Age 8 for girls
Age 9 for boys
- early puberty is seen in girls with increased BMI and often more in black girls
girls breast development stages:
Stage 1
prepubertal
Stage 2
- Breast bud stage with elevation of breast and papilla - enlargement of areola
Stage 3
- Further enlargement of breast and areola - no separation of their contour
Stage 4
Areola and papilla form a secondary mound above level of breast
Stage 5
Mature stage: projection of papilla only, related to recession of areola
tanner for girls pubic hair
Stage 1
prepubertal
Stage 2
Sparse growth of long, slightly pigmented hair, straight or curled, along labia
Stage 3
Darker, coarser and more curled hair, spreading sparsely
Stage 4
Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs
Stage 5
Adult female in type and quantity, with horizontal upper border
tanner for boys pubic hair
Stage 1
prepubertal
Stage 2
Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis
Stage 3
Darker, coarser and more curled hair, spreading sparsely
Stage 4
Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs
Stage 5
Adult male in type and quantity, with horizontal upper border
tanner for boys external genitalia
Stage 1
prepubertal
Stage 2
Enlargement of scrotum and testes; scrotal skin reddens and changes in texture
Stage 3
Enlargement of penis (length at first); further growth of testes
Stage 4
Increased size of penis with growth in breadth and development of glans; testes and scrotum larger, scrotal skin darker
Stage 5
Adult genitalia
best way to evaluate precocious puberty
evaluate with bone age
incomplete precocious puberty
Premature pubarche and premature thelarche are two common, benign, normal variant conditions that can resemble precocious puberty but are nonprogressive or very slowly progressive.
- Premature thelarche refers to the isolated appearance of breast development, usually in girls younger than 3 years; (under 3 is usually ok, if there is nothing else going on - above age 4 is problematic )
- Of note, 10% of girls with benign idiopathic thelarche eventually develp true central precocious puberty requiring treatment
- premature pubarche refers to appearance of pubic hair without other signs of puberty in girls or boys younger than 7-8 years (usually progression is slow, so ultimate height is okay)
central precocious puberty
Gonadotropin-dependent–> have activated the whole HPA axis change
- ** Idiopathic central precocious puberty > 80 percent (a diagnosis of exclusion) - if girls have it, its usually not a big deal : almost all idiopathic cases occur in girls
- ** boys, if they have precocious puberty, need to investigate for a tumor
CNS abnormalities:
- hypothalamic hamartomas: benign tumors that secrete GnRH
- tumors
- CNS injury
- congenital anomalies
how to determine central vs peripheral Central precocious puberty
Central precocious puberty can be distinguished from peripheral precocious puberty by measuring LH levels.
In central precocious puberty (GDPP), basal LH levels are often elevated into the pubertal range and show a pubertal (heightened) response to GnRH stimulation.
In peripheral precocious puberty (GIPP), the LH level is low at baseline and fails to respond to GnRH stimulation.
findings of precocious puberty in girls
breast enlargment is usually the first and most obvious sign
pubic and axillary hair may appear before, at about the same time, or well after the appearance of breast tissue
axillary odor, growth spurt, enlargment of the clitoris (indicates sig. androgen excess), mild acne
boys change in prevovious puverty
The earliest sign of central precocious puberty (CPP) is enlargement of the testes, which depends on increased production of follicle-stimulating hormone (FSH); testicular length is more than 2.5 cm or testicular volume (with Prader orchidometer beads) is ***4 mL or more
other signs:
- penis growth, reddening and thinning of scrotum, increaseed pubic hair, growth spurt, acne, voice change
peripheral precocious puberty
1/5 as common
ovarian cysts and tumors: large functioning follicular cyst of the ovaries is the most common cause of peripheral precocious puberty in girls
testicular/leydig cell tumors
adrenal gland tumors
what are androgenic effects?
Acne, hirsutism, increased muscle mass, and clitoromegaly in females –> will focus the differential diagnosis toward androgenic causes of precocious puberty.
esetrogenic effects?
Breast development and changes in the vaginal mucosa are signs of estrogen exposure.
what is the first step in the work up for precocious puberty?
bone age - evaluate nondominant hand and wrist
- helps determine if should be treated or not, if their bone plates have already fused, won’t be able to change their height
what labs are done with precocious puverty?
stimulate GnRH stimulation test to see if there is an increase in LH
in GIPP: , the LH level is low at baseline and fails to respond to GnRH stimulation.
In central: basal LH levels are often elevated into the pubertal range and show a pubertal (heightened) response to GnRH stimulation.
what to worry about for boys younger than 9 w/ PP?
The younger the child with central precocious puberty, the greater the chance of finding CNS pathology (among children younger than 6 years).
*** For boys younger than 9 years, the incidence of CNS findings is much higher than in girls, and MRI should be part of the evaluation.
Note: For healthy girls aged 6-8 years with no signs or symptoms of CNS disease, the likelihood of finding a tumor or hamartoma is only about 2%; therefore, this test may be unnecessary depending on the clinical situation.
treatment for central precocious puberty
Primary goal of treatment for GDPP is to allow a child to grow to a normal adult height.
Medical:
GnRH analogs or agonists
Example: Leuprolide
- Increases final adult height
