Precocious Puberty (part 3 of 3)
Dr. Joel Steelman's series on precocious puberty (part 3)
I began this series by describing precocious puberty followed by a post on its causes. This is the final article in this series and will explain diagnosis through discussion and diagnostic testing, treatment of precocious puberty and how to help your child cope with this stress-inducing condition.
Diagnosis through discussion
For a pediatric endocrinologist, getting a complete medical history of the child is the important first step in arriving at a diagnosis. Next, by asking basic questions such as:
- When did you first see signs of puberty?
- How rapidly are you seeing changes of puberty?
- What specific changes of puberty are you seeing?
- Is your child growing too fast?
- Does your child have any other health problems?
The answers provide important clues to any underlying causes of a child’s precocious puberty.
Children with a history of neurological symptoms such as headaches or changes in vision cause concern for puberty problems that may be coming from within the pituitary gland or brain. We’ll ask if the child has access to birth control pills, estrogen creams, or testosterone creams to see if hormone exposure is the culprit of a child’s precocious puberty.
We also look at diet and clues: Phytoestrogens (a compound found in plants that can mimic the effects of estrogen) eaten as part of a high soy diet may lead to premature breast development. Obesity from too many calories can lead to early pubic hair and body odor in some children.
Careful tracking of height and weight on a growth chart is the cornerstone in the physical assessment of precocious puberty. Seeing rapid or even subtle changes in growth patterns can indicate the need for immediate intervention.
A thorough skin examination sometimes reveals the tell-tale sign of Café au lait spots (shown above) that we know are linked to two conditions, Neurofibromatosis and McCune-Albright syndrome. Both of which can spur on precocious puberty.
After taking the child’s medical history and physical exam, next comes medical testing that includes blood work, imaging studies, or other special medical procedures.
A bone age x-ray (example on right) is perhaps the most useful test in helping to evaluate the progression and severity of precocious puberty. The bone age study looks at the appearance of the growth plates in the hand to see if the bones have matured earlier than they should.
A measurement of hormone levels in the blood is used to help confirm early theories on the cause of early puberty as well as evaluate its severity. Hormones measured in testing could include any of the following:
Androgens – hormones made by the adrenal gland that cause pubic hair and body odor
- Gonadotropins – hormones made by the pituitary that activate puberty
- Thyroid hormone – thyroid hormone has a role in regulating puberty
- Estrogen – the female hormone responsible for breast development
- Testosterone – the male hormone responsible for pubic hair and body odor
Sometimes, specialized stimulation testing is needed to help further evaluate our suspicions. We order these tests when a child is in early onset of precocious puberty and blood hormone levels don’t show a definite pattern or in cases where all the information combined fails to give a clear enough picture. Stimulation tests involve more comprehensive blood work combined with IV medications to stimulate temporarily higher hormone levels. Stimulation testing can help in assessing adrenal function to rule out subtle forms of congenital adrenal hyperplasia as well.
Radiology scans such as an MRI of the adrenal glands or ultrasound of the pelvic area may be prescribed to determine the size of the adrenals, ovaries or testes. An MRI brain scan will indicate if the hypothalamus and pituitary gland are normal and often occurs at the end of the testing process when confirmation of a preliminary diagnosis is required.
Once the source of puberty is identified, the options for treatment are then discussed. Sometimes not treating precocious puberty is an option. This happens mainly during cases of idiopathic central precocious puberty. After careful consideration of the risks and benefits, some families simply wish to allow nature to take its course and not intervene.
Today, we are fortunate to have medicines called GnRH (Gonadotropin-releasing hormone) agonists that are effective treatments for the majority of children. They work specifically to stop the progression of central precocious puberty by telling the pituitary gland to ignore the GnRH signal it is receiving from the hypothalamus and tells it to lower or stop the level of sex hormones it is releasing. This countermeasure will also stop bone maturation and help the child reach his or her anticipated adult height. These medications are given by monthly injection or by an implant under the skin.
Helping your child to cope
A diagnosis of precocious puberty and its imposing physical trauma can be emotionally unsettling for any child. The good news is that with the right treatment, both physically and emotionally, a youngster experiencing early puberty can enjoy a normal, happy childhood and grow into a well-adjusted adult.
No child likes to be viewed as ‘different’ than their friends, so it is important for every young person to understand that puberty is a normal process in life that everyone will experience—some earlier than others. As children develop self-esteem and behave according to how they are treated, pay close attention to your child’s interactions with others. If you sense or know that your child is being teased or bullied about the changes in his or her body that puberty has initiated, it’s important that you try to get him or her to talk to you or another trusted adult or medical professional who can offer sound advice on how to cope with what’s happening.
All children need to be taught how to care for their personal hygiene and with this condition, they may also need to change sizes in clothing more frequently. It’s also important to make other adults in your child’s life aware that they should treat your child according to his or her real age, no matter what age they may look like.
About the author
As a self-described ‘techie,’ Joel Steelman, M.D., has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices.