How Doctors Diagnose and Treat Precocious Puberty

From the WebMD Archives

You might think that diagnosing early puberty is simple. If your 6-year-old daughter seems to be developing breasts or your 7-year-old son has hair under his arms, isn't that evidence enough?

Actually, it's not. Early puberty can be hard to diagnose, even for the experts. So how do doctors settle on a diagnosis and treatment plan for precocious puberty? Here’s a rundown of some of the things they might consider.

Is It Early Puberty?

Puberty is considered precocious when it starts, on average, in girls younger than 8 and boys younger than 9. Estimates vary, but some experts say that early puberty affects about 1 out of 5,000 children.

"Of all the kids who are referred to me for signs of early puberty, only about 10% of them have true precocious puberty," says Paul Kaplowitz, MD, PhD, chief of the division of endocrinology at Children's National Medical Center in Washington D.C. "A lot of the parents who come in are very anxious without good cause."

Many of the kids Kaplowitz sees have conditions like premature thelarche and premature pubarche. These can cause, respectively, isolated breast development and pubic hair without other symptoms. These conditions are not signs of puberty, but just normal variations, Kaplowitz says.

If you think your child is showing signs of early puberty, don't make assumptions, says Jami Josefson, MD, an endocrinologist at Children's Memorial Hospital in Chicago. Ask your pediatrician for a referral to an expert, like a pediatric endocrinologist.

Diagnosing Early Puberty

There are two kinds of early puberty. The more common form is central precocious puberty. This is when the brain starts the normal process of puberty -- triggering the release of various hormones -- but does it early. In most cases, there is no known reason. Very rarely, central precocious puberty has a medical cause, like an infection or growth in the brain.

Peripheral precocious puberty is less common. It usually develops when a problem with the ovaries or testicles -- like a cyst or a tumor -- triggers the release of the hormones estrogen or testosterone.

To diagnose early puberty, your child's doctor will ask some questions and run some tests. They might include:

  • A physical exam, to evaluate any changes in the body.
  • A family history, to find out if early puberty might run in the family.
  • Blood tests, which check a child's hormone and sometimes thyroid levels.
  • X-rays, usually of the hand and wrist, to check a child's bone age. This is a way of seeing how quickly he or she is growing.
  • MRIs of the brain. These are sometimes used to rule out medical problems that could cause central precocious puberty, like tumors. MRIs are not routine for most kids. They're used when an underlying cause is more likely, as in children under 6 or kids with other symptoms.
  • Ultrasounds -- of the ovaries, for instance -- can be helpful in some cases.

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Early Puberty: Treatment Options

For central precocious puberty, medications called GnRH analogs are the standard treatment. They work by blocking the hormones coming from the pituitary gland that trigger puberty. Most children who need treatment get these medicines as injections or implants.

  • Injections are given as monthly shots into muscles or daily shots given just under the skin.
  • Implants are tiny tubes -- a little over an inch long -- that are placed under the skin, usually in the upper arm. They gradually release medicine into the body.
  • Nasal sprays are given daily.

GnRH analogs work quite well. During the first month of treatment, the signs of puberty might actually become more pronounced. But after that, they will go away. "In girls, the breasts will have shrunk after 6-12 months of treatment," says Kaplowitz. "In some cases, they almost disappear."



Side effects from GnRH analogs are generally mild. They include headaches, menopausal symptoms (like hot flashes), and abscesses at the injection site. There's no evidence that these drugs cause any long-term problems.

Other treatments for central precocious puberty include:

  • Progestin. Injections of progestin used to be the standard treatment for central precocious puberty. They are less effective than GnRH analogs.
  • Other treatments. Surgery and radiation might be necessary in cases where central precocious puberty has been triggered by a brain tumor. Removing the tumor won't always resolve all the symptoms.

These treatments delay puberty as long as your child takes them. How long does treatment for central precocious puberty last? That depends on the individual child and how well he or she is growing. Some studies have suggested that kids don't benefit from treatment beyond age 11.

Treatment for peripheral precocious puberty is quite different. It depends on the cause. In some cases, surgery might be necessary to remove a tumor or cyst from the ovaries or testicles. Medicines may help in some cases.

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Central Precocious Puberty: Treatment Considerations

While treatment for central precocious puberty works well, not all kids may need it. How would a doctor decide? Here are some things he or she might consider.

  • Time since diagnosis. After seeing a child with signs of early puberty, a doctor might wait up to six months before deciding on treatment. In some children with apparent early puberty, the symptoms slow down or stop on their own.
  • Age. The younger the child, the more likely a doctor will suggest treatment. A 7 1/2-year-old girl with signs of early puberty might not need it. She's already close to the normal age of puberty. Treatment could have a bigger benefit for a 5- or 6-year-old.
  • Rate of development. The rate that puberty is progressing is key. If a girl has some breast development, but it's happening slowly, a doctor might recommend holding off. But rapid changes -- even in an older child -- might mean treatment is a good idea.
  • Current height. Without treatment, most kids with central precocious puberty attain an average height as adults, Kaplowitz says. However, some kids are at a higher risk of being short adults -- specifically, kids who are under 6 and kids who are substantially shorter than average when they start having symptoms. For these children, a doctor is likely to recommend treatment.
  • Emotional maturity. This is related to age, but it's a distinct issue. Some kids have a harder time with the physical and emotional changes of puberty. Menstruation can be confusing or even frightening for some very young girls.

Partnering With Your Child's Doctor

If you think your child is showing signs of early puberty, don't delay in getting help. If you wait too long, it can be harder to control the development, Josefson says.

There's no surefire formula for deciding when a child needs treatment. Doctors have different approaches. It's important to find a doctor whom you trust. If you're not comfortable with his or her suggestions, get a second opinion, Kaplowitz says.

Try to guard against your own anxieties -- and separate your child's feelings from your own. While you might be worried about the possible effects of early puberty, your kid might be doing OK.

If your child is feeling self-conscious about the changes to her body -- or getting teased at school -- a therapist may help. Ask your doctor for a referral to someone who has experience in treating kids with early puberty.

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Early Puberty: Talking to Your Kids

Don't leave everything to the experts. You have an important role to play, too. It might not be easy to discuss early puberty with your child -- you probably thought the dreaded sex talk was a few years off at least -- but you need to do it.

"Parents really need to teach their kids with early puberty what to expect as their bodies change," says Kaplowitz. "I've found that when parents take the time to explain what's happening and prepare their kids, they often handle it quite well."

One of the most important things you can do, Josefson says, is to reassure your kids that they're normal. They don't have a disease and they shouldn't see themselves as sick.

"Parents should help their kids see that central precocious puberty isn't a big medical problem they need to worry about," Josefson says. "They're going through a normal process that everybody goes through. It might have started earlier than usual, but it's still normal."

WebMD Feature Reviewed by Brunilda Nazario, MD on June 02, 2010

Sources

SOURCES:

Paul Kaplowitz, MD, PhD, chief of the division of endocrinology, Children's National Medical Center, Washington D.C.; professor of pediatrics, George Washington University School of Medicine, Washington D.C.

Jami Josefson, MD, assistant professor of pediatrics, Northwestern University Feinberg School of Medicine; attending physician, division of endocrinology, Children's Memorial Hospital, Chicago.

Carel J. Pediatrics, April 2009: vol 123: pp e752-e762.

eMedicine: "Precocious Puberty."

Carel J. New England Journal of Medicine, May 29, 2008; vol 358: pp 2366-2377.

Cesario, S. Journal of Obstetric, Gynecologic, & Neonatal Nursing, May/June 2007; vol 36: pp 263-274.

The Hormone Foundation: "Hormones & You."

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