Precocious puberty in girls and the risk of a central nervous system abnormality: the elusive search for diagnostic certainty

Changing Etiological Trends in Male Precocious Puberty: Evaluation of 100 Cases with Central Precocious Puberty over the Last Decade

BACKGROUND/AIMS

There are few studies in the literature that have evaluated the etiological factors in boys with central precocious puberty (CPP), and these studies are limited in terms of the sample size. In the present study, we aimed to evaluate the etiological factors in male CPP cases.

METHODS

One hundred male CPP subjects, aged between 9 months and 10.5 years, were included. The medical records were screened, and age at diagnosis, bone age, body weight, height, pubertal stage, imaging findings of the pituitary gland, testosterone, and basal and stimulated gonadotropin levels were recorded.

RESULTS

There was no underlying cause in 74% of the cases, and an organic cause was determined in only 26%. Most of the organic cases had been diagnosed before the age of 7 years, whereas most of the idiopathic cases had been diagnosed after the age of 7 years.

CONCLUSION

An organic cause was determined in 26% of the male patients with CPP. This rate is one of the lowest rates in the literature and indicates that the number of idiopathic male CPP cases is increasing over time. When a boy is diagnosed with CPP above the age of 7 years, the odds of detecting an underlying pathology are very low, and these cases are mostly idiopathic.

A longitudinal assessment of early pubertal timing as a predictor of psychosocial changes in adolescent girls with and without spina bifida

OBJECTIVE

A longitudinal comparison of adolescent girls with and without spina bifida (SB), regarding the effects of early pubertal timing on girls' depressive symptoms, mother-daughter conflict, and emotional distancing.

METHODS

62 mother-daughter dyads (31 with SB and 31 without) reported on psychosocial outcomes at 5 time points (ages 8/9 to 16/17 years).

RESULTS

A pubertal timing × SB status interaction predicted emotional distancing (T2), conflict (T2, T5), and depressive symptoms (T4), such that early maturing girls without SB reported the greatest increase in each outcome. Main effects of pubertal timing predicted emotional distancing (T4), conflict (T4), and depressive symptoms (T2, T3, T5). Findings were not always consistent across reporters, assessments of pubertal timing, and time-points.

CONCLUSIONS

Although early maturing girls in both groups may experience greater psychosocial difficulties, early maturing girls without SB may be most at-risk. The somewhat reduced impact of early pubertal timing in girls with SB is discussed.

Gonadotropin-dependent precocious puberty: neoplastic causes and endocrine considerations

Premature activation of the hypothalamic-pituitary-gonadal (HPG) axis manifests as gonadotropin-dependent precocious puberty. The mechanisms behind HPG activation are complex and a clear etiology for early activation is often not elucidated. Though collectively uncommon, the neoplastic and developmental causes of gonadotropin-dependent precocious puberty are very important to consider, as a delay in diagnosis may lead to adverse patient outcomes. The intent of the current paper is to review the neoplastic and developmental causes of gonadotropin-dependent precocious puberty. We discuss the common CNS lesions and human chorionic gonadotropin-secreting tumors that cause sexual precocity, review the relationship between therapeutic radiation and gonadotropin-dependent precocious puberty, and finally, provide an overview of the therapies available for height preservation in this unique patient population.

Pubertal development and menarche

Puberty is the developmental process that culminates in reproductive capability and is the result of a complex series of molecular and physiological events. The release of gonadotropin-releasing hormone from specialized neurons of the hypothalamus begins the hormonal cascade that causes gonadal activation and the physical changes of puberty. Several factors have been proposed to influence the activation of the hypothalamus to trigger puberty, but the involved pathways have not been fully elucidated. The recent observations that the age of pubertal onset may be lowering in American girls calls attention to the lack of knowledge of modulating factors that affect the pubertal process. Genes necessary for puberty have been found by studying persons who do not achieve puberty; such studies have provided insights into the pathways necessary for pubertal development. A multidisciplinary focus is required to elucidate the complex mechanisms involved in the initiation and progression of puberty.

Puberty: timing is everything

When evaluating delayed puberty, it is essential to determine the underlying cause. This can be done with history and physical exam as well as basal gonadotropin levels, bone age, and further testing as indicated. When the cause is hypogonadism, an underlying condition should be treated if present; otherwise lifelong hormonal therapy is necessary. When constitutional delay is present, each case must be handled individually. Most patients can be reassured while some may require transient hormonal treatment for psychosocial reasons. Patients receiving hormonal therapy may require assistance from an endocrinologist and close monitoring.

El tratamiento con triptorelina en las niñas con pubertad precoz central provoca incremento del índice de masa corporal

INTRODUCTION

The most important complications of central precocious puberty (CPP) in girls are loss of height and multiple psychosocial problems.

OBJECTIVES

To study the effect of triptorelin therapy in a cohort of girls with CPP.

PATIENTS AND METHODS

Thirty-four girls diagnosed with organic or idiopathic CPP and treated with monthly triptorelin were studied. Age, height in standard deviation (SD), bone age (Greulich and Pyle), height prediction (Bayle-Pinneau), body mass index (BMI) in SD, uterine size (pelvic ultrasound), target height, cranial magnetic resonance imaging, triptorelin dose, and treatment duration were studied.

RESULTS

Triptorelin produced a statistically significant reduction in growth velocity and an increase in BMI after 1 year of therapy and these changes were maintained after discontinuation of therapy. Adult height in these patients was in accordance with their target genetic height, as well as with their predicted height according to the method of Bayley-Pinneau. No significant differences were found between age of menarche in our patients and in controls. Adult height in patients with organic CPP was significantly lower than that in patients with idiopathic CPP.

CONCLUSIONS

1. Triptorelin can increase BMI in girls with CPP. 2. The presence of an organic cause in patients with CPP worsens the prognosis for adult height. 3. The Bayley-Pinneau prediction method for "average" bone age is useful for establishing a prognosis of adult height in girls with CPP treated with triptorelin.

Presentation and evolution of organic central precocious puberty according to the type of CNS lesion

OBJECTIVE

To evaluate the influence of the type and treatment of CNS lesion causing central precocious puberty (CPP) on the presentation, hypothalamic-pituitary function and final height.

PATIENTS

One hundred patients with CPP caused by central nervous system (CNS) lesion.

RESULTS

The CPP was the presenting symptom of the lesion in 25 (10 boys) and occurred in 75 patients (23 boys) previously treated for lesions. These were optic glioma or astrocytoma (n = 45), hydrocephalus (n = 22), hypothalamic hamartoma (n = 15), suprasellar arachnoid cyst (n = 10) and others (n = 8). The percentages of patients with increased height, bone age advance, testicular volume, LH/FSH peaks ratio after gonadotrophin-releasing hormone (GnRH) test and plasma testosterone concentration in boys and oestradiol in girls varied from one aetiology to another. The boys with hamartoma were significantly taller and had greater bone age advance, LH peak and testosterone than boys with optic glioma. The girls with hamartoma and suprasellar arachnoid cyst were significantly younger and had greater LH peak than girls in the other groups. All patients treated for optic glioma had hypothalamic-pituitary deficiencies, including GH (100%), thyrotrophin (71.4%), corticotrophin (12.5%) and pubertal (34.3%) deficiencies. Sixty percent of those with suprasellar cysts lacked GH. Final height was below -2 SD in 15/59 (25%) patients, including 5/11 not treated with GnRH analogue, 3/5 not treated with GH despite GH deficiency, and 2 with hydrocephalus as a result of meningomyelocele.

CONCLUSIONS

The type of CNS lesion influences the presentation of CPP. This is probably caused by differences in the mechanisms inducing puberty and to the hypothalamic-pituitary deficiencies associated with the CPP as a result of a lesion and/or its treatment.

Early growth acceleration in girls with idiopathic precocious puberty

OBJECTIVE

To determine the growth pattern of girls with idiopathic precocious puberty (IPP) from birth until diagnosis.

STUDY DESIGN

We studied 47 girls with IPP and 35 control girls. In each subject, height and weight were measured at diagnosis, whereas data on height from birth until diagnosis were taken from the personal health book of the patient. Height standard deviation score (HSDS) and body mass index SDS were calculated.

RESULTS

Mean age (+/-SD) of the girls with IPP was 7.6 (1.1) years and of control girls was 7.5 (0.9) years. At birth, HSDS of the patients with IPP was -0.01 (0.8); at the age of 2 years, 0.42 (1.2); at the age of 4 years, 0.64 (1.1); and at diagnosis, 1.23 (1.7) (P < .001). HSDS of control girls was 0.02 (0.8) at birth, 0.25 (0.8) at 2 years, 0.12 (0.9) at 4 years, and 0.19 (1.1) at assessment (P > .05). There was no statistical difference between body mass index SDS of the patients 0.6 (1.1) versus that of control girls 0.5 (1.0).

CONCLUSIONS

The early growth acceleration pattern may be used as an additional clue to the diagnosis of idiopathic precocious puberty.

[Idiopathic central precocious puberty in girls in Bahia, Brazil]

INTRODUCTION

Although the therapeutic effects of GnRH analogues (GnRHa) in central precocious puberty (CPP) have been established, clinical aspects may vary according to racial groups.

OBJECTIVE AND METHODS

To describe the profile of 175 girls from Bahia, Brazil, treated with GnRHa for idiopathic CPP.

RESULTS

The mulatto racial group predominated in the sample. The chronological age at puberty was 6.3 +/- 0.1 years. At diagnosis, height was 2.2 +/- 0.1 SD and body mass index (BMI) was 1.5 +/- 0.1 SD (> 2 SD in 32%), this one, inversely associated with age at onset of puberty (R = -0.20, p = 0.008). At treatment, chronological and bone ages were 8.4 +/- 0.1 years and 10.3 +/- 0.1 years, respectively. At the end of treatment (n = 52) age, BMI and height were 10.6 +/- 0.1 years, 1.6 +/- 0.2 SD and 1.9 +/- 0.2 SD, respectively.

CONCLUSION

Clinical presentation and evolution were similar to other studies, independently of racial characteristics. In this sample, treatment with GnRHa was not associated to significant weight gain.

Selecting girls with precocious puberty for brain imaging: validation of European evidence-based diagnosis rule

OBJECTIVES

To test the sensitivities of recently published American recommendations predicting occult intracranial lesion (OICL) in girls with central precocious puberty (CPP), and to validate a previously derived diagnosis rule predicting OICL based on age at puberty onset and estradiol (E2) level.

STUDY DESIGN

A retrospective, multicenter, hospital-based, cohort study was performed, including all girls with CPP seen in 7 centers in 6 European countries during given periods. American recommendations and the previously derived diagnosis rule were tested.

RESULTS

Girls with CPP (n=443), including 35 with OICL, were recruited. American recommendations did not identify all OICL. Previously identified independent risk factors for OICL were confirmed: age <6 years (adjusted odds ratio 20.5; 95% CI, 8.1-52.1) and E2 >45th percentile (3.0; 95% CI, 1.3-7.1). The previously derived diagnosis rule had 100% sensitivity (95% CI, 90-100): all girls with OICL had either an age <6 years or an E2 level >45th percentile. The specificity was 39% (95% CI, 34-44).

CONCLUSIONS

American recommendations do not seem safe to select European girls with CPP who require brain imaging. In settings where systematic brain imaging is not possible, the proposed diagnosis rule could safely help to avoid more than one third of unnecessary brain imaging.