1
|
Leung AKC, Lam JM, Hon KL. Premature Thelarche: An Updated Review. Curr Pediatr Rev 2024; 20:500-509. [PMID: 37496240 DOI: 10.2174/1573396320666230726110658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/06/2023] [Accepted: 06/20/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Premature thelarche is the most common pubertal disorder in girls. The condition should be differentiated from central precocious puberty which may result in early epiphyseal fusion and reduced adult height, necessitating treatment. OBJECTIVES The purpose of this article is to familiarize physicians with the clinical manifestations of premature thelarche and laboratory tests that may help distinguish premature thelarche from central precocious puberty. METHODS A search was conducted in September 2022 in PubMed Clinical Queries using the key term "Premature thelarche". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used to compile the present article. RESULTS Premature thelarche denotes isolated breast development before the age of 8 years in girls who do not manifest other signs of pubertal development. The condition is especially prevalent during the first two years of life. The majority of cases of premature thelarche are idiopathic. The condition may result from an unsuppressed hypothalamic-pituitary-gonadal axis in the early years of life, an "overactivation" of the hypothalamic-pituitary axis in early childhood secondary to altered sensitivity to steroids of the hypothalamic receptors controlling sexual maturation, increased circulating free estradiol, increased sensitivity of breast tissue to estrogens, and exposure to exogenous estrogens. The cardinal feature of premature thelarche is breast development which occurs without additional signs of pubertal development in girls under 8 years of age. The enlargement may involve only one breast, both breasts asymmetrically, or both breasts symmetrically. The breast size may fluctuate cyclically. The enlarged breast tissue may be transiently tender. There should be no significant changes in the nipples or areolae and no pubic or axillary hair. The vulva, labia majora, labia minora, and vagina remain prepubertal. Affected girls have a childlike body habitus and do not have mature contours. They are of average height and weight. Growth and osseous maturation, the onset of puberty and menarche, and the pattern of adolescent sexual development remain normal. Most cases of premature thelarche can be diagnosed on clinical grounds. Laboratory tests are seldom indicated. No single test can reliably differentiate premature thelarche from precocious puberty. CONCLUSION Premature thelarche is benign, and no therapy is necessary apart from parental reassurance. As enlargement of breasts may be the first sign of central precocious puberty, a prolonged follow- up period every 3 to 6 months with close monitoring of other pubertal events and linear growth is indicated in all instances.
Collapse
Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, China
- Department of Paediatrics, and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| |
Collapse
|
2
|
Choi Y, Barbier N, Fürst-Recktenwald S, Ye J, Wajsbrot DB, Ishida E, Gamalo M. Analysis and reporting of pediatric growth and development assessment from clinical trials: overview and challenges. J Biopharm Stat 2023; 33:786-799. [PMID: 36541817 DOI: 10.1080/10543406.2022.2154357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Pediatric drug development has many unique challenges, one of which is the evaluation of growth and development changes in children that are expected and are not due to the study intervention. Children grow and mature at different pace. The potential impact of the drug could vary with the developmental age of the participants receiving the treatment. For example, sexual maturation is a critical consideration in children of age 10 and above, but not in younger age groups. How the investigational drug impacts children is ultimately a risk-benefit consideration. In this paper, practical considerations and recommendations are provided on how to assess growth and development based on data collected from clinical trials in pediatric patients. The endpoints and measures related to growth, sexual maturation and neurocognitive development are discussed. Basic analysis approaches are recommended.
Collapse
Affiliation(s)
- YounJeong Choi
- Data and Statistical Sciences, Genentech Inc, South San Francisco, California, USA
| | | | | | - Jingjing Ye
- Global Statistics and Data Sciences, BeiGene, Fulton, Maryland, USA
| | | | - Eiji Ishida
- Data Science, Sunovion Pharmaceuticals Inc, Marlborough, MA, Massachusetts, USA
| | - Margaret Gamalo
- Global Product Development, Pfizer Inc, New York, New York, USA
| |
Collapse
|
3
|
Kang S, Park MJ, Kim JM, Yuk JS, Kim SH. Ongoing increasing trends in central precocious puberty incidence among Korean boys and girls from 2008 to 2020. PLoS One 2023; 18:e0283510. [PMID: 36947549 PMCID: PMC10032490 DOI: 10.1371/journal.pone.0283510] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Over the last few decades, there has been growing evidence of earlier onset and progression of puberty worldwide. This population-based longitudinal cohort study aimed to analyze the change in the annual incidence rate of central precocious puberty (CPP) among Korean children over the most recent decade, using the national registry data. METHOD The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and insurance claims for gonadotropin-releasing hormone agonist (GnRHa) treatment were used to identify CPP patients who were using the Korean Health Insurance Review & Assessment Service (HIRA) database between 2008 and 2020. Patients who began GnRHa therapy before the age of 9 and 10 for girls and boys, respectively, were included in the study. RESULTS A total of 6,906 boys and 126,377 girls were diagnosed with CPP between 2008 and 2020. The annual incidence of CPP increased by 83.3 times in boys (from 1.2 to 100 per 100,000 persons) and by 15.9 times in girls (from 88.9 to 1414.7 per 100,000 persons). The age-specific annual incidence of CPP increased remarkably more in older children than in younger ones; the 2020 CPP incidence among 9-year-old boys and 8-year-old girls reached 705.2 and 7,967.3 per 100,000 persons, respectively. The annual prevalence of CPP in boys and girls increased from 2.7 to 206.5 (76.5 times) and from 141.8 to 3439.9 (24.3 times) per 100,000 persons, respectively. CONCLUSION Based on GnRHa treatment insurance claims, our study suggests that the annual incidence of CPP has substantially increased in Korea during the past 13 years. These findings highlight the importance of meticulous judgment by doctors in determining GnRHa treatment.
Collapse
Affiliation(s)
- Sinyoung Kang
- Department of Pediatrics, Samil Hospital, Daegu, Korea
| | - Mi Jung Park
- Dr. Park Mijung's Child Growth Clinic, Seoul, Korea
| | - Jung Min Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Shin-Hye Kim
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea
| |
Collapse
|
4
|
Abstract
Onset of puberty, as defined by breast stage 2, appears to be starting at younger ages since the 1940s. There is an ongoing controversy regarding what is normative, as well as what is normal, and the evaluation that is deemed necessary for girls maturing before 8 years of age. There are potential implications of earlier pubertal timing, including psychosocial consequences during adolescence, as well as longer term risks, such as breast cancer and cardiometabolic risks. There are additional consequences derived from slower pubertal tempo, for age of menarche has not decreased as much as age of breast development; these include longer interval between sexual initiation and intentional childbearing, as well as a broadened window of susceptibility to endocrine-related cancers.
Collapse
Affiliation(s)
- Colby E Smith
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center
| | - Frank M Biro
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
5
|
Chen Y, Liu J. Do Most 7- to 8-Year-Old Girls with Early Puberty Require Extensive Investigation and Treatment? J Pediatr Adolesc Gynecol 2021; 34:124-129. [PMID: 33276126 DOI: 10.1016/j.jpag.2020.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/14/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To investigate the etiology, progression, and treatment of precocious puberty in 7- to 8-year-old girls with breast development. Additionally, we evaluated the value of diagnostic tests in differentiating rapidly progressive precocious puberty (RP-PP) and slowly progressive precocious puberty (SP-PP) in these girls. DESIGN Ambispective cohort study. SETTING Single-center, pediatric endocrinology unit. PARTICIPANTS Girls with breast development between the ages of 7 and 8 years and assessed between July 2016 and July 2018. INTERVENTIONS Collected of clinical data and followed-up for 2 to 3 years. Girls were divided into RP-PP and SP-PP groups. MAIN OUTCOME MEASURES Described the etiology, rate of progression of puberty, and proportion intervened and compared the results of auxiliary examinations between the groups. RESULTS A total of 212 girls were enrolled, of which 211 (99.53%) were diagnosed with central precocious puberty (CPP) and 1 with peripheral precocious puberty (PPP). Hypophysis magnetic resonance imaging revealed that none had pathological brain lesions requiring surgical intervention. A total of 95 girls (44.81%) developed RP-PP, and 117 girls (55.19%) developed SP-PP. A total of 31 girls (14.62%) with RP-PP received treatment due to deteriorated predicting adult height. As compared with the SP-PP group, the RP-PP group showed more advanced bone age (BA), a higher level of basal luteinizing hormone (LH), and larger ovarian volume and uterine volumes. Receiver operating characteristic analyses revealed that BA was the best at identifying girls with RP-PP. CONCLUSION The majority of girls with breast development between the ages of 7-8 years do not need treatment. BA is a useful preliminary test for identifying girls with RP-PP who are more likely to require treatment.
Collapse
Affiliation(s)
- Yun Chen
- Department of Pediatrics, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jian Liu
- Department of Pediatrics, Affiliated Baoan Hospital of Shenzhen, Southern Medical University, Shenzhen, China.
| |
Collapse
|
6
|
Kim YJ, Kwon A, Jung MK, Kim KE, Suh J, Chae HW, Kim DH, Ha S, Seo GH, Kim HS. Incidence and Prevalence of Central Precocious Puberty in Korea: An Epidemiologic Study Based on a National Database. J Pediatr 2019; 208:221-228. [PMID: 30857777 DOI: 10.1016/j.jpeds.2018.12.022] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 11/07/2018] [Accepted: 12/06/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate the prevalence and incidence of central precocious puberty in Korea using claims data provided by the Health Insurance Review and Assessment Service in Korea as the population-based epidemiologic study. STUDY DESIGN In this national registry-based, longitudinal, epidemiologic study, patients who were registered with an International Classifications of Diseases, Tenth Revision diagnosis of central precocious puberty (E22.8 according to International Classifications of Diseases, Tenth Revision) and treated with gonadotropin-releasing hormone agonist were included. We assessed the age- and sex-specific prevalence and incidence rates of central precocious puberty in Korea from 2008 to 2014. RESULTS A total of 37 890 girls and 1220 boys were newly registered with a diagnosis of central precocious puberty from 2008 to 2014. The overall incidence of central precocious puberty during the study period was 122.8 per 100 000 persons (girls, 262.8; boys, 7.0). The overall prevalence of central precocious puberty during the study period was 193.2 per 100 000 persons (girls, 410.6; boys, 10.9). The incidence and prevalence of central precocious puberty steeply increased during the study period in both girls and boys. CONCLUSIONS This epidemiologic study, based on a national registry that included Korean children, demonstrated that the incidence and prevalence rates of central precocious puberty were high and increased steeply during the study period. Further investigations to determine the underlying causes for this rapid increase in central precocious puberty are needed.
Collapse
Affiliation(s)
- Ye Jin Kim
- Department of Pediatrics, Inje University Haeundae Hospital, Busan, Korea
| | - Ahreum Kwon
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, Bundang CHA Medical Center, CHA University, Gyeonggi-do, Korea
| | - Ki Eun Kim
- Department of Pediatrics, Gangnam Cha Hospital, CHA University, Seoul, Korea
| | - Jungwhan Suh
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | | | - Sangmi Ha
- Korean Health Insurance Review and Assessment Service, Seoul, Korea
| | - Gi Hyeon Seo
- Korean Health Insurance Review and Assessment Service, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
7
|
Farello G, Altieri C, Cutini M, Pozzobon G, Verrotti A. Review of the Literature on Current Changes in the Timing of Pubertal Development and the Incomplete Forms of Early Puberty. Front Pediatr 2019; 7:147. [PMID: 31139600 PMCID: PMC6519308 DOI: 10.3389/fped.2019.00147] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/29/2019] [Indexed: 01/25/2023] Open
Abstract
Puberty is a sensitive period of life characterized by the appearance of secondary sex characteristics which leads to a complete sexual maturation. It physiologically starts between the age of 8 and 13 years in girls and 9 and 14 years in boys. In the last two decades, several studies have showed that start of puberty has moved up to younger ages by 12-18 months, and some of the hypotheses trying to explain this change include the role of nutritional status and obesity and the influence of extrinsic factors such as exposure to endocrine-disrupting chemicals (EDCs), as well. The hypothalamic-hypophysis-gonadal axis develops during embryogenesis, and except for a period of activation immediately after birth, remains suppressed until the onset of pubertal development. At the beginning of puberty, the pulse generator is reactivated, probably due to progressive stimulatory influences on GnRH neurons from glial signals and neurotrasmitters. Kisspeptin and its receptor play a fundamental role in this phase. Premature Pubarche/Adrenarche, Premature Thelarche, and Premature Menarche are incomplete forms of precocious pubertal development that have their origin in endocrine mechanisms that only recently have started to be understood. It is important to distinguish these forms from the complete ones in order to reassure patients and parents about the non-evolution of pubertal progression and avoid non-useful treatments with analogous LHRH.
Collapse
Affiliation(s)
- Giovanni Farello
- Pediatric Unit, Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Carla Altieri
- Pediatric Unit, Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maristella Cutini
- Pediatric Unit, Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Alberto Verrotti
- Pediatric Unit, Department of Biotechnology and Applied Sciences, University of L'Aquila, Aquila, Italy
| |
Collapse
|
8
|
Kaplowitz PB, Backeljauw PF, Allen DB. Toward More Targeted and Cost-Effective Gonadotropin-Releasing Hormone Analog Treatment in Girls with Central Precocious Puberty. Horm Res Paediatr 2018; 90:1-7. [PMID: 30048994 DOI: 10.1159/000491103] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/20/2018] [Indexed: 11/19/2022] Open
Abstract
The use of gonadotropin-releasing hormone analogs (GnRHa) for the treatment of central precocious puberty (CPP), especially in girls, has increased rapidly in recent years. In the context of a secular trend towards earlier puberty onset, many girls now treated for CPP are healthy children experiencing puberty onset within the early end of the normal range. Justifications for GnRHa treatment include the preservation of adult height (AH) potential and the alleviation of presumed distress of early maturation and menarche. With a case of a family requesting treatment for an 8-year-old girl in early puberty as a background, studies of the effect of untreated CPP and of GnRHa treatment of CPP on AH are reviewed. In addition, the limited evidence relating CPP to significant psychological distress - in part due to early menses, and for the amelioration of such distress by GnRHa treatment - is discussed. Taken together, current information suggests that for girls with mildly early onset of puberty (ages 7-9 years), an informed assent discussion with the family should include the consideration of reassurance and observation for many girls who might otherwise receive 2-4 years of GnRHa treatment for a poorly defined benefit and at a cost of at least $20-30,000 per year.
Collapse
Affiliation(s)
- Paul B Kaplowitz
- Division of Endocrinology, Children's National Health System, Washington, District of Columbia, USA
| | - Philippe F Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David B Allen
- Division of Pediatric Diabetes and Endocrinology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
9
|
Early-life nutritional status and metabolic syndrome: gender-specific associations from a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Public Health Nutr 2018; 21:1546-1553. [PMID: 29455688 DOI: 10.1017/s1368980017004256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In the present study we investigated gender-specific associations of low birth weight (LBW) and shorter relative leg length with metabolic syndrome (MetS) after adjusting for sociodemographic characteristics and health-related behaviours. We also investigated whether these associations are independent of age at menarche and BMI at 20 years old. DESIGN Cross-sectional analysis. SUBJECTS Baseline data from 12 602 participants (35-74 years) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), 2008-2010. SETTING MetS was defined according to the revised National Cholesterol Education Program Adult Treatment Panel III guidelines. LBW (<2·5 kg) and age- and sex-standardized relative leg length (high, medium and low) were the explanatory variables studied. The strength of the associations between the explanatory variables and MetS was estimated by Poisson regression with robust variance. RESULTS MetS prevalence was 34·2 %; it was more prevalent in men (36·8 %) than in women (32·2 %). In multivariate analysis, LBW was associated (prevalence ratio; 95 % CI) with MetS only in women (1·28; 1·24, 1·45). Shorter leg length was associated with MetS in both men (1·21; 1·09, 1·35 and 1·46; 1·29, 1·65 for low and medium lengths, respectively) and women (1·12; 1·00, 1·25 and 1·40; 1·22, 1·59 for low and medium lengths, respectively). Additional adjustments for age at menarche and BMI at 20 years old did not change the associations. CONCLUSIONS Poor nutritional status as estimated by LBW and lower leg length in childhood was associated with a higher prevalence of MetS, although LBW was a significant factor only among women.
Collapse
|
10
|
Bereket A. A Critical Appraisal of the Effect of Gonadotropin-Releasing Hormon Analog Treatment on Adult Height of Girls with Central Precocious Puberty. J Clin Res Pediatr Endocrinol 2017; 9:33-48. [PMID: 29280737 PMCID: PMC5790330 DOI: 10.4274/jcrpe.2017.s004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 12/01/2022] Open
Abstract
Central precocious puberty (CPP) is a diagnosis that pediatric endocrinologists worldwide increasingly make in girls of age 6-8 years and is mostly idiopathic. Part of the reason for increasing referral and diagnosis is the perception among the doctors as well as the patients that treatment of CPP with long-acting gonadotropin-releasing hormon analogues (GnRHa) promote height of the child. Although, the timing and the tempo of puberty does influence statural growth and achieved adult height, the extent of this effect is variable depending on several factors and is modest in most cases. Studies investigating GnRHa treatment in girls with idiopathic CPP demonstrate that treatment is able to restore adult height compromised by precocious puberty. However, reports on untreated girls with precocious puberty demonstrate that some of these girls achieve their target height without treatment as well, thus, blurring the net effect of GnRHa treatment on height in girls with CPP. Clinical studies on treatment of girls with idiopathic CPP on adult stature suffers from the solid evidence-base due mainly to the lack of well-designed randomized controlled studies and our insufficiencies of predicting adult height of a child with narrow precision. This is particularly true for girls in whom age of pubertal onset is close to physiological age of puberty, which are the majority of cases treated with GnRHa nowadays. Heterogeneous nature of pubertal tempo (progressive vs. nonprogressive) leading to different height outcomes also complicates the interpretation of the results in both treated and untreated cases. This review will attemp to summarize and critically appraise available data in the field.
Collapse
Affiliation(s)
- Abdullah Bereket
- Marmara University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| |
Collapse
|
11
|
Abreu AP, Kaiser UB. Pubertal development and regulation. Lancet Diabetes Endocrinol 2016; 4:254-264. [PMID: 26852256 PMCID: PMC5192018 DOI: 10.1016/s2213-8587(15)00418-0] [Citation(s) in RCA: 285] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/22/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022]
Abstract
Puberty marks the end of childhood and is a period when individuals undergo physiological and psychological changes to achieve sexual maturation and fertility. The hypothalamic-pituitary-gonadal axis controls puberty and reproduction and is tightly regulated by a complex network of excitatory and inhibitory factors. This axis is active in the embryonic and early postnatal stages of life and is subsequently restrained during childhood, and its reactivation culminates in puberty initiation. The mechanisms underlying this reactivation are not completely known. The age of puberty onset varies between individuals and the timing of puberty initiation is associated with several health outcomes in adult life. In this Series paper, we discuss pubertal markers, epidemiological trends of puberty initiation over time, and the mechanisms whereby genetic, metabolic, and other factors control secretion of gonadotropin-releasing hormone to determine initiation of puberty.
Collapse
Affiliation(s)
- Ana Paula Abreu
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ursula B Kaiser
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
12
|
Giordano D, Kavasidis I, Spampinato C. Modeling skeletal bone development with hidden Markov models. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2016; 124:138-147. [PMID: 26563685 DOI: 10.1016/j.cmpb.2015.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/06/2015] [Accepted: 10/15/2015] [Indexed: 06/05/2023]
Abstract
This paper presents a tool for automatic assessment of skeletal bone age according to a modified version of the Tanner and Whitehouse (TW2) clinical method. The tool is able to provide an accurate bone age assessment in the range 0-6 years by processing epiphysial/metaphysial ROIs with image-processing techniques, and assigning TW2 stage to each ROI by means of hidden Markov models. The system was evaluated on a set of 360 X-rays (180 for males and 180 for females) achieving a high success rate in bone age evaluation (mean error rate of 0.41±0.33 years comparable to human error) as well as outperforming other effective methods. The paper also describes the graphical user interface of the tool, which is also released, thus to support and speed up clinicians' practices when dealing with bone age assessment.
Collapse
Affiliation(s)
- Daniela Giordano
- The Department of Electrical, Electronics and Computer Engineering, University of Catania, 95125 Catania, Italy.
| | - Isaak Kavasidis
- The Department of Electrical, Electronics and Computer Engineering, University of Catania, 95125 Catania, Italy.
| | - Concetto Spampinato
- The Department of Electrical, Electronics and Computer Engineering, University of Catania, 95125 Catania, Italy.
| |
Collapse
|
13
|
Abstract
Concerns about possible early pubertal development are a common cause for referral to pediatric medical subspecialists. Several recent studies have suggested that onset of breast and/or pubic hair development may be occurring earlier than in the past. Although there is a chance of finding pathology in girls with signs of puberty before 8 years of age and in boys before 9 years of age, the vast majority of these children with signs of apparent puberty have variations of normal growth and physical development and do not require laboratory testing, bone age radiographs, or intervention. The most common of these signs of early puberty are premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (nonprogressive breast development, usually occurring before 2 years of age), and lipomastia, in which girls have apparent breast development which, on careful palpation, is determined to be adipose tissue. Indicators that the signs of sexual maturation may represent true, central precocious puberty include progressive breast development over a 4- to 6-month period of observation or progressive penis and testicular enlargement, especially if accompanied by rapid linear growth. Children exhibiting these true indicators of early puberty need prompt evaluation by the appropriate pediatric medical subspecialist. Therapy with a gonadotropin-releasing hormone agonist may be indicated, as discussed in this report.
Collapse
|
14
|
Autonomous Ovarian Cysts in Prepubertal Girls. How Aggressive Should We Be? A Review of the Literature. J Pediatr Adolesc Gynecol 2015; 28:292-6. [PMID: 26228588 DOI: 10.1016/j.jpag.2015.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 04/09/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Precocious pseudopuberty in girls occurs as a result of peripheral estrogen production, most commonly through an autonomous ovarian cyst or in patients with McCune Albright syndrome. Current management is either conservative or surgical. The aim of this study was to identify available literature on presentation, course and treatment of such cases. DESIGN We performed a medline literature search using the key words 'ovarian autonomous cyst' and 'pseudopuberty'. We included articles published in English, from 1980 to date relating to females aged 2 to 8 years. We excluded papers on other endocrine conditions resulting in premature puberty. OUTCOME MEASURES Type of management, time of resolution, recurrence, progression to Central Precocious Puberty and McCune Albright Syndrome. RESULTS We identified 9 articles referring to 26 cases of autonomous ovarian cysts. All patients had suppressed LHRH testing and had simple ovarian cysts producing estradiol. Median age of patients was 5 years (range 2.2-8) and size of cyst was 41.5mm (9-60). Ten patients underwent cystectomy or oophorectomy, three were given cyproterone acetate and 13 were managed conservatively. Nine of 13 patients that were managed conservatively and two of those that had a cystectomy had a recurrence. There were three cases that progressed to central precocious puberty (CPP) and one case that was then identified to have McCune Albright (MCA) syndrome. One further case with multiple recurrences was given long term treatment with letrozole. CONCLUSION We conclude that although a conservative approach should always be proposed in the first instance, one should be aware of the risk of recurrence and progression to CPP or MCA. Antiestrogen treatment appears promising; however data comparing it with surgical options and particularly long term consequences with regards to future reproductive outcomes are not available.
Collapse
|
15
|
Brito VN, Latronico AC. Puberty: When is it normal? ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015; 59:93-4. [DOI: 10.1590/2359-3997000000018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 11/22/2022]
|
16
|
Tan QKG, Stockton DW, Pivnick E, Choudhri AF, Hines-Dowell S, Pena LDM, Deimling MA, Freemark MS, Kishnani PS. Premature pubarche in children with Pompe disease. J Pediatr 2015; 166:1075-8.e1. [PMID: 25687635 PMCID: PMC10880744 DOI: 10.1016/j.jpeds.2014.12.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 11/24/2014] [Accepted: 12/30/2014] [Indexed: 12/27/2022]
Abstract
Pompe disease (PD), or glycogen storage disease type II, results from deficiency of acid α-glucosidase. Patients with infantile-onset PD die by early childhood if untreated. Patient survival has improved with enzyme replacement therapy. We report a case series of 8 patients with infantile-onset PD on enzyme replacement therapy with premature pubarche.
Collapse
Affiliation(s)
- Queenie K-G Tan
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - David W Stockton
- Division of Genetic and Metabolic Disorders, Departments of Pediatrics and Internal Medicine, Wayne State University and Children's Hospital of Michigan, Detroit, MI
| | - Eniko Pivnick
- Division of Medical Genetics, Department of Pediatrics, University of Tennessee; Le Bonheur Children's Hospital, Memphis, TN
| | - Asim F Choudhri
- Departments of Radiology, Ophthalmology, and Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN
| | - Stacy Hines-Dowell
- Division of Medical Genetics, Department of Pediatrics, University of Tennessee; Le Bonheur Children's Hospital, Memphis, TN
| | - Loren D M Pena
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Melissa A Deimling
- Division of Primary Care, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Michael S Freemark
- Division of Endocrinology, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC.
| |
Collapse
|
17
|
|
18
|
|
19
|
Willemsen RH, Elleri D, Williams RM, Ong KK, Dunger DB. Pros and cons of GnRHa treatment for early puberty in girls. Nat Rev Endocrinol 2014; 10:352-63. [PMID: 24709660 DOI: 10.1038/nrendo.2014.40] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The timing of puberty has considerable biological, psychosocial and long-term health implications. Secular trends in age at pubertal development, the effects of obesity and the potential effects of environmental endocrine disruptors challenge the standard definitions of precocious puberty and the indications for intervention with gonadotropin-releasing hormone agonists (GnRHa) in girls with precocious puberty. GnRHa therapy is effective in improving adult height in patients who present with classic central precocious puberty (at <8 years old), without causing adverse effects on body composition, BMD and reproductive function. However, its benefits in patients with atypical forms of early puberty not driven by luteinising hormone are not well defined. The role of GnRHa in these patients and the potential benefits in terms of later growth, psychosocial functioning and long-term risk of adult diseases that are associated with early menarche, such as breast cancer and the metabolic syndrome, have not been established.
Collapse
Affiliation(s)
- Ruben H Willemsen
- Department of Paediatrics and Wellcome Trust-MRC Institute of Metabolic Science, Box 116, Level 8, Addenbrooke's Hospital, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - Daniela Elleri
- Department of Paediatrics and Wellcome Trust-MRC Institute of Metabolic Science, Box 116, Level 8, Addenbrooke's Hospital, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - Rachel M Williams
- Department of Paediatrics and Wellcome Trust-MRC Institute of Metabolic Science, Box 116, Level 8, Addenbrooke's Hospital, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - Ken K Ong
- MRC Epidemiology Unit, Box 285, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - David B Dunger
- Department of Paediatrics and Wellcome Trust-MRC Institute of Metabolic Science, Box 116, Level 8, Addenbrooke's Hospital, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| |
Collapse
|
20
|
Presentation of 493 consecutive girls with idiopathic central precocious puberty: a single-center study. PLoS One 2013; 8:e70931. [PMID: 23936254 PMCID: PMC3728106 DOI: 10.1371/journal.pone.0070931] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 06/24/2013] [Indexed: 11/30/2022] Open
Abstract
Background Despite the number of reported data concerning idiopathic central precocious puberty (CPP) in girls, major questions remain including its diagnosis, factors, and indications of gonadotropin releasing hormone (GnRH) analog treatment. Methods A retrospective, single-center study was carried out on 493 girls with CPP. Results Eleven girls (2.2%) were aged less than 3 years. Breast development was either isolated (Group 0, n = 99), or associated with one sign, pubic hair development, growth rate greater than 2 standard deviation score (SDS) or bone age (BA) >2 years above chronological age, (Group 1, n = 187), two signs (Group 2, n = 142) or three signs (Group 3, n = 65). The interval between onset of puberty and evaluation, body mass index (BMI) SDS, plasma luteinising hormone (LH) concentrations (basal and peak) and LH/ follicle-stimulating hormone (FSH) peak ratio after GnRH test, plasma estradiol and uterus length were significantly greater in Groups 2 and 3 than in Groups 0 and 1 respectively. 211 (42.8%) patients were obese and/or had excessive weight gain during the year before puberty. Obese girls more often had BA advance of >2 years (p = 0.0004) and pubic hair development (p = 0.003) than the others. BMI did not correlate with LH or with LH/FSH peak ratio. Girls with familial history of early puberty (41.4%) had greater frequencies of pubertal LH/FSH peak ratios (p = 0.02) than the others. During the 31 years of the study, there was no increase in the frequency of CPP or variation in its characteristics. Conclusion Obesity is associated with a higher BA advance and higher frequency of pubic or axillary hair development but not with LH secretion, suggesting that obesity accelerates adrenarche but not the maturation of the hypothalamic-pituitary-ovarian axis. The LH/FSH peak ratio was more frequently pubertal in girls with a familial history of early puberty, suggesting that this maturation depends on genetic factors.
Collapse
|
21
|
Brown DB, Loomba-Albrecht LA, Bremer AA. Sexual precocity and its treatment. World J Pediatr 2013; 9:103-11. [PMID: 23677828 DOI: 10.1007/s12519-013-0411-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 03/19/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Puberty is a complex and dynamic period in development during which individuals transition from the juvenile to adult state. Regulated by multiple genetic and endocrine controls, it is characterized by somatic growth and sexual maturation. Sexual precocity is defined as the appearance of secondary sexual characteristics before the lower limit of the normal age for pubertal onset. DATA SOURCES Based on recent publications and the experience with the disease of our group, we reviewed the normal timing and order of puberty, the definition of sexual precocity, the classification of sexual precocity, the differential diagnosis of sexual precocity, variations in pubertal development, the diagnosis of sexual precocity, and the treatment of sexual precocity. RESULTS Sexual precocity can be classified as either gonadotropin-releasing hormone (GnRH)-dependent or GnRH-independent. Regardless of the etiology, sexual precocity causes increased height velocity, somatic development, and skeletal maturation, which may have profound physical and psychological implications. CONCLUSIONS The treatment of sexual precocity is focused on its cause and must address both its psychosocial and clinical implications. For GnRH-dependent precocious puberty, GnRH agonists are the main pharmacological agents used. Alternatively, the treatment of disorders causing GnRH-independent sexual precocity is directed toward the underlying abnormality.
Collapse
Affiliation(s)
- DeAnna B Brown
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | | | | |
Collapse
|
22
|
Curfman AL, Reljanovic SM, McNelis KM, Dong TT, Lewis SA, Jackson LW, Cromer BA. Premature thelarche in infants and toddlers: prevalence, natural history and environmental determinants. J Pediatr Adolesc Gynecol 2011; 24:338-41. [PMID: 22099730 DOI: 10.1016/j.jpag.2011.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 01/12/2011] [Accepted: 01/17/2011] [Indexed: 10/15/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to measure the prevalence of premature thelarche in infant and toddler girls and to determine if environmental sources of estrogen were associated with early breast development. DESIGN Observational with mixed methods: Retrospective chart review, cross-sectional component involving an interview survey, along with longitudinal follow-up of girls with thelarche up to six months. SETTING A general pediatric clinic within a teaching hospital located in a large Midwestern city. PARTICIPANTS Girls, between the ages of 12 and 48 months, and their mothers, presenting for well-child care. INTERVENTIONS None. MAIN OUTCOME MEASURES Prevalence of premature thelarche; association of premature thelarche with selected environmental exposures. RESULTS Among the 318 subjects, the overall prevalence of premature thelarche was measured at 4.7% (n = 15). The prevalence by race/ethnicity was 4.2% among White Non-Hispanics, 4.6% among Blacks and 6.5% among White Hispanics. The peak prevalence occurred between 12-17 months of age. All thelarche cases were Tanner stage 2. No statistically significant relationship was found between premature thelarche and environmental exposures. Upon follow-up, 44% of the cases of premature thelarche had persistent breast development. CONCLUSIONS Our study demonstrated a higher prevalence of premature thelarche than has been previously reported. This study lacked power because of the small number of premature thelarche cases, the ubiquitous presence of environmental exposure as well as the potentially small effect of each environmental factor. Future studies need to employ a very large sample in order to accurately analyze the relationship between environmental toxicants and premature thelarche.
Collapse
Affiliation(s)
- Alison L Curfman
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
Precocious puberty poses significant diagnostic and therapeutic challenge to the physician. Recent advances in the understanding of pathophysiology of precocious puberty have resulted in improved management. Timely intervention is mandatory to achieve successful outcome. The identification of critical role of KISS-1-kisspeptin-GPR54 system has gone a long way to provide an insight into pubertal physiology. It is likely that the system would become an important diagnostic and therapeutic target in children with precocious puberty. Epidemiological studies point toward earlier thelarche. This is, however, associated with slower progression as the age of menarche is static. These changes have led to suggestions of lowering the age cutoffs for precocious puberty in girls. New developments in assessment of precocious puberty including gonadotropin releasing hormone (GnRH) agonist test have made characterization of precocious puberty easier. Longstanding GnRH analogs have become the mainstay of treatment of gonadotropin-dependent precocious puberty, while aromatase inhibitors and inhibitors of sex hormone action are increasingly being used in gonadotropin-independent precocious puberty.
Collapse
Affiliation(s)
- Anurag Bajpai
- Department of Pediatric Endocrinology, Regency Hospital Limited, Kanpur, Uttar Pradesh, India
| | - P. S. N Menon
- Department of Pediatrics, Jaber Al-Ahmed Armed Forces Hospital, Kuwait
| |
Collapse
|
24
|
Gonadotropin-dependent precocious puberty: neoplastic causes and endocrine considerations. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2011; 2011:184502. [PMID: 21603196 DOI: 10.1155/2011/184502] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 01/11/2011] [Indexed: 11/18/2022]
Abstract
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.
Collapse
|
25
|
Jaruratanasirikul S, Thaiwong M. Etiologies of precocious puberty: 15-year experience in a tertiary hospital in southern Thailand. J Pediatr Endocrinol Metab 2010; 23:1263-71. [PMID: 21714460 DOI: 10.1515/jpem.2010.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Precocious puberty (PP) is defined as the appearance of secondary sex characteristic at an age <8 years in girls and <9 years in boys, or menarche <9 years in girls. OBJECTIVE To determine the etiologies and clinical characteristics of children presenting with PP. SUBJECTS AND METHOD The medical records of 307 children (292 girls, 15 boys) with PP (1995-2009) were reviewed. RESULTS The most common etiology of PP in girls was premature thelarche (35.5%), followed by early puberty (25.4%) and central precocious puberty (23.8%). All boys had underlying pathologic etiologies. The average age of girls with premature thelarche was significantly younger than those with any other etiologies (2.8 +/- 1.6 vs 6.7 +/- 1.7 years, p <0.001). Height and weight SDSs of girls with central precocious puberty and early puberty were significantly greater than those with premature thelarche. CONCLUSIONS The most common etiologies of PP in girls are premature thelarche in girls <6 years and early puberty in girls >6 years. PP in boys has to be investigated for underlying etiologies.
Collapse
Affiliation(s)
- Somchit Jaruratanasirikul
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | | |
Collapse
|
26
|
Age of puberty in a representative sample of Iranian girls. World J Pediatr 2009; 5:132-5. [PMID: 19718536 DOI: 10.1007/s12519-009-0026-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 11/06/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND To obtain normal references for growth and pubertal development in a given population, assessment of pubertal stages is of great importance. This study aimed to determine the age of appearance of secondary sexual characteristics in a representative sample of Iranian girls. METHODS This cross-sectional study was conducted during 2005-2006 in 3192 girl students, aged 6-17 years, in Isfahan, Iran. Participants were selected by multistage random cluster sampling from school students. Secondary sexual characteristics were evaluated by inspection and palpation, and were recorded according to Tanner staging. The self-reported date of menarche (if any) was recorded as well. Data were analyzed with Probit analysis based on the status quo method. RESULTS The median ages (10th-90th percentile) of Tanner stage 2 breast development (B2) and Tanner stage 2 pubic hair growth (PH2) were 10.14 years (8.33-11.95 years) and 10.78 years (9.09-12.48 years), respectively. The ages of the 3rd percentile for B2 and PH2 were 7.48 and 8.29 years, respectively. The median age of menarche among the 3192 girls who had experienced menarche was 12.65 years (11.18-14.11 years). CONCLUSIONS The median age of puberty onset is 10.14 years, and the onset of puberty before 7.5 years is considered as precocious puberty in a representative sample of Iranian girls. The values obtained from the present study can provide baseline data for analysis of time trends, as well as for international comparisons.
Collapse
|
27
|
Brito VN, Latronico AC, Arnhold IJP, Mendonça BB. Update on the etiology, diagnosis and therapeutic management of sexual precocity. ACTA ACUST UNITED AC 2009; 52:18-31. [PMID: 18345393 DOI: 10.1590/s0004-27302008000100005] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 10/10/2007] [Indexed: 11/22/2022]
Abstract
Precocious puberty is defined as the development of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys. Gonadotropin-dependent precocious puberty (GDPP) results from the premature activation of the hypothalamic-pituitary-gonadal axis and mimics the physiological pubertal development, although at an inadequate chronological age. Hormonal evaluation, mainly through basal and GnRH-stimulated LH levels shows activation of the gonadotropic axis. Gonadotropin-independent precocious puberty (GIPP) is the result of the secretion of sex steroids, independently from the activation of the gonadotropic axis. Several genetic causes, including constitutive activating mutations in the human LH-receptor gene and activating mutations in the Gs protein a-subunit gene are described as the etiology of testotoxicosis and McCune-Albright syndrome, respectively. The differential diagnosis between GDPP and GIPP has direct implications on the therapeutic option. Long-acting gonadotropin-releasing hormone (GnRH) analogs are the treatment of choice in GDPP. The treatment monitoring is carried out by clinical examination, hormonal evaluation measurements and image studies. For treatment of GIPP, drugs that act by blocking the action of sex steroids on their specific receptors (cyproterone, tamoxifen) or through their synthesis (ketoconazole, medroxyprogesterone, aromatase inhibitors) are used. In addition, variants of the normal pubertal development include isolated forms of precocious thelarche, precocious pubarche and precocious menarche. Here, we provide an update on the etiology, diagnosis and management of sexual precocity.
Collapse
Affiliation(s)
- Vinicius Nahime Brito
- Unidade de Endocrinologia do Desenvolvimento, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | | | | | | |
Collapse
|
28
|
Borges MF, Pacheco KD, Oliveira AA, Rita CVC, Pacheco KD, Resende EAM, Lara BHJ, Ferreira BP. Premature thelarche: clinical and laboratorial assessment by immunochemiluminescent assay. ACTA ACUST UNITED AC 2009; 52:93-100. [PMID: 18345401 DOI: 10.1590/s0004-27302008000100013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 10/02/2007] [Indexed: 11/22/2022]
Abstract
In order to establish cut-off limits and to distinguish isolated premature thelarche (IPT) from precocious puberty (PP), we evaluated data from 79 girls with premature thelarche, comparing basal and stimulated LH and FSH serum concentrations with those from 91 healthy girls. A GnRH stimulation test was performed in 10 normal girls and in 42 with premature thelarche. Comparison among groups was performed by Kruskal-Wallis and Dunns tests. LH values were significantly greater in girls with IPT than in control groups. Basal gonadotropin concentrations were higher in patients with PP than in controls, but not different from patients with IPT. Peak LH levels after GnRH stimulation distinguished those two groups, with a cut-off value of 4.0 IU/L, but still with minimal overlap. In conclusion, a girl with premature thelarche and LH peak value above 4.5 IU/L has, indeed, PP, but values between 3.5 and 4.5 IU/L point to careful follow-up.
Collapse
Affiliation(s)
- Maria F Borges
- Endocrinology Department, Faculdade de Medicina, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Kim JH, Shin CH, Lee SY. Observed Trends for an Earlier Onset of Puberty: When is the Need for Treatment Indicated? JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2009. [DOI: 10.5124/jkma.2009.52.12.1189] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jae Hyun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Korea.
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Korea.
| | | |
Collapse
|
30
|
Bundak R, Darendeliler F, Günöz H, Baş F, Saka N, Neyzi O. Puberty and pubertal growth in healthy Turkish girls: no evidence for secular trend. J Clin Res Pediatr Endocrinol 2008; 1:8-14. [PMID: 21318059 PMCID: PMC3005633 DOI: 10.4008/jcrpe.v1i1.16] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 09/03/2008] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Assessment of pubertal stages should be related to updated and reliable referance data from the same background population. OBJECTIVE The aim of this study was to provide normative data for the onset and tempo of puberty in Turkish girls and analyze the growth parameters in puberty. METHODS The analyses are based on data that were collected and evaluated biannually on 1020 Turkish school children aged 8-18 years and a subsample of 101 girls who had reached final height (FH). The data were analyzed cross-sectionally in the total group and longitudinally in the subsample. RESULTS Mean age and height (Ht) at onset of puberty were 10.1 ± 1.0 years and 141.7 ± 7.6 cm, respectively. Peak height velocity (HtV) was 8.5 ± 1.0 cm/year. Total pubertal height gain was 16.0 ± 3.9 cm. The duration of puberty was 4.9 ± 1.2 years. Age at menarche was 12.2 ± 0.9 years. Height at onset of puberty was positively correlated with FH (p < 0.0001). Body size (weight and height) at onset of puberty and weight and height velocity before the year of onset of puberty correlated negatively with age at onset of puberty (p < 0.05). CONCLUSION In conclusion, these results provide normative data for pubertal stages and growth parameters in girls in puberty. Height at onset of puberty is the most important determinant of FH. There is no secular trend for the onset of puberty. Weight does seem to affect the onset of puberty but not FH.
Collapse
Affiliation(s)
- Rüveyde Bundak
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, İstanbul, Turkey.
| | - Feyza Darendeliler
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, İstanbul, Turkey
| | - Hülya Günöz
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, İstanbul, Turkey
| | - Firdevs Baş
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, İstanbul, Turkey
| | - Nurçin Saka
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, İstanbul, Turkey
| | - Olcay Neyzi
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Endocrinology Unit, İstanbul, Turkey
| |
Collapse
|
31
|
Prété G, Couto-Silva AC, Trivin C, Brauner R. Idiopathic central precocious puberty in girls: presentation factors. BMC Pediatr 2008; 8:27. [PMID: 18601733 PMCID: PMC2459158 DOI: 10.1186/1471-2431-8-27] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 07/04/2008] [Indexed: 11/10/2022] Open
Abstract
Background It is sometimes difficult to distinguish between premature thelarche and precocious puberty in girls who develop breasts before the age of 8 years. We evaluated the frequencies of the signs associated with breast development and the factors influencing the presentation of girls with idiopathic central precocious puberty (CPP). Methods 353 girls monitored 0.9 ± 0.7 year after the onset of CPP. Results The age at CPP was < 3 years in 2%, 3–7 years in 38% and 7–8 years in 60% of cases. Pubic hair was present in 67%, growth rate greater than 2 SDS in 46% and bone age advance greater than 2 years in 33% of cases. Breast development was clinically isolated in 70 (20%) cases. However, only 31 of these (8.8% of the population) had a prepubertal length uterus and gonadotropin responses to gonadotropin releasing hormone and plasma estradiol. The clinical picture of CPP became complete during the year following the initial evaluation. 25% of cases were obese. The increase in weight during the previous year (3.7 ± 1.4 kg) and body mass index were positively correlated with the statural growth and bone age advance (P < 0.0001). There was no relationship between the clinical-biological presentation and the age at puberty, the interval between the onset of puberty and evaluation, or the presence of familial CPP. Conclusion The variation in presentation of girls with CPP does not depend on their age, interval between the onset and evaluation, or familial factors. This suggests that there are degrees of hypothalamic-pituitary-ovarian activation that are not explained by these factors.
Collapse
Affiliation(s)
- Géraldine Prété
- Université Paris Descartes and Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Unité d'Endocrinologie Pédiatrique, 94270 Le Kremlin Bicêtre, France.
| | | | | | | |
Collapse
|
32
|
Affiliation(s)
- Jean-Claude Carel
- Department of Pediatric Endocrinology and Diabetology, INSERM Unité 690, and Centre de Référence des Maladies Endocriniennes de la Croissance, Robert Debré Hospital and University of Paris 7-Denis Diderot, Paris, France.
| | | |
Collapse
|
33
|
Dorn LD, Rose SR, Rotenstein D, Susman EJ, Huang B, Loucks TL, Berga SL. Differences in endocrine parameters and psychopathology in girls with premature adrenarche versus on-time adrenarche. J Pediatr Endocrinol Metab 2008; 21:439-48. [PMID: 18655525 PMCID: PMC3677514 DOI: 10.1515/jpem.2008.21.5.439] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Girls with premature adrenarche (PA) are at risk for multiple problems related to exaggerated androgen synthesis. Whether PA carries a risk of psychopathology remains unknown. This study examined group differences in: (a) anthropometric and endocrine parameters, and (b) mood and behavior problems, in 6-8 year-old girls with PA (n = 40) compared to on-time adrenarche girls (n = 36). PA girls were taller (p < or =0.05) and heavier (p < or =0.01) than the on-time adrenarche girls but body mass index showed no difference. PA girls had significantly (p <0.05) higher adrenal androgen and testosterone concentrations but not cortisol or leptin. PA girls also had significantly more oppositional defiant disorder, and higher symptom counts reflecting anxiety, mood or disruptive behavior disorders. PA girls may be more vulnerable to psychopathology than on-time adrenarche girls. The challenge of future studies is to determine which PA girls are at risk for psychopathology and which are more resilient.
Collapse
Affiliation(s)
- Lorah D Dorn
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.
| | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
BACKGROUND Atypical presentations of gynecomastia not associated with obesity are often underappreciated. Unilateral manifestation, prepubertal onset, and a history of associated disorders may contribute to a unique clinical presentation for which the diagnosis and management may remain uncertain. This report reviews neurofibromatosis as a cause for atypical presentation of gynecomastia in prepubertal boys to help establish guidelines for diagnosis and management. METHODS Six nonobese male patients (body mass index <or=20) had an onset of gynecomastia at younger than 9 years and were referred for evaluation between June of 1994 and December of 2006. RESULTS The median age of onset of breast enlargement was 7(1/2) years (range, 4 to 8 years). Three had bilateral involvement, four had localized involvement of the nipple-areola complex, and two had diffusely involved breast tissue. Five of the six patients were African American (compared with 20 percent for classic gynecomastia). Median postoperative follow-up was 7 years, and all were followed beyond puberty. No recurrences were seen, although one patient developed a metachronous lesion in the contralateral breast. No patient had an abnormal endocrine metabolic workup. CONCLUSIONS Atypical gynecomastia may present in the prepubertal boy and appears more prevalent in African Americans. For neurofibromatosis, it is more likely unilateral, can be localized to the nipple-areola complex, or entails diffuse breast involvement. An endocrine workup appears to be noncontributory.
Collapse
|
35
|
Abstract
CONTEXT Precocious puberty currently affects 1 in 5,000 children and is 10 times more common in girls. Statistics indicate that girls in the United States are maturing at an earlier age than they did 30 years ago and the number of girls with diagnosed precocious puberty (the appearance of secondary sex characteristics before 8 years of age or the onset of menarche before age 9) is on the rise. A summary of the growing body of literature on this topic is necessary to inform nurses and other health care providers of the current trends and incidence of precocious puberty to better meet the physical and psychosocial needs of these girls and their families. METHODS EBSCOhost Research Databases that included CINAHL Plus, Health Source: Nursing Edition, MEDLINE, PsycINFO, and Women's Studies International were searched for journal articles published in the past 10 years (1997-2006) that explicitly examined precocious puberty in females and proposed theories to describe the phenomenon. Search terms included precocious puberty, sexual maturation, menarche, and secondary sex characteristics. These terms were searched individually and in combination with proximate determinants such as endocrine disruptors, environmental toxins, phthalates, stress, skin care, genetics, age, ethnicity, obesity, and assisted reproduction. The search yielded 947 articles addressing this issue. RESULTS Eighty-two studies or case reports met the criteria for inclusion in this literature review that captured six attributable causes of early sexual maturation in female children. These included genetic, ethnic, and pediatric obesity, as well as environmental toxins that disrupt endocrine function (chemicals, toxins, plasticizers, infant feeding methods, skin and hair products, assisted reproductive technologies), psychosocial stress, and early exposure to a sexualized society. The robustness of the reports varied and few of the studies were widely generalizable but did offer suggestions for assessment and nursing care. CONCLUSIONS Precocious puberty has health and social implications that are complex and influenced by multiple factors. Further research is needed to expand and elucidate theoretical relationships between the early development of secondary sex characteristics in young girls and the proposed causative factors.
Collapse
Affiliation(s)
- Sandra K Cesario
- College of Nursing, Texas Woman's University, Houston, TX 77030-2343, USA.
| | | |
Collapse
|
36
|
Affiliation(s)
- Linda S Nield
- West Virginia University School of Medicine, Morgantown, USA
| | | | | |
Collapse
|
37
|
Affiliation(s)
- Todd D Nebesio
- Department of Pediatrics, Section of Pediatric Endocrinology/Diabetology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | |
Collapse
|
38
|
Affiliation(s)
- Andrew Muir
- Department of Pediatrics, Medical College of Georgia, Augusta, Ga, USA
| |
Collapse
|
39
|
Trivin C, Couto-Silva AC, Sainte-Rose C, Chemaitilly W, Kalifa C, Doz F, Zerah M, Brauner R. Presentation and evolution of organic central precocious puberty according to the type of CNS lesion. Clin Endocrinol (Oxf) 2006; 65:239-45. [PMID: 16886967 DOI: 10.1111/j.1365-2265.2006.02582.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Christine Trivin
- AP-HP, Hôpital Necker-Enfants Malades, Service d'Explorations Fonctionnelles, Paris, France
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Papadimitriou A, Beri D, Tsialla A, Fretzayas A, Psychou F, Nicolaidou P. Early growth acceleration in girls with idiopathic precocious puberty. J Pediatr 2006; 149:43-6. [PMID: 16860125 DOI: 10.1016/j.jpeds.2006.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Revised: 12/29/2005] [Accepted: 02/10/2006] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
41
|
Slyper AH. The pubertal timing controversy in the USA, and a review of possible causative factors for the advance in timing of onset of puberty. Clin Endocrinol (Oxf) 2006; 65:1-8. [PMID: 16817811 DOI: 10.1111/j.1365-2265.2006.02539.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Previously used standards for the diagnosis of precocious puberty in girls no longer appear to be appropriate in the USA, in that a significant number of girls are being seen in paediatricians' offices with breast budding before 8 years of age. The timing of menarche, however, has changed little over the past few decades. Early maturing girls are more likely to become obese in adolescence and adulthood than normal or late maturing girls. Early maturing white girls are heavier at the onset of puberty, but this is not the case for African-American girls or boys of either race. Boys and girls with premature pubarche may be more hyperinsulinaemic than normal children, and girls with premature pubarche more likely to develop functional ovarian and adrenal hyperandrogenism. Early menarche is preceded by prepubertal hyperinsulinaemia. It is proposed that pubertal onset, although not necessarily the tempo of puberty, is influenced by hyperinsulinaemia and insulin resistance. If this hypothesis is correct, insulin resistance may be more prevalent in US children than previously recognized. An advance in timing of onset of puberty has not been noted in other countries, although it is likely that this phenomenon may become more prevalent as other countries adopt a more American lifestyle and diet.
Collapse
Affiliation(s)
- Arnold H Slyper
- Department of Pediatrics, Loyola University Medical Center, Maywood, IL 60153, USA.
| |
Collapse
|
42
|
Aksglaede L, Juul A, Leffers H, Skakkebaek NE, Andersson AM. The sensitivity of the child to sex steroids: possible impact of exogenous estrogens. Hum Reprod Update 2006; 12:341-9. [PMID: 16672247 DOI: 10.1093/humupd/dml018] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The current trends of increasing incidences of testis, breast and prostate cancers are poorly understood, although it is assumed that sex hormones play a role. Disrupted sex hormone action is also believed to be involved in the increased occurrence of genital abnormalities among newborn boys and precocious puberty in girls. In this article, recent literature on sex steroid levels and their physiological roles during childhood is reviewed. It is concluded that (i) circulating levels of estradiol in prepubertal children are lower than originally claimed; (ii) children are extremely sensitive to estradiol and may respond with increased growth and/or breast development even at serum levels below the current detection limits; (iii) no threshold has been established, below which no hormonal effects can be seen in children exposed to exogenous steroids or endocrine disruptors; (iv) changes in hormone levels during fetal and prepubertal development may have severe effects in adult life and (v) the daily production rates of sex steroids in children estimated by the Food and Drug Administration in 1999 and still used in risk assessments are highly overestimated and should be revised. Because no lower threshold for estrogenic action has been established, caution should be taken to avoid unnecessary exposure of fetuses and children to exogenous sex steroids and endocrine disruptors, even at very low levels.
Collapse
Affiliation(s)
- Lise Aksglaede
- University Department of Growth and Reproduction, GR 5064, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | | | | | | | | |
Collapse
|
43
|
Juul A, Teilmann G, Scheike T, Hertel NT, Holm K, Laursen EM, Main KM, Skakkebaek NE. Pubertal development in Danish children: comparison of recent European and US data. ACTA ACUST UNITED AC 2006; 29:247-55; discussion 286-90. [PMID: 16466546 DOI: 10.1111/j.1365-2605.2005.00556.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Two recent epidemiological studies (PROS and NHANES III) from the USA noted earlier sexual maturation in girls, leading to increased attention internationally to the age at onset of puberty. We studied the timing of puberty in a large cohort of healthy Danish children in order to evaluate differences between USA and Denmark, as well as to look for possible secular trends in pubertal development. Healthy Caucasian children from public schools in Denmark participated in the study which was carried out in 1991-1993. A total number of 826 boys and 1,100 girls (aged 6.0-19.9 years) were included, and pubertal stages were assessed by clinical examination according to methods of Tanner. In boys testicular volume was determined using an orchidometer. We found that age at breast development 2 (B2) was 10.88 years, and mean menarcheal age was 13.42 years. Girls with body mass index (BMI) above the median had significantly earlier puberty (age at B2 10.42 years) compared with girls with BMI below the median (age at B2 11.24 years, p < 0.0001). Similarly, menarcheal age was significantly lower in girls with BMI above the median compared with girls with BMI below the median (13.12 vs. 13.70 years, p = 0.0012). In Danish boys we found that age at genital stage 2 (G2) was 11.83 years. Both sexes were significantly taller compared with data from 1964, but timing of pubertal maturation seemed unaltered. Finally, puberty occurred much later in Denmark compared with recent data from USA. We could not detect any downwards secular trend in the timing of puberty in Denmark between 1964 and 1991-1993 as seen in the US. Obesity certainly plays a role in the timing of puberty, but the marked differences between Denmark and USA cannot be attributed exclusively to differences in BMI. A possible role of other factors like genetic polymorphisms, nutrition, physical activity or endocrine disrupting chemicals must therefore also be considered. Therefore, we believe it is crucial to monitor the pubertal development closely in Denmark in the coming decades.
Collapse
Affiliation(s)
- A Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Denmark.
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Growth in precocious puberty is a subject of concern to families and clinicians alike. The definition of precocious puberty and the role of obesity in the age of onset have also been areas of debate since the Lawson Wilkins Society recommended a lowering of the age of onset of precocious puberty in US girls. An understanding of growth patterns in normal children with earlier or later onset of puberty and the variable rate of progression between individuals with central precocious puberty as well as the imprecision in available height prediction methods are important in assessing height outcomes in this condition. In the absence of randomised controlled trials in this area, only qualified conclusions about the effectiveness of interventions can be drawn. In general, it appears that height outcome is not compromised in untreated slowly progressive variants of central precocious puberty. In rapidly progressing central precocious puberty in girls, gonadotrophin releasing hormone agonists (GnRH agonists) appear to increase final height by about 5 cm in girls treated before the age of eight, but there is no height benefit in those treated after eight years. Scanly data is available to assess treatment effects in boys. GnRH agonists appear to be relatively safe. The decision to treat central precocious puberty should take into account rate of progression of pubertal changes as well as biochemical markers and may need to address other factors (for example psychosocial and behavioural issues) as well as height outcome.
Collapse
Affiliation(s)
- Justin J Brown
- Department of Endocrinology and Diabetes Royal Children's Hospital, Parkville, Victoria, Australia
| | | |
Collapse
|
45
|
Ahn BH, Han HS. Effect of GnRH analogue on predicted adult height in girls with early puberty. KOREAN JOURNAL OF PEDIATRICS 2006. [DOI: 10.3345/kjp.2006.49.5.552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Byung-Hoon Ahn
- Department of Pediatrics, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
| | - Heon-Seok Han
- Department of Pediatrics, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
| |
Collapse
|
46
|
Dorn LD, Dahl RE, Woodward HR, Biro F. Defining the Boundaries of Early Adolescence: A User's Guide to Assessing Pubertal Status and Pubertal Timing in Research With Adolescents. APPLIED DEVELOPMENTAL SCIENCE 2006. [DOI: 10.1207/s1532480xads1001_3] [Citation(s) in RCA: 296] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
47
|
Aguiar AL, Couto-Silva AC, Freitas I, Cruz T, Rodrigues M, Adan LF. [Idiopathic central precocious puberty in girls in Bahia, Brazil]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2005; 49:536-41. [PMID: 16358082 DOI: 10.1590/s0004-27302005000400011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ana Luísa Aguiar
- Departamento de Pediatria, Faculdade de Medicina, Universidade Federal da Bahia, Centro de Diabetes e Endocrinologia, Salvador, BA
| | | | | | | | | | | |
Collapse
|
48
|
Teilmann G, Pedersen CB, Jensen TK, Skakkebaek NE, Juul A. Prevalence and incidence of precocious pubertal development in Denmark: an epidemiologic study based on national registries. Pediatrics 2005; 116:1323-8. [PMID: 16322154 DOI: 10.1542/peds.2005-0012] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To our knowledge, no population-based epidemiologic studies on the incidence and prevalence of precocious pubertal development have been published. Danish national registries provide sufficient data for estimating the prevalence and incidence of this condition. The aim of this study was to estimate the prevalence and incidence of precocious pubertal development in Denmark in a 9-year period. METHODS The age- and gender-specific incidence rates as well as prevalence rates of precocious pubertal development in Denmark were estimated using data from the Danish National Patient Registry and Statistics Denmark from 1993 to 2001. RESULTS Overall, 670 children with precocious pubertal development were registered with a diagnosis of precocious puberty (PP) from 1993 to 2001, corresponding to 50 to 70 new cases of PP per year in Denmark. The incidence of PP was constant during the study period from 1993 to 2001. The incidence of PP subdivided by gender and age at diagnosis was approximately 0.5 per 10000 in girls who were younger than 2 years, decreasing to levels below 0.05 per 10000 in girls aged 2 to 4 years, thereafter gradually rising to 8 per 10000 for girls aged 5 to 9 years. For boys who were younger than 8 years, the incidence was very low (<1 per 10000) and increased only slightly to 1 to 2 per 10000 in boys aged 8 to 10 years. The prevalence of PP was approximately 20 to 23 per 10000 in girls, whereas the prevalence was fivefold lower for boys (<5 per 10000). CONCLUSIONS From this first epidemiologic study based on national registries, we estimated that 0.2% of all Danish girls and <0.05% of Danish boys had some form of precocious pubertal development.
Collapse
Affiliation(s)
- Grete Teilmann
- Department of Growth and Reproduction GR, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | | | | | | | | |
Collapse
|
49
|
Farage M, Maibach H. Lifetime changes in the vulva and vagina. Arch Gynecol Obstet 2005; 273:195-202. [PMID: 16208476 DOI: 10.1007/s00404-005-0079-x] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Accepted: 09/01/2005] [Indexed: 01/26/2023]
Abstract
The morphology and physiology of the vulva and vagina change over a lifetime. The most salient changes are linked to puberty, the menstrual cycle, pregnancy, and menopause. The cutaneous epithelia of the mons pubis, labia, and clitoris originate from the embryonic ectoderm and exhibit a keratinized, stratified structure similar to the skin at other sites. The mucosa of the vulvar vestibule, which originates from the embryonic endoderm, is non-keratinized. The vagina, derived from the embryonic mesoderm, is responsive to estrogen cycling. At birth, the vulva and vagina exhibit the effects of residual maternal estrogens. During puberty, the vulva and vagina acquire mature characteristics in a sequential fashion in response to adrenal and gonadal maturation. A trend to earlier pubertal onset has been observed in Western developed countries. In women of reproductive age, the vaginal mucosa responds to steroid hormone cycling, exhibiting maximal thickness and intracellular glycogen content at mid-cycle. Vulvar skin thickness remains unchanged but menstrual cycle-associated changes in ortho- and parakeratosis occur at the cytological level. The vulva and vagina further adapt to the needs of pregnancy and delivery. After menopause, tissue atrophy ensues. Post-menopausal changes in skin barrier function, skin hydration, and irritant susceptibility have been observed on exposed skin but not on the vulva. Nevertheless, older women with incontinence are at increased risk for developing incontinence dermatitis. A combination of factors, such as tissue atrophy, slower dissipation of excess skin hydration, shear forces associated with limited mobility, and lower tissue regeneration capacity increase the risk of morbidity from incontinence dermatitis in older women.
Collapse
Affiliation(s)
- Miranda Farage
- The Procter & Gamble Company, Feminine Care Clinical Sciences, Winton Hill Technical Center, 6110 Center Hill Rd, Box 136, Cincinnati, OH 45224, USA.
| | | |
Collapse
|
50
|
Abstract
Growth delay is one of the most common and persistent findings in children who have been adopted from abroad. Although the cause is not clearly understood, it may be related to the observed phenomenon of psychosocial short stature described in children from abusive and neglectful settings in western countries. Fortunately, adopted children generally experience significant improvement in growth after joining their new family, but this may put girls at risk for early and rapidly progressing puberty. This review should help the health care team to understand these issues and work better with the adoptive parents to ensure a child's smooth transition into family life.
Collapse
Affiliation(s)
- Patrick Mason
- International Adoption Center, Inova Fairfax Hospital for Children, 8505 Arlington Boulevard, Suite 100, Fairfax, VA 22031, USA.
| | | |
Collapse
|