Precocious puberty

1. PRECOCIOUS PUBERTY
Dr.MANOJ PRABHAKAR
Resident , Dept. of Paediatrics

3. • 3 yrs old girl with complaints of enlargement of
breast from 1 yr and per vaginal discharge for one
yr.Child alright 1 yr back.
• Normal develeopmental milestones.
• White discharge per vagina +
• No H/O birth injury,head
injury,encephalitis,headache or seizures.
• O/E b/l breast enlargement and firm in
consistency.Nipple and areola developed ,
• Axillary and pubic hair sparse.
• LH & FSH elevated.
• USG abdomen shows enlarged uterus and ovaries of
adult size.

4. OBJECTIVES
• Physiology of Puberty
• Tanner staging
• Def. of Precocious Puberty
• Causes
• Treatment

5. PUBERTY
• Puberty is the developmental stage during
which a child becomes a young adult,
characterized by the maturation of
gametogenesis, secretion of gonadal hormones,
and development of secondary sexual
characteristics and reproductive functions.

6. Hypothalamic-pituitary-gonadal axis

7. Tanner Staging

8. STAGES OF BREAST DEVELOPMENT
• B-1: pre-pubertal
• B-2: breast bud
• B-3: enlargement of breast and areola with no
separation of the contours
• B-4: projection of areola and papilla to form a
secondary mound above the level of the breast
• B-5: recession of the areola to the general
contour of the breast with projection of the
papilla only.

9. STAGES OF PUBIC HAIR DEVELOPMENT IN FEMALES
• Ph-1: pre-pubertal
• Ph-2: sparse growth of long slightly pigmented
hair usually slightly curly mainly along the labia
• Ph-3: the hair is darker, coarser and curlier and
spreads over the junction of the pubes
• Ph-4: the hair spreads covering the pubes
• Ph-5 the hair extends to the medial surface of
the thighs and is distributed as an inverse
triangle.

10. Tanner
Staging –
Males

11. STAGES OF PUBIC HAIR AND GENITAL DEVELOPMENT IN THE MALE.
• G-1: pre-pubertal
• G-2: the testis and scrotum enlarge, and the skin of
the scrotum shows some reddening and change in
the texture. Sparse growth of pigmented hair usually
slightly curly mainly at the base of the penis (Ph-2)
• G-3: Testis and scrotum enlarge further, the penis
grows mainly in length but also in breadth. The hair
is darker, coarser and curlier and spreads over the
junction of the pubes (Ph-3)
• G-4: Scrotum, testis and penis grow further with
development of the glans and further darkening of
the scrotal skin. The hair spreads covering the pubes
• G-5: adult stage with spreading of the hair to the
medial surface of the thighs.

12. • Thelarche denotes the onset of breast
development, an estrogen effect.
• Pubarche denotes the onset of sexual hair
growth, an androgen effect.
• Menarche indicates the onset of menses and
spermarche the appearance of spermatozoa
in seminal fluid

13. DEF:
• Onset of secondary sexual characteristics before
the age of 8yrs in girls and 9 yrs in boys.
• Depending on the primary source of the
hormonal production classified as :
- Central
- Peripheral

14. Classification :
• Central Precocious Puberty aka GDPP is
caused by early maturation of the hypothalamic-
pituitary-gonadal axis.
• It is characterized in girls by both breast
development and pubic hair sexual maturation.
• In boys by both pubic hair and testicular
enlargement.

15. Cntd..
• Peripheral Precocious Puberty aka GIPP is
caused by excess secretions of sex hormones
derived either from the gonads or adrenal
glands.

16. • Isosexual precocious puberty, feminizing
signs appear in girls, masculinization in boys.
• Heterosexual precocious puberty causes
signs of masculine characteristics in girls and
feminization in boys.

17. Conditions Causing Precocious Puberty
• CENTRAL PRECOCIOUS PUBERTY:
- Idiopathic
- Organic brain lesions
- Brain tumors , head trauma etc
- Hypothyroidism.

18. • Peripheral Precocius puberty:
Isosexual ( Feminizing) conditions in females:
- McCune-Albright Syndrome.
- Ovarian Tumors
Heterosexual (Masculinizing) conditions in
females:
CAH
Adrenal tumors
Ovarian tumors
Conditions Causing Precocious
Puberty

19. Contd..
Isosexual (Masculinizing )conditions in boys:
• CAH
• Leydig cell tumors
• hCG secreting tumors
Heterosexual (Feminizing ) conditions in boys:
• Faminizing adrenocortical tumor.

20. EVALUATION
• MEDICAL HISTORY:
- Age at onset
- Sex
- Pubertal Progression
- Symptoms suggestive of hypothyroidism
- H/o past CNS infection, headache, visual
disturbances & seizures.

21. Natural course of idiopathic central precocious puberty.

22. EVALUATION
• Physical Examination :
- Measurements of height, weight, height velocity
- Pubertal staging according to Tanner’s staging.
- Evaluate androgen & estrogen effects.
- Inspection of skin. ( Café au lait macules in
McCune –Albright Syndrome.
- Examination for signs of hypothyroidism.

23. EVALUATION
Basic Radiology :
• Bone Age
• Pelvic & Abdominal Sonography

24. Hormone Evaluation:
• Intravenous administration of gonadotropin
releasing hormone (GnRH stimulation test) or a
GnRH agonist (leuprolide stimulation test) is a
helpful diagnostic tool for boys.
• In girls, the central nature of sexual precocity
can be proven by detecting pubertal levels of
estradiol (>50 pg/mL), 20-24 hr after
stimulation with leuprolide.

25. TREATMENT
• MEDICAL :
Indications of treatment:
- Predicted adult height is less.
- Psychologically distressing to child.
- Rapid progression.
- GnRH Agonists :
- Inj .Leuprolide ( 0.5-0.3 mg/kg/dose)
monthly.

26. TREATMENT
Surgery :
- Tumors of the ovary,testis & adrenals require
surgical removal.
- Hypothalamic Hamartomas is hazardous and is
not recommended because they never grow or
become malignant.
- Germ cell,pineal tumors & hCG producing
suprasellar tumors can be treated by
radiotherapy.