Trending Clinical Topic: Precocious Puberty

Ryan Syrek


July 29, 2022

Each week, we identify one top search term, speculate about what caused its popularity, and provide an infographic on a related condition. If you have thoughts about what's trending and why, share them with us on Twitter or Facebook

In late March, a report copublished by The Washington Post and The Fuller Project detailed a worldwide spike in early puberty cases, specifically among girls (see Infographic below). Now, experts are weighing in on appropriate approaches to evaluate and manage precocious puberty, leading to this week's top trending clinical topic.

A recent study from Italy found that more than 300 girls were referred to five pediatric endocrinology centers between March and September 2020 compared with just 140 referrals during the same period in 2019. In another study, in Turkey, a pediatric endocrinology clinic reported 58 cases during the first year of the pandemic compared with 66 total cases over the previous 3 years. The current uptick may be due to stress associated with the pandemic and lockdowns. In most cases, these changes reduced physical activity levels and increased consumption of unhealthy food, both of which are linked to a higher risk for precocious puberty.

In a recent article, Mark P. Trolice, MD established that the first step in evaluating affected patients is determining whether central precocious puberty (CPP) or peripheral precocious puberty (PPP) is the cause. As Trolice explains, CPP is gonadotropin dependent. This means the hypothalamic-pituitary-ovarian (HPO) axis is prematurely activated, which leads to the normal progression of puberty. Idiopathic causes account for 80%-90% of presentations in girls and for 25%-80% in boys. On the other hand, PPP is gonadotropin independent. It is the result of sex steroid secretion from ovaries, the adrenal gland, or exogenous or ectopic production (eg, germ-cell tumor). Pubertal milestones occur in disordered progression.

Trolice explains that CPP treatment is mostly about maximizing adult height, most often through HPO suppression from pituitary downregulation with a gonadotropin-releasing hormone (GnRH) agonist. In girls with PPP, the primary treatment is dictated by the underlying causative pathology. For example, in patients with ovarian or adrenal tumors, albeit rare, surgical excision is the likely treatment.

Even before the recent uptick, whether to treat early puberty was a matter of some debate. Specifically, when it comes to girls with breast development who are aged between 6 and 8 years, many experts advocate for observation before deciding whether to begin treatment with a GnRH analog to suppress puberty. Evidence clearly suggests that stopping puberty before age 6 years benefits adult height. However, interventions in those aged 6-8 years are less well-supported. Experts say that the key to treatment is determining the best fit on an individual basis.

A recent study examined how to best approach the evaluation and management of precocious puberty in children with obesity. Among the suggestions provided:

  • Age cutoffs should not differ substantially between children with healthy weight and those with obesity. Girls with obesity who have confirmed thelarche should be evaluated for gonadotropin-dependent CPP to determine if additional investigation or treatment is indicated.

  • Basal luteinizing hormone (LH) levels are recommended as first-line testing in children with obesity and precocious puberty. However, false negative results may theoretically be a concern.

  • The diagnostic utility of assessing bone age (BA) is limited because girls with obesity often have advanced BA.

  • In girls with true CPP, obesity does not eliminate the need for MRI. Neuroimaging is determined by age and clinical features.

  • BA can be used to predict adult height in girls with CPP and obesity to inform counseling.

  • Use of GnRH analogues leads to increased adult height in girls with precocious puberty and obesity.

  • Obesity should not limit use of GnRH analogues because those drugs do not worsen weight status in this population.

Given the rising case counts, interest in optimal strategies to assess and manage precocious puberty is likely to also increase, as it did this week.

Learn more about precocious puberty.