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let's talk a little bit about precocious
puberty precocious puberty
unlike benign premature Theia larkey is
when the full appearance of puberty is
happening before the age one will expect
today children are developing earlier
than children used to develop we're not
entirely sure why it may relate to
having more hormones in our environment
people are taking oral contraceptive
pills that gets in the wastewater and
then is cycled through and we are
actually measuring estrogens and
drinking water perhaps that's the cause
it's unclear but right now if a boy is
developing puberty before the age of
nine or a girl is developing puberty
before the age of eight we consider this
precocious puberty so there are two key
types of precocious puberty one is
mitigated by a central process and the
other is mitigated by a peripheral
process typically in the adrenal glands
or in the testes or in the ovaries a
central process is really in the brain
and in particularly in the pituitary
gland for central precocious puberty
this requires an activation of the HPA
axis or hypothalamic-pituitary-adrenal
axis that is resulting in increased
levels of LH and FSH this results in
elevated testosterone or estrogen in the
genitalia or the testes and ovaries of
the child in girls
90% of precocious puberty is idiopathic
we don't know why it's happening in boys
90% of precocious puberty is a result of
a CNS tumor an example would be a
hamartoma so in boys we are much more
concerned about the possibility of a
tumor driving this and in girls this is
more likely to be idiopathic nonetheless
evaluation is likely indicated for
peripheral activation there is no
activation of the pituitary gland this
not an activation of the axis this is an
eczema sorg own a ttle excess production
of sex steroids there are a lot of
reasons why this might be happening
examples are if a father is using
testosterone gel to lift weights and
it's rubbing off on a child other
examples might be tumors that can revise
such as go nate'll tumors in either boys
or girls
tumors secreting HCG can cause this kids
with congenital adrenal hyperplasia can
develop symptoms where they have
excessive sex steroid production because
of shunting of hormones across into
testosterone there are a number of
reasons why this can happen but key is
to understand whether this is peripheral
or central so there are some key
questions that we can ask to try and
break this down first is we should
always ask what was the age of onset of
theall Archy which is when breasts are
developing pubic hair growth spurts and
menarche this can create a picture of us
understanding we should ask for a
history of CNS problems classic for a
pituitary lesion is impingement on the
optic chiasm and the subsequent visual
problems that you've learned about in
your neurology courses any CNS symptom
of a mass such as morning headaches
things along those lines
are certainly concerning but it is
typical for pituitary tumors to not
cause an increase in pressure inside the
head so this does not the absence of
these symptoms does not rule out a
central process any exposure to Exodus
sex hormones are important to understand
certainly we would like to know if this
child is having abdominal pain this may
indicate a peripheral tumor such as one
that's secreting HCG like a teratoma any
rapidly advancing puberty is addictive
of the possibility of adrenal tumor
these tend to cause very rapidly
advancing puberty and that can be
concerning and we might want to just
empirically image the
glands so if we suspect procures
precocious puberty and we want to delve
into what exactly is causing it the best
way to check is to get an LH an FSH and
in boys a testosterone level and in
girls an estradiol level typically in
both central and peripheral puberty you
will have elevated testosterone boys and
estradiol and girls
but as would make sense if it's a
central lesion the LH and FSH will be
high in central precocious puberty and
they will be low in peripheral
precocious puberty as there is a
negative feedback loop often in
precocious puberty there is bone delay
and if you want to learn more about how
we check bone age delay you can look at
our talk on short stature but generally
we will expect that they are more than
two years older than their hand x-ray
ultrasound should be obtained to show
precocious enlargement of the uterus or
ovaries and girls
and if suspected studies should be done
to find the tumor so if a child has a
high HCG level we should then go looking
for where that tumor is so it might be
excised in patients with central
precocious puberty it's critically
important to obtain a brain MRI and
especially with a cut down on the
pituitary a cut down is just extra
focused high resolution images of the
pituitary so that we know exactly what's
going on remember that see a serum HCG
is high also in a paddle blastoma so in
this those cases evaluation of the liver
is indicated from a radiographic
standpoint and certainly we're gonna
check labs such as 17 hydroxy
progesterone if we suspect the patient
has congenital adrenal hyperplasia if
you want to know more about that you can
check out the lecture on congenital
adrenal hyperplasia
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