EARLY PUBERTY

VS
PRECOCIOUS PUBERTY

Siska Mayasari Lubis

Pediatric Endocrinology Division, Child Health Department

Faculty of Medicine, Universitas Sumatera Utara /
H. Adam Malik General Hospital
OUTLINES
Normal Puberty

Precocious Puberty

Early Puberty
 Puberty
§ Puberty refers to the stage of transition from the sexually immature child to the
potentially fertile adolescent.
§ Puberty is initiated upon activation of the hypothalamic–pituitary–gonad (HPG) axis
containing the GnRH pulse generator or gonadostat.

§ Appearance of secondary sexual characteristics

§ Acceleration of growth
§ Maturation of reproductive organs and fertility.

De Silva NK & Tschirhart J. Curr Treat Options Peds. 2016;2:121–30

How Puberty Begin..?

Howard SR et al. Brook’s Clinical Pediatric Endocrinology. 7th ed, 2020

When does puberty happen..?

Puberty Onset
Girls : 8 – 13 years
Boys : 9 – 14 years

What are the first signs of puberty?

Breast development Testicular volume ≳ 4 ml

(Breast buds)

Howard SR et al. Brook’s Clinical Pediatric Endocrinology. 7th ed, 2020

 Physical Changes that Occur During
Puberty

The physical changes are classified by the definitions

described by Tanner --> TANNER STAGE

Klein DA et al. Am Fam Physician. 2017;96:590-9

Pubertal Sequencing

Adapted from Division of Adolescent Medicine, Children’s Hospital Medical Center, Cincinnati, OH, 1995
Precocious Puberty

The onset of physical The onset of physical

signs of puberty before signs of puberty before
the age of 9 years the age of 8 years

Progressive development of secondary sexual characteristics à Breast development in girls and testicular
enlargement in boys, together with the pubic hair, acceleration of growth velocity and bone maturation resulting
in premature fusion of the growth plates.

Adult height deficit and psychosocial distress

(Decreased peer interaction, social withdrawal, impairment in school performance, altered
behavioral development, increased aggression, increased risk of sexual abuse)

Mucaria C et al. Sexes 2021; 2: 119–31

Pathogenesis of Central Precocious Puberty

Hypothalamus

GnRH
Primary lesion
(-) Pituitary

LH/FSH

Gonad

E2 or T
Pathogenesis of Peripheral Precocious Puberty

Hypothalamus
GnRH

(-) Pituitary
Primary lesion

LH/FSH

Gonad
extra gonadal

E2 or T T
What causes precocious puberty..???

Bradley SH, et al. Br Med J. 2020; 368: 1-7

When should
suspected
precocious puberty
be explored..?

Howard SR et al. Brook’s Clinical Pediatric Endocrinology. 7th ed, 2020

 Clinical characteristics of precocious puberty
Central Precocious
Puberty
• Always isosexual
• Pubertal development according
to the normal pubertal pattern.
• Increased hormone levels in
hypothalamic – pituitary - gonadal
axis
• CPP in girls is usually idiopathic,
whereas the vast majority in boys
are due to an intracranial lesion
Peripheral Precocious
Puberty
• Isosexual or heterosexual
• The pattern of pubertal
development may be
asynchronous
• Serum sex steroid levels are
elevated independent of
gonadotrophin secretion, and
therefore, gonadotrophin levels
are low, and the gonads do not
undergo maturation
Nasir et al. Int J Med Res Prof. 2017; 3: 9-13
Evaluation of the Child with Precocious Puberty

Pallavee P, et al. Int J Reprod Contracept Obstet Gynecol. 2018; 7: 771-7

Normal Variant of Puberty
Cases of premature sexual maturation that correspond to variants of
normal development can mimic precocious puberty but do not lead to
long-term consequences and are usually benign.

Thelarche Premature
§ Isolated breast development before the age of 8 years, without other sexual characteristics, no
acceleration of height velocity or significant advance in bone maturation (≥2 years).
§ Mechanisms that may play a role in inducing thelarche include increased sensitivity of breast
receptors to estrogen and increased aromatization of adrenal precursors.
§ No further investigation / treatment is required, but need to do follow up because premature
thelarche may precede the onset of CPP (patients develop other pubertal signs and/or an
acceleration of height velocity).

Diamantopoulos S & Bou Y. Pediatr. Rev. 2007; 28; e57-68

 Premature Pubarche

§ The appearance of pubic hair before the age of 8 years in girls and 9 years in boys, without other
signs of puberty.
§ Endogenous puberty occurs at a normal time and adult height is within the expected range for
parents.
§ Possible differential diagnoses to be excluded in a child with premature pubarche associated with
accelerated growth, advanced bone age, especially if other signs including clitoromegaly, voice
deepening, or extreme hirsutism are present, include adrenal tumours and CAH.

Novello L & Speiser PW. Pediatr Ann. 2018; 47: e7-11

Diagnostic
Approach to
Precocious
Puberty

Klein DA et al. Am Fam Physician. 2017;96:590-599

 Early Puberty

Between normal puberty and precocious puberty, there is a population in a

“borderline” situation, which can be defined as early puberty

Although there is a lot of discussion surrounding the age at onset of the latter, early
puberty is generally understood to be the onset of pubertal between 8 - 9 years of
age in girls and between 9 - 10.5 years in boys.

Children in whom puberty appears early within the physiological age range and
progresses at an accelerated rate, leading to a state of sexual precocity for age

Lazar et al. J Clin Endocrinol Metab. 2001; 86: 4127–32

In early puberty, the transition from Tanner stage 2 to 3 was shorter than normal, thus,
children with accelerated early puberty also achieved a state of sexual precocity for age.
This course was characterized by accelerated growth and bone maturation rates.

Gonadotropin-suppressive therapy should be offered after a follow-up of at least 6

months for children with accelerated puberty.

The indications for gonadotropin-suppressive therapy (GnRH agonist)

not only age at onset of puberty but also rate of pubertal progression
 Conclusion

§ Precocious puberty is a common problem seen in pediatric endocrinology practice.

Identification of the child with pathological pubertal development allows for
accurate diagnosis and application of current treatment strategie

§ Although early puberty is considered a normal variant of puberty, it is approached in

the same way as precocious puberty in practice since it may end up having negative
repercussions both on final stature and on social and psycho emotional factors.
Thank You