Precocious Puberty

Anyone else concerned that young girls are entering puberty earlier that a generation or two ago? It's made the news lately and seems to be getting more attention although attentive physicians have been concerned for a long time.

In 1999, the American Academy of Pediatrics published guidelines revising what defined precocious puberty based on a study looking at 6-8 year olds in 1997. This guideline did 2 things. It separated out African-American and Caucasian girls and lowered the "OK" range of what 'normal' puberty ages were to as young as age 6. Interestingly, they did not find a change in boys puberty ages. According to these guidelines, it is considered "OK" for girls to develop breasts or pubic hair as young as 7 for Caucasian girls and as young as 6 for African-American girls. It is only considered precocious puberty if there are 2 signs under the age of 8 in girls.

Fairly recently, Dr Biro repeated this study, comparing the results to those found in the 1997 study. What he found was startling. Link to abstract of the article here.
• 10.4% of Caucasian girls had breast development - double the 1997 study.
• 23.4% of African-American girls had breast development vs. 15.4% in 1997. That is almost 1/4 of all African-American little girls.
These are 6-8 year olds!

So, what are a few of the causes behind this situation and more importantly what can we do right now for our children and our young patients?

1. There is no doubt that the increasing obesity numbers in young children is dramatically increasing. Children today are heavier. Even the non-obese children are heavier than they were one to two generations ago. If you look back at your elementary school photos, there probably were one or two children that were heavier. Now, start watching children today walking around. The thinner children often stand out because they are the more unusual in the community. There are many reasons for this situation of course, changing social structures, changing food quality and quantity and social acceptance. A growing proportion of our children are sadly also becoming insulin resistant; crossing that line between "baby fat" and into obesity. Obesity and the associated hyperinsulinemia, increases the stimulation on DHEAS production from the adrenal glands. As a result, the zona reticularis, becomes hypertrophied setting up an anatomical problem leading to higher androgens life-long. Higher androgens lead to development of early pubic hair and breast development, but long term contribute to hirsutism, acne and infertility. Yikes.

2. Bisphenol A or BPA is a recognized environmental estrogen receptor agonist. In fact, BPA was discovered when researching hormone replacement, but instead, they stumbled upon the wonders of DES instead. BPA is found in can linings (including powdered baby formula) and plastic containers (unless noted BPA free: 2, 4, and 5 plastics are considered “safe”). BPA has been found by major university studies to contribute to health problems both at low doses and at high doses, but different problems at each titration. And if that wasn't bad enough, BPA has been found to cause problems in-utero for the reproductive tract of the offspring. BPA is bad; try to avoid it.

3. Other environmental estrogens have been found in normal household products. One that has been identified as more commonly used in the African-American population is protein enriched shampoo - enriched with placenta. Since the placenta makes hormones, the hormones get into the shampoo and cause precocious puberty. Cases have been reported of infants being washed with placenta containing shampoos and developing pubic hair. Of course, family members using topical hormones may also contribute to environmental exposure.

4. Pituitary tumors may also cause early sexual development. These are always considered, but generally found with rapid and extreme precocious puberty and are more common in boys.

Testing recommended for precocious puberty: MORNING levels (bloodspot works great)
o Testosterone
o Estradiol
o DHEAS
o LH
o FSH
o Thyroid - especially with additional symptoms

o Additional testing that may be recommended afterwards includes MRI and/or ultrasound.

So what to do if you suspect that your patient/daughter/son has precocious puberty?
First, assess whether they fit the guidelines, then, follow-up with a pediatrician who can examine them thoroughly. For instance, don't assume that it's the drinking from the BPA-filled water bottle is the cause until a pituitary tumor has been ruled out. Certainly avoid environmental estrogens, eat organic, don't shampoo with estrogen, but make sure you are doing that while waiting for your appointment. That way, when you are told it's idiopathic (i.e. “unknown cause”) you'll be well on your way to helping the situation.

Treatment for precocious puberty depends on finding the cause. If a cause is not found, depending on the age, no treatment may be suggested. However, it is common that children who are young will be offered Lupron or another medication to cause the LH and FSH to shut down the testicles and ovaries until the appropriate time for development. Since they shouldn't have hormones already, this does not cause the problems and side effects that you see with adults. Using hormone blockade allows for a normal childhood and attainment of full height which may be blunted by high hormone levels.

Some children will always be the early bloomers and some children will always be late. But if we can watch for those that are negatively been affected by the world around us and rather than just accept this new baseline and instead take action to educate others and change what we can, perhaps our children have a better chance of reaching their full potential.

Best Wishes

Dr Alison McAllister

For more information on precocious puberty see http://emedicine.medscape.com/article/924002-overview OR http://www.nichd.nih.gov/health/topics/precocious_puberty.cfm