Precocious Puberty Clinical Presentation

  • Author: Paul B Kaplowitz, MD, PhD; Chief Editor: Stephen Kemp, MD, PhD   more...
 
Updated: Apr 17, 2012
 

History

Precocious puberty in girls

  • The first and most obvious sign of early puberty is usually breast enlargement, which may initially be unilateral.
  • Pubic and axillary hair may appear before, at about the same time, or well after the appearance of breast tissue. Axillary odor usually starts about the same time as the appearance of pubic hair.
  • Menarche is a late event and does not usually occur until 2-3 years after onset of breast enlargement.
  • The pubertal growth spurt occurs early in female puberty and usually is evident by the time of initial evaluation.

Precocious puberty in boys

  • The earliest evidence of puberty is testicular enlargement, a subtle finding that often goes unnoticed by patients and parents.
  • Growth of the penis and scrotum and typically occur at least a year after testicular enlargement.
  • Accelerated linear growth (the pubertal growth spurt) occurs later in the course of male puberty than in female puberty but often occurs by the time other physical changes are noted.
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Physical

Precocious puberty in girls

  • The most reliable sign of increased estrogen production is breast enlargement. Initially, breast budding may be unilateral or asymmetric. Gradually, the breast diameter increases, the areola darkens and thickens, and the nipple becomes more prominent. Distinguishing glandular breast tissue from fat, which can mimic true breast tissue, is essential. Examining the patient while she is in the supine position usually minimizes the chance of misinterpreting fat as true breast enlargement.
  • Genital examination may or may not reveal pubic hair, but enlargement of the clitoris indicates significant androgen excess that must be promptly evaluated. The vaginal mucosa, which is a deep-red color in prepubertal girls, takes on a moist pastel-pink appearance as estrogen exposure increases.
  • Mild acne may be normal in early puberty, but rapid onset of severe acne, like clitoral enlargement, should increase suspicion of an androgen-excess disorder.

Precocious puberty in boys

  • The earliest sign of central precocious puberty (CPP) is enlargement of the testes, which depends on increased production of follicle-stimulating hormone (FSH); testicular length is more than 2.5 cm or testicular volume (with Prader orchidometer beads) is more than 4 mL. If progressive signs of androgen excess occur in a boy without increased testicular size, consider possible causes of precocious pseudopuberty, including congenital adrenal hyperplasia, familial male precocious puberty, and Leydig-cell tumors (a testicular nodule is usually palpable). Human chorionic gonadotropin (HCG)-secreting tumors somewhat increase testicular size by stimulating testicular Leydig-cell LH receptors.
  • Other signs of puberty (eg, penis growth, reddening and thinning of the scrotum, increased pubic hair) are a consequence of increased testosterone production and occur within 1-2 years after testicular enlargement.
  • Pubic hair growth that occurs without penis and testicular enlargement and other signs of increased androgen production usually reflects increased adrenal androgen production (ie, premature adrenarche) rather than true puberty.
  • Later signs of puberty include the pubertal growth spurt, acne, voice change, and facial hair.
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Causes

Genetics: The timing of puberty has a genetic component. A history of early puberty in a parent or sibling is relevant and decreases the likelihood that early puberty has an organic cause. One study from Israel estimated that precocious puberty was familial in one fourth of cases and that the predominant mode of inheritance was autosomal dominant.[14]

Body fat

  • An increased body mass index (BMI) has been associated with early puberty.[15] In some studies the association is stronger in white girls than in black girls. Obesity is not clearly associated with early puberty in boys.
  • In the 1970s, Frisch et al proposed that girls need a certain weight or body fat content to trigger menarche and to maintain cyclical menses.[16] The relationship between body fat and puberty is complex and has many exceptions; however, body weight and fat mass are clearly among the factors that may influence puberty onset in girls.
  • A recent longitudinal study of 354 girls by Lee et al found that increased BMI at age 3 years and the rate of increase in BMI from age 3-6 years were both positively associated with an earlier onset of puberty.[17]
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Contributor Information and Disclosures
Author

Paul B Kaplowitz, MD, PhD  Professor of Pediatrics, George Washington University School of Medicine and Health Sciences; Chief of Endocrinology, Children's National Medical Center

Paul B Kaplowitz, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, Endocrine Society, and Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Phyllis W Speiser, MD  Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Hofstra-North Shore LIJ School of Medicine at Hofstra University

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Lynne Lipton Levitsky, MD  Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School

Lynne Lipton Levitsky, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Diabetes Association, American Pediatric Society, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Pfizer Grant/research funds P.I.; Tercica Grant/research funds Other; Eli Lily Grant/research funds PI; NovoNordisk Grant/research funds PI; NovoNordisk Consulting fee Consulting; Onyx Heart Valve Consulting fee Consulting

Merrily P M Poth, MD  Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences

Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD  Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

References

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Graph represents the prevalence of breast development at Tanner stage 2 or greater by age and race.
Graph represents the prevalence of pubic hair at Tanner stage 2 or greater by age and race.
 
 
 
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