Early Puberty and Avoiding Unnecessary Treatment

After stumbling upon a family last week who had come all the way from Fethiye just to get answers to the questions in their minds regarding their daughter whose precocious puberty was brought to a halt when she was 9.5 years old -currently 11.5- (Was it a mistake to start her on treatment? When will she start menstruating? Will she continue to grow taller?, How tall can she grow?), I decided to once again write a few words to reassure parents -particularly mothers- who are worried about early puberty among young girls. In fact, a lot of parents -particularly those residing in larger cities, although it is becoming common in everywhere else around the country- continue to bring their daughters to see a doctor after early development of breasts or hair growth. This is mostly because of interactions with various medical specialists, including pediatric endocrinologists, who like to make exaggerated statements especially on (social?) media. Despite the warnings provided by physicians like us, the complaint of early puberty still constitutes a significant reason for visiting a doctor, which incurs miscellaneous costs that are higher than what meets the eye.

The expenditure on puberty inhibitors is 30 million liras!

As we will be discussing in the rest of this article, many children are unnecessarily started on inhibitor injections because of the ongoing ambiguities surrounding the definition and treatment of early puberty. For example, according to the data found in the Intercontinental Marketing Services Health (IMS Health) database, where you can access a detailed breakdown of the drugs sold on the market in our country, the number of puberty inhibitors sold increased from 104.556 packs in 2014 to 152.938 in 2017, which means an approximately 50% increase. It is known that the majority of these drugs are used for children. A 50% spike should not be seen in the use of any specific drug over the course of 3 years, unless there is a pandemic going on. Therefore, this increase is associated as much with parents consulting physicians with their children due to unfounded concerns as much as it is with the fact that differences within normal limits are being perceived as ‘conditions’ and puberty inhibitors are expected to have an adverse impact on height.

Upon making a rough calculation, it can be said that puberty inhibitors annually cost about 30 million TL in our country. Add diagnostic and follow-up costs on top of it and the bill goes up by a few times. While young girls are being brought to the hospital to see a doctor 5-10 times more frequently in comparison to previous years because of the effect of women’s day talks, it should be recognized that physicians’ attitudes are likely influenced by those who are marketing puberty inhibitors. I would personally like to point out that the manipulation comes mainly from social and conventional media where the topic of puberty is constantly kept on the agenda. The way many different factors from chicken meat to plastic are blown out of proportion and presented as if they were ‘a new problem brought forth by modern life’ should not be ignored either.

Current dats about estimated height, bone age and risks of early menstruation

I have been practicing medicine for years in firm belief that we should respect the normal physiology of puberty and avoid use of puberty inhibitors as much as possible. Then again, avoiding medical treatment recommendations is kind of a risk in a setting where some physicians will accuse you of ‘not living in the present’ and make statements like ‘she will not grow taller than 153 or she will definitely start menstruating within 6 months; puberty should be inhibited immediately’. On the other hand, three consecutive articles have been published this year, all defending the opinion that starting treatment after 8 years of age for the purpose of gaining height is completely unnecessary. Note that one of these was authored by Prof. Abdullah Bereket, M.D., and the others were published in the USA. These come as a relief (see the titles of these articles below). I would like to briefly list the important points from these articles below in hopes that they might calm down mothers.

It is not possible to draw a strict and clear line between puberty and prepubertal period. This is because transition to puberty is a gradual process and varies among individuals.
The majority of cases that present with early puberty are merely variants of the normal or cases of puberty in slow progress. The mechanism underlying slowly progressive puberty is not known at this time. These cases show signs of puberty, yet their hormonal systems are not activated.
The majority of cases treated in various countries are unfortunately just cases of ‘normal early puberty’. For instance, the average age of starting treatment is 9 in the USA and 11-15% of the cases start before the age of 8. The average age of starting treatment is not known in our country, but it is estimated to be close to the aforementioned numbers.
Overall, starting treatment after the age of 8 because of concerns related to height is not recommended, because youngsters starting treatment after this age do not really grow much taller. Those children who are born with a low weight at birth and show signs of early puberty should be evaluated separately, as progression might be rapid in such cases.
Cases where the eventual height is impacted are early puberty cases between the ages of 3 and 6. Past studies pointing out that the eventual height suffers a markedly adverse impact (20 cm shorter in boys and 12 cm shorter in girls) involve cases with a very early onset. This is why a pessimistic conclusion about height should not be drawn up based on this data.
Likewise, it is not appropriate to make decisions on the basis of estimated height calculations. A higher bone age does not necessarily mean that height will be stunted in all cases. Estimated height calculations may be misleading most of the time.
One of the primary concerns among parents is the risk of early menstruation. However, there is no precise method that allows us to estimate the beginning of menstruation in cases of early puberty. In general, the time between the initial findings and menstruation is noticeably longer, which means that menstruation does not start earlier.
It is wrong to assume that growth will be stunted as if someone ‘hit the brakes’ as soon as menstruation starts. A larger extent of height acquisition might take place after menstruation among girls who start menstruating around the age of 10 in comparison to those who start at normal ages. The overall growth is 3-9 cm after menstruation (could also be 6-9 cm among girls who start menstruating earlier).
There is no sufficient data proving that menstruating at around the age of 10 causes anxiety in girls. In fact, observations indicate that parents are more anxious than girls themselves. Menstruation starts 2.4-3 years later in girls whose breasts start developing at around the age of 8, which means that they will usually menstruate after the age of 10.
Similarly, there is no reliable date with regard to cognitive and psychological problems among children with early puberty when compared to their peers. It is actually known that they do not really have much of a difference in this regard.
Data showing correlation between early puberty and adult conditions (cardiovascular diseases, breast cancer etc.) or psychosocial issues is quite limited. It would rather be more appropriate to say that there does not seem to be a notable problem within this framework either.
The most appropriate approach is to usually make a decision based on the progress seen 3-6 months later instead of diagnosing/treating the case. It may be a better approach to decide after obtaining a second opinion in cases where starting treatment is recommended.
Recent early puberty cases without an identified underlying cause have been proven to be partially associated with mutations in some genes relevant to puberty. Genetic analysis should be conducted in cases with a history of early puberty in their family.
Premature pubarche (early genital hair growth) is actually not even a topic that should be a part of differential diagnosis of early puberty. Investigation of conditions causing secretion of higher amounts of male hormone from adrenal glands is necessary in such cases.
The optimal age for discontinuing treatment is 11. Menarche usually takes place 16 months after discontinuing treatment on average. It has also recently been discussed that treatment could be discontinued around the age of 10.
No satisfactory data exists with regard to use of growth hormones, aromatase inhibitors or oxandrolone to stimulate growth in cases of early puberty.

Recommendations to avoid unnecessary treatment

In the end, just like the use of growth hormones, it seems that the industry primarily encourages studies that perceive borderline conditions as diseases and emphasize on parents’ concerns. This leads to unnecessary treatment of early puberty cases. In order to avoid such a situation, the following should be advised particularly to parents of girls who show signs of puberty between the ages of 7 and 9:

If your child is currently taller than their peers, their height will most likely be normal and inhibiting their puberty will not result in a notable change.
While it is not essentially certain that your child will experience psychological stress due to early puberty, it is also not certain whether or not inhibiting their puberty can stop or alleviate such stress.
Your child’s puberty will most probably follow a slower course and she will possibly not start menstruating as early as you may be afraid of. In most cases, it is an appropriate approach to observe them in intervals of 4-6 months and decide on whether or not treatment is warranted based on the progress of breast development.
It is not essential to prevent menarche in order to interfere with or inhibit later menstruations. In other words, it is not necessary to focus so much on preventing menarche. If the concern is about early menstruation, it is still possible to inhibit it after menstruation has started.
Treatment costs are high when you also take into account follow-up costs. The stress induced by the treatment itself should also not be ignored. In accordance with these facts, one should think thoroughly before deciding on initiating a treatment that is based on poor evidence and will last 2-4 years.

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