Precocious Puberty in Girls: Concerns and Facts
Precocious puberty is one of the problems that the families are most concerned about in recent years. Recently, there is a common idea that there is an important transformation in healthcare services and this change is favorable. Indeed, at first glance, we may say that the people living in our country has a healthcare insurance that can be considered generous, it is easier to access to the physicians and medications and therefore the number of seeking medical advice per person in a year has increased to 8.2 from 3.2 in 12 years and that the healthcare service infrastructure, particularly the hospitals, have been improved and number of physicians have increased. In spite of these developments, we see that the families are more concerned especially about their children, they go from one hospital to another for many conditions that are not considered as diseases, the physicians often use a language that increase the concerns of the families and refer the patients without racking their brains too much (in other words without having a great deal of trouble) and eventually, many families have difficulty in finding a reliable expert.
In other words, as easily reaching to a physician does not mostly ensure the accurate diagnosis, many patients need to present to 3 physicians/hospitals on average and the process itself can be as wearing as the diseases. Further to that, the specialists most of who are working as faculty members at medical faculties where the families present to as a last resort (as we tell to many families in recent weeks) can say “you actually come here in vain, your child is completely healthy” and can cause a feeling of pointlessness for the families.
Today, there is an apparent vicious cycle between the increase in anxiety levels of families and superficial medical practice. Health consumption gradually constitutes the main pattern of the healthcare system in our country. Precocious puberty is one of the problems that the families are most concerned about in recent years.
Why does the concern regarding precocious puberty increase?
Especially for their daughters, many mothers are concerned about the newly growing hairs and the initial development of their daughters’ breasts and apply to pediatric endocrinologists with the panic that their daughters will start menstruating within weeks or will have cancer in the future. One reason why this concern has increased is the fact that the frequency of breast development of girls between 6 and 9 years of age has increased from 5 percent to 10 percent. However, the main reason is the increase in internet use at home and many articles that pop up when the term “early puberty” is searched are written with a concerning language. This condition is not unique for our country. An increase in frequency of contacting a physician for precocious puberty and using puberty blockers is observed in many countries within the last decade. The news stating that “sugary foods increase the risk of precocious and therefore, breast cancer” that took place in many papers in western countries lately can be given as an example. (http://www.telegraph.co.uk/news/health/11373312/Fizzy-drinks-cause-early-puberty-and-increases-cancer-risk-in-girls-study-finds.html).
The common features of news about puberty are presenting the medical discussions about earlier breast development of girls with exaggerated statements like “puberty explosion” and giving an impression like the girls are commonly heaving menstruation at earlier ages. This kind of news equates the early breast development to precocious puberty to early menstruation and all these to short stature. Moreover, the possibility of a disease for all children presenting for precocious puberty is highlighted. Some families take chicken meat or fruits like strawberry responsible for early development of breasts in their children while some of them see nightmares by concerning that early breast development increases risk of cancer. Furthermore, almost all news state that hormone treatment is necessary for all precocious puberty cases and therefore, short stature can be prevented. Many of those articles/news are either false or exaggerated; therefore, they are filled with emphasizing that may cause misunderstandings. Also, the potential effects of chemicals known as “endocrine disruptors” (certain substances such as phthalate found in plastics and toys) are pictured as if they correspond to a common, proven and dangerous problem.
We know that the conditions that are not actually diseases are imaged like diseases with the effect of market dynamics in healthcare sector in recent years and therefore, it is aimed to increase number of individuals presenting to privately owned healthcare institutions. Therefore, works like health education or public disclosure which are among the main duties of physicians are largely applied in the context of “public relations” works and health programs are used for that purpose in many press/media institutions. The information recently provided to the press by a physicians who is a laboratory manager can be shown as an example (http://www.aksam.com.tr/saglik/erken-ergenlik-cocugunuzu-nasil-etkiler/haber-379602). All these not only cause unnecessary use of healthcare services and examinations but also performing unnecessary treatment to eliminate the concerns of the family by the physicians. Many researchers pointed out that the first one of medications prescribed unnecessarily is puberty blockers in European Pediatric Endocrinology Congress recently that took place.
When and how does puberty start? Does early breast development always indicate precocious puberty?
Puberty is the period of transition from childhood to adulthood and important developments develop in this period including breast development, hair growth in genital region and female-specific fat distribution in girls and sex-specific visible changes growth in testicles and penis along with genital hair growth in genital region as well as gaining reproductive skills and quickly getting tall in boys. Menstrual bleeding in girls and ejaculation in boys start towards the end of puberty and increase in length stops after a while.
Puberty is evaluated with breast development which demonstrates the effect of estrogen hormone as the ovaries cannot be visualized from outside in girls while it is evaluated with growth in testicles in boys. In others words, the point where breasts start to grow in girls and testicles start to grow in boys is called “triangulation point” of puberty and it is assumed that this is followed by other endocrinologic, biological, physical and psychological changes. The age limits of puberty which are also accepted today is 8 at earliest, 10.5 on average and 13 at latest in girls and 9 at earliest, 11.5 on average, 14 at latest in boys. This statistical data mean that 95 of children will reach puberty within this age ranges. It should be remembered that “normal” and “average” are different concepts and puberty between the earliest and the latest ages should also be accepted as in normal ranges.
Scientifically speaking, breast development before the age of 8 in girls is accepted as precocious puberty. However, breast development can be solely seen before the puberty center in brain starts functioning, in other words before ovaries start to grow and other findings of puberty develops. These cases are defined as premature thelarche or “normal precocious puberty”. In other words, premature breast enlargement before 8 years of age does not necessarily mean precocious puberty. In most of these cases, breast develops before the hormones that initiate puberty are activated, in other words, independently from the puberty hormones. It has been observed that the hair growth starts in genital regions and armpits of girls who gain weight fast and this is mostly associated with breast development mixed with adipose tissue in recent years. For some girls, change in body odor specific for puberty may also occur early. Those events are caused by premature production of hormones called androgen in adrenal glands due to the reasons which are not clearly known yet and this condition does not cause any negative results most of the time. These children do not start menstruating at early ages and their heights are also not affected negatively.
Another important point is the relation between breast development and menstruation time. Generally, for girls whose breasts start to enlarge around 10.5 years of age, menstruation starts approximately 2 years later. However, as mentioned above, when there is premature breast develop which is not related to a disease, the period between breast development and menstruation prolongs, in other words, menstruation occurs earlier than normal.
Does puberty starts at earlier ages?
There is an ongoing discussion in pediatric endocrinology field regarding earlier puberty in girls and increase in prevalence of precocious puberty in girls for the last 15 years. A research based on the data from offices of pediatricians in the USA performed in 1997 which argued that there is an unexpected/unexplained shift to earlier ages in breast development. In this research and the following discussions, it was proposed to draw the puberty age to 6 in black girls and 7 in Caucasian girls and girls who are members of other ethnic groups, although this suggestion was not accepted. Today, pediatric endocrinologist in the USA and other countries continue to accept 8 as age limit for precocious puberty for girls and 9 for bodys. The age of menstruation was found similar to other researches in the researches stating that the breast development shifted to earlier ages performed in the USA, in other words, no shift to earlier ages has been noted in menstruation age. It is also observed that the menstruation age is stabilized in developed countries. Researches performed in European countries also demonstrate that there is a shift to earlier ages in breast development, but not in menstruation, and breast development does not negatively affect the height. The most important exception for that is adopted girls; precocious puberty is more commonly seen in these girls while the reasons are yet to be explained.
Researches performed in our country also shows that there is no shift to early ages in puberty based on the menstruation age. Although there is an increase in frequency of breast development between 8 and 10.5 years of age and before 8 years of age in girls, we can say that there is no need to worry about short stature and early menstruation in case of early breast development and/or early puberty which are not caused by a disease. Most of the children brought to hospital by worried families are 6 to 9 year old girls who experience only genital hair growth or breast development. Puberty of those children has slow course and most of them start menstruating at normal time, also their heights are consistent with their genetic potential.
Do environmental factors play a role in early development of breasts and/or partial precocious puberty?
Recent studies conducted on Finn twins indicate that genetic factors affect the timing and tempo of puberty in girls and boys by 82%-86%. As well as genetic factors, it is emphasized that ethnicity, nutrition pattern, overweight or obesity particularly during infancy or early childhood, consumption of sugary drinks, low birth weight, menstruation age of mother, mother’s age at menarche, child adoption by families in developed countries, father-absent home and Estrogen-like endocrine disrupting chemicals have influence on the age of puberty. For early development of breasts, secondary to good nutrition and/or overweight, and/ or girls who enter puberty earlier, early puberty linked with health conditions is not considered and generally medication therapy is not necessary. Today, data, not confirmed completely yet, regarding environmental factors that affect the timing and normal physiology of puberty and the rate of pubertal development, are available and extensive discussions are done on this issue in scientific platforms.
When to see early puberty in girls as a problem?
Generally, delayed puberty is observed in boys, while early puberty is observed in girls. The underlying cause of most delayed puberty cases in boys cannot be identified and no disease is identified in most of early puberty cases in girls. First, it should be kept in mind that early puberty in boys is generally caused by a health condition. The probability of a health condition is high in early puberty cases identified before the age of 6 years in girls. The main sign of early puberty in girls is breast development, but rapid height increase, genital hair growth, heavy smell of sweat and puberty-related mood swings also occur. Thus, if other signs of puberty exist along with early development of breasts and the rate of pubertal development is high, the probability of early puberty is high. If not so, early development of breast should be considered.
The probability of a health condition in early puberty cases identified between the age of 6-8 years in girls is around 2%. Treatment should be planned based on hormone levels, bone age determination, the rate of pubertal development, ovarian and uterine dimensions and results of brain MRI, if required. There is no doubt that early puberty cases, secondary to a pathology, should be treated. In cases that do not have an underlying cause, the decision for the treatment in patients who enter adolescence after the age of 6, should be made depending on the progressive status of adolescence and other parameters. It should be remembered that early development of breasts in these cases do not suggest early menstrual period and treatment has no significant effect on height gain. it should be known that the breast development that occurs between the ages of 8-10.5 does not generally require treatment if there is no underlying disease.
In conclusion…
In many countries ,relevant specialty organizations are in charge of subjects that affect the entire society such as shift of adolescence to younger ages. Media institutions should also publish news that mirror mutual opinion of these specialty organizations. Similarly in our country, it is important to prevent health related news from being relayed to the public with an agitative discourse for both stopping the families from getting destructively anxious and decreasing health consumption.
Prof. Şükrü Hatun, M.D.
Note: Family guides included in web sites of Pediatric Endocrinology and Diabetes Society may be beneficial.
http://www.cocukendokrindiyabet.org/