EARLY ("PRECOCIOUS") PUBERTY
Puberty is the process of physical development from the first signs
of adolescence to full adult maturity. It is brought about by a series
of chemical messengers (hormones) which are secreted into the blood from
the endocrine (hormone secreting) glands. Thus messages are conveyed from
the brain to the pituitary gland in the head, then from the pituitary to
the sex glands (the ovaries in girls and the testes in boys), then these
in turn secrete the sex hormones (oestrogen in girls and testosterone in
boys) that cause the physical changes of puberty. Normal puberty takes
from 4 to 5 years in both sexes but it is an earlier event in girls than
in boys.
Typically girls show breast budding, pubic hair growth and an increased
rate of growth in height at 11-12, reach their fastest rate of growth at
12, start menstruating at 13 and finish growing at 15.
In boys enlargement of the testes and penis starts around 12 but the
growth spurt is delayed, reaching a maximum at 14, and final height is
not reached until 17 or later.
Variation in the timing of the changes of puberty and some variation
in the sequence is common but in the great majority of children the changes
occur within a span of 2 years before or after the average. The greater
the deviation from the average age of puberty the more likely is there
to be malfunction or disease of some part of this complex process. Problems
most commonly arise through "mistiming" of puberty which is either
early ("precocious") or delayed. Precocious puberty can therefore
be defined as pubertal development occurring before the age of 9 in a girl
or 10 in a boy. This is not a very rare condition and, for reasons which
are not understood, it occurs much more frequently in girls than in boys.
Invstigation:
Investigation is usually straightforward, requiring a blood test to
measure the levels of the relevant hormones and sometimes scans of the
head, and the pelvis in girls, to check on the anatomy of the brain and
the ovaries. These investigations usually confirm that the problem is simply
one of early activation of the normal process of puberty. This is most
commonly genetic, children tend to follow a similar pattern of development
as their parents. If an underlying problem is found, the implications will
clearly be different.
Problems:
The problems associated with early puberty are largely due to the disparity
in size and sexual development between the child and his or her peers.
With sympathetic handling this is seldom a major source of embarassment
but it may, for instance, be difficult for a girl at primary school to
cope with having periods. Some boys make the best of their early growth
and become sporting or athletic stars. Difficulties do often arise because
people, especially of course those who are unaware of the child's age,
assume a level of intellectual and emotional maturity equivalent to the
child's physical maturity. Although early developing children are often
advanced in these respects, there is a lag in such development. Sexual
feelings are awakened early by the adult hormones but seldom cause serious
behavioural difficulties. Nonetheless, it is important to be aware that
such children can be sexually exploited and indeed that girls can be fertile
at a very early age. Generally, if all concerned understand the implications
of the condition and the child receives kind and sympathetic handling,
remarkably few problems do occur. A more practical concern is that, although
early developing children have an early growth spurt and are usually tall
for their age in childhood, they also finish growth early and may be of
short stature as adults.
Treatment:
There are two options for the management of early puberty: The first
is to use no active treatment and to let nature take its course. Not only
the parents but also the child, the teachers and other important people
in the child's life need to understand the condition and to be reminded
to treat the child according to chronological rather than maturational
age. The alternative is to suppress the secretion of the pituitary hormones
(gonadotrophins) which initiate puberty. There are available oral drugs
(e.g.cyproterone) and injectable preparations (e.g.Zoladex, a depot preparation
of which a single injection lasts for either one month or three months).
The progression of puberty can usually be halted with cyproterone. It generally
has few side effects but some children are a little sleepy to start with
and very rarely serious liver toxicity has occurred. Zoladex is highly
effective and safe but does require a large subcutaneous injection. Unfortunately,
neither form of treatment fully controls the advance in bone maturity which
causes the early completion of growth. Treatment therefore has only a limited
effect on final height.
Future:
Since all their peers eventually catch up with them, there are few long-term
problems from early puberty . Starting early does not imply finishing early,
there is no evidence that girls with early puberty have an ealry menopause,
indeed they seem to have a longer than usual reproductive life. Usually
the only long- term concern is growth and in this respect also most children
with early puberty do better than the methods of height prediction suggest.
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