Precocious puberty should be considered when secondary sexual characteristics appear before 8 years of age in girls and 9 years in boys.
It results in accelerated skeletal development and sometimes a reduced adult height, and may have a psychosocial impact, especially due to early menses in girls.
Two forms exist: gonadotropin-dependent precocious puberty (GDPP; due to premature activation of the hypothalamo-pituitary-gonadal axis) and gonadotropin-independent precocious puberty (GIPP; due to autonomous secretion of sex steroids).
History should be directed dependent on whether puberty is consonant or disconsonant (i.e., whether the pattern of endocrine change is the same as in normal puberty or not).
Treatment of GDPP is usually straightforward with gonadotropin-releasing hormone agonists.
GIPP is more difficult to treat, and may require medications to block production or action of sex steroids.
Treatment should be stopped once an acceptable age of puberty is reached.
Puberty is an interval characterized by the acquisition of the secondary sexual characteristics, accelerated linear growth, increase in the secretion of sex hormones, maturation of gonads (testes in boys; ovaries in girls), and the potential for reproduction. It is typically complete within 2 to 5 years. Precocious puberty should be considered when secondary sexual characteristics appear before 8 years in girls and 9 years in boys. It also results in accelerated skeletal development with a reduced adult height.
History and exam
Key diagnostic factors
- boys: testes >4 mL
- girls: breast development
- pubic/axillary hair
- increased growth velocity
- tall stature
Other diagnostic factors
- café au lait spots
- symptoms of other autonomous endocrine hyperfunction
- polyostotic fibrous dysplasia
- neurofibromas, axillary freckling, and kyphoscoliosis
- facial dysmorphism
- eye abnormalities
- motor deficits
- abnormal head size
- brain tumors
- cranial irradiation
- McCune-Albright syndrome
- gonadal tumors
- congenital adrenal hyperplasia (CAH)
- positive family history
- exposure to exogenous hormones
- head injury
- neurofibromatosis type 1
- previous central nervous system infections
- congenital pituitary abnormalities
- sexual abuse
1st investigations to order
- bone age assessment
- basal follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
- serum testosterone
- serum estrogen
- ultrasound pelvis
- LHRH stimulation test
Investigations to consider
- MRI brain
- CT brain
- urinary steroid profile
- adrenocorticotropic hormone (ACTH) stimulation test
- CT or MRI adrenals
- ultrasound adrenals
- bone scan/skeletal survey
- other pituitary hormone investigations
- genetic testing
- thyroid function tests
- overnight gonadotropin profile
gonadotropin-dependent precocious puberty (GDPP)
gonadotropin-independent precocious puberty (GIPP)
Ameeta Mehta, MBBS, DCH, DNBE, MSc, MRCP, MD
AM is an author of several articles cited within this topic.
Peter Hindmarsh, BSc, MD, FRCP, FRCPCH
Professor of Paediatric Endocrinology
University College London
PH is an author of several articles cited within this topic.
Malcolm Donaldson, MD, FRCP, FRCPCH, DCH
Senior Lecturer in Child Health
Department of Child Health
Royal Hospital for Sick Children
MD has received lecture fees and financial support from pharmaceutical companies (Pfizer, Novo Nordisk, Serono) who manufacture growth hormone and whose brands of growth hormone MD recommends. MD is also an author of articles cited in this topic.
Dianne Deplewski, MD
Assistant Professor of Pediatrics
University of Chicago
DD declares that she has no competing interests.
- Premature thelarche
- Premature adrenarche
- Congenital adrenal hyperplasia (CAH)
- Evaluation and referral of children with signs of early puberty
- Consensus statement on the use of gonadotropin-releasing hormone analogs in children
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer