Precocious Puberty

Objectives

After completing this article, readers should be able to:

1. Know the normal ages of pubertal onset in boys and girls.

2. Discuss the clinical signs of puberty, their usual sequence of appearance, and their typical rate of progression.

3. Use the physiology of puberty to diagnose the cause of abnormal puberty.

4. Describe the factors involved in the appropriate management of precocious puberty.

5. Determine whether to follow or refer children who have signs of early puberty.

Introduction

Although precocious puberty has standard clinical definitions and diagnostic tests are improving, the management of children who have signs of early puberty has become more complex in some ways during the last decade than ever before. This review illustrates how an understanding of the anatomy and physiology of puberty forms the foundation for managing children who experience puberty early.

Case History

A 4-year-old female has developed pubic hair in the past 3 months and has had an adult body odor for 6 months. She is otherwise healthy and has no pertinent findings on medical and surgical history. Her height and weight are just above the 97th percentile for age, and her physical examination reveals Sexual Maturity Rating (SMR) 2 breast and pubic hair development.

Definitions

By convention, normal puberty begins between ages 8 and 12 years in girls and between 9 and 14 years in boys. The lower ages of normal pubertal onset recently have been challenged, but a consensus to accept puberty among younger children as being normal without diagnostic evaluation has not been reached. Criteria for defining the five stages of puberty in boys and girls, proposed by Marshall and Tanner in 1969 and 1970, remain the standard (Fig. 1).