There comes a time when we all grow up, and puberty is where all the hormonal magic happens. Puberty can be at different times for everyone, but when should pediatricians get concerned that it is too late, or too early? Join us with our guest Dr. Juanita Hodax, Pediatric Endocrinologist, to discuss hormone pathways, Tanner stages, and approaching puberty in a gender inclusive way.
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Puberty is the transition from a childhood body to adult body. Pediatricians should start assessing for puberty with Tanner stage exams at all well child exams starting at 7 years old.
Physiologically, true puberty is determined by the Hypothalamus-Pituitary-Gonadal (HPG) Axis. Some unknown gene activates the hypothalamus to release GnRH in a pulsatile manner to start puberty. This causes the pituitary to release FSH and LH, which the stimulates gonads to release estrogen and testosterone.
In determining puberty history, it is important to assess the start and tempo of puberty. It is important to also to get a history of parent’s puberty, such as mother’s menarche and father’s growth spurt timing. Finally, when discussing puberty, it is important to use inclusive language that allow children to explore their gender identity in puberty, such as people with ovaries or people with testes.
Delayed puberty is defined as lack of pubertal signs or Tanner Stage 1 at 14 years old for children with testes and 12-13 years old (depending on source) for children with ovaries. This can be independent of signs of adrenarche.
First, get a good history, family history of puberty, and assess the growth curve. Pertinent history includes signs of anosmia, history of chemotherapy, history of traumatic brain injury or trauma, and concerning neurological symptoms like headaches or visual changes. Next step is to evaluate with morning hormone lab levels of LH, FSH, testosterone, and estrogen. A bone age may be considered in the work-up as well.
Expert Opinion: Dr. Hodax would send the lab work in children with testes ≥ 14 years old if they lack pubertal signs.
Delayed puberty can be considered in different categories:
Referral to a pediatric endocrinologist after these initial assessments is preferred for further evaluation and treatment. They can determine if treatment with growth hormone may benefit.
Precocious puberty can be more variable in age based on observational studies, but typically should be concerning if there are signs of puberty at 6-8 years old in children with ovaries or <9 years old in children with testes. Precocious puberty is more likely to be pathological in children with testes. It is important when getting a history and physical to determine if the concern is for isolated premature adrenarche, concerning signs of progression in Tanner stages, or concern for early menarche. Isolated premature adrenarche is generally less concerning. Risk factors for precocious puberty include obesity, environmental stress, exposure to environmental endocrine disruptors, infant born SGA, and prematurity.
Similarly, initial work-up for precocious puberty includes initial morning hormone levels of LH, FSH, testosterone, and estrogen. Bone age can also determine if height and growth may be affected if bone age is older than chronological age.
Precocious puberty can be considered in different categories:
Referral to a pediatric endocrinologist after these initial assessments is preferred for further evaluation and treatment. They can determine if treatment with growth hormone may benefit, as early puberty may indicate premature growth plate closure and limit height potential. Treatment usually involves GnRH agonist to disrupt the pulsatile GnRH that initiates puberty, and can at times may help with height preservation.
Listeners will understand the normal progression of puberty and how to identify delayed or precocious puberty and initial work-up.
After listening to this episode listeners will…
Dr Hodax reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Castillo J, Hodax J, Lee N, Masur S, Chiu C, Berk J. “#56: Late Bloomers: Catching Up on Puberty Knowledge”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ July 20, 2022.
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