Precocious Puberty Causes

See Also

Causes
Central (GnRH dependent, complete Isosexual)

Idiopathic
CNS Lesion (e.g. pituitary tumor, hypothalamic hamartoma)
Severe Head Trauma
Cranial irradiation
Perinatal conditions
Meningoencephalitis history
Secondary to GnRH independent Precocious Puberty
Hypothyroidism
Chronic Adrenal Insufficiency

Causes
Peripheral (GnRH independent - always abnormal)

Adrenal Causes
1. Adrenal causes result in rapidly progressive Adrenarche and Virilization
  1. Girls: contrasexual (e.g. clitoromegaly)
  2. Boys: Isosexual (e.g. penile enlargement)
  3. Other findings
    1. Growth acceleration
    2. Severe acne
    3. Hirsutism
    4. Pubic and axillary Hair Growth
    5. Voice change
2. Causes
  1. Congenital Adrenal Hyperplasia
    1. 21-OH deficiency (21 Hydroxlase deficiency, most common)
    2. 11-OH deficiency (11 Hydroxylase Deficiency)
  2. Adrenal Tumor: contrasexual or Isosexual)
    1. Functioning adenoma or carcinoma results in Glucocorticoid excess or Virilization
  3. Cushing Syndrome
    1. Glucocorticoid excess
Gonadal Causes in Females
1. McCune-Albright Syndrome (Isosexual)
  1. Autonomously functioning Ovarian Cysts release Estradiol
  2. Findings
    1. Polyostotic fibrous dysplasiaof bones
    2. Cafe Au Lait spots
    3. Precocious Puberty
    4. Vaginal Bleeding (may be only sign)
    5. Associated with Hyperthyroidism, Cushing's Syndrome
2. Functional Ovarian Cysts (releasing Estradiol)
3. Granulosa cell tumor
  1. Abdominal Pain
  2. Estradiol or Testosterone excess
Gonadal Causes in Males
1. Familial Male (Testotoxicosis, Isosexual)
  1. Luteinizing hromone receptor activating mutation
  2. Results in premature Testosterone secretion
  3. Presents with testicular enlargement and Virilization onset in age <4 years
2. HCG-Secreting tumor (high HCG levels, tumor may be ectopic from Testes)
  1. Mild testicular enlargement
  2. Virilization
3. Leydig Cell Tumor
  1. Asymmetric testicular enlargement
  2. Virilization
Miscellaneous Cause
1. Hypothyroidism
2. Exogenous Hormone exposure (e.g. Testosterone gel, Estrogen Creams)
3. Endocrine disrupting chemical exposures (e.g. Pesticides, BPA, phthalates, flame retardants)

Causes
Benign Early Puberty

Constitutional or Idiopathic Precocious Puberty
1. Bone Age is GREATER than Chronological Age
2. Lab markers (if checked) are all consistent with early Puberty
3. Contrast with all other benign causes in which Bone Age is CONSISTENT with Chronological Age
Girls
1. Fatty Breast tissue (Lipomastia)
2. Benign Premature Thelarche
  1. Isolated Breast development with glandular tissue development
3. Benign premature Menarche
  1. Prepubertal Vaginal Bleeding
  2. DDx includes Hypothyroidism, McCune-Albright Syndrome, genital Trauma, mass, infection or foreign body
4. Benign Premature Adrenarche
  1. Isolated pubic hair (and may include axillary hair) develops under age 6 years
  2. Distinguish from Congenital Adrenal Hyperplasia, Cortisol excess, adrenal tumor (see step 2c)
Boys
1. Benign Gynecomastia of Adolescence
2. Familial Gynecomastia
  1. DDx includes Testicular Cancer, Adrenal Adenoma, performance enhancing drugs, Hypogonadism
Infants
1. Isolated Pubic Hair in Infancy
  1. Isolated pubic hair of infancy typically resolves by age 6-24 months
  2. Consider exogenous exposure to Hormones and endocrine disruptors (e.g. Pesticides)
2. Minipuberty of infancy
  1. Transient activation of hypothalamic-pituitary axis after birth until 6 months in boys, 2-4 years in girls
  2. Transient sex Hormone rise causes acne, Penile Growth Breast development, Vaginal Bleeding

Causes
Contrasexual Development Causes

Boys
1. Estrogen-Secreting adrenal tumor
Girls
1. Excessive pubic hair
  1. Adrenal hyperplasia
  2. Benign Premature Adrenarche
  3. Polycystic Ovary Disease (older girls)
2. Virilization (clitoromegaly and increased Muscle)
  1. Ovarian tumor
  2. Adrenal tumor
  3. Cushing's Syndrome
  4. Hyperprolactinemia
  5. Acromegaly
  6. Exogenous androgens

References