Increasingly common precocious puberty: girls most affected

We talked to Anna Claudia Romeo, Professor of General and Specialist Paediatrics at UniCamillus University

Today’s society presents models that lead adolescents and pre-adolescents to ‘grow up earlier’, both in looks and in manners. However, there are cases where one becomes an adult suddenly, and not only in appearance: it is called ‘precocious puberty’, and it is the sexual maturation that occurs much earlier than expected, i.e. before the age of 8 in girls and before the age of 9 in boys. This results in early manifestations of physiological puberty—which can destabilise both the parents and the children concerned—and they are:

  • breast development and first menstrual cycle in girls;
  • enlarged testicles and penis, facial hair and deep voice in boys;
  • appearance of pubic and axillary hair;
  • rapid growth in height and muscles;
  • appearance of acne.

‘The typical manifestations of puberty depend on sex hormones, oestrogen in females and androgen in males’, explains Prof. Anna Claudia Romeo, lecturer in General and Specialist Paediatrics and Clinical Pathology and Immunohaematology at UniCamillus University. ‘In girls the first sign of pubertal onset is represented by the appearance of the breast button, i.e. an initial enlargement of the mammary gland which feels like a “peanut” under the nipple. In boys pubertal onset is characterised by an increase in testicular volume of more than 4 ml, which is sometimes more difficult to recognise’.

In girls, however, it is a much more frequent problem, with a ratio of 10:1 compared to boys. ‘In recent years, there has been a steady trend towards an earlier onset of the first menstrual cycle, from 12 ½ years in the 1950s to 11 ½ years now, and, in parallel, an increased incidence of precocious puberty especially among girls’, says Prof. Romeo.

Possible causes

Lifestyle changes and exposure to environmental factors have contributed to this, but not only that, because there is also a familial component at play. ‘Underlying most cases of precocious puberty are no diseases’, reassures Romeo. ‘However, it is good to remember that in some cases precocious puberty can be caused by diseases or tumours, both of the central nervous system and of the gonads and adrenal glands’.

Finding oneself a teenager while still playing with toys is not at all easy, both because one feels different from others and because early puberty is also associated with risks, such as ovarian cysts and tumours in females and testicular cell tumours in males. Normal growth processes are also at risk. ‘The hormonal changes that occur in early puberty, in addition to causing psychological, relational and social discomfort related to body change, can impair normal growth processes. For example, they can anticipate bone maturation and cartilage closure resulting in the risk of short stature as adults’, our expert illustrates. ‘In the medium to long term, these children may also be more prone to developing hypertension, diabetes, obesity and infertility in adulthood’.

What are the risk factors? First of all, there are categories of individuals in whom this predisposition is more frequent: predisposing elements are being female, of Hispanic or Afro origin, having a family history of precocious puberty, being obese and having a sedentary lifestyle with poor diet. Regarding the latter factor, Prof. Romeo cites a current study that confirms this hypothesis. ‘A recent Italian study by the Gaslini Institute in Genoa has shown that an increase in body mass (in particular an increase and distribution of body fat), the sudden cessation of sporting activity, an increase in stressful conditions and the growing use of screens (tablets, laptops and smartphones)—which characterised our children’s lives during the COVID-19 pandemic—have a huge impact on that. They seem to have contributed to a significant increase in the incidence of precocious puberty over the last 4 years, with 80% more check-ups for suspected precocious puberty among girls and a 35% diagnostic increase in rapidly progressive forms’.

However, as already mentioned, there is a suspicion that environmental factors may also play a dispositive role. ‘Chronic and multiple exposures to endocrine disruptors, i.e. ubiquitous environmental contaminants (bisphenol A, perfluorinated compounds, alkylphenols, tributyltin and many others) found in air, soil, water, food, plastics, clothing and detergents can interfere with our biological systems. At the endocrine level, this could cause premature activation of pubertal timing, either through mechanisms of similarity with pubertal hormones or receptor activation at the level of the hypothalamic-pituitary-gonadal axis’.

Prevention, diagnosis and treatment

In the face of this progressive change affecting the new generations, can we talk about prevention? ‘As far as modifiable factors are concerned, yes’, reassures Romeo. ‘For example, it is possible to intervene on lifestyle and overweight prevention’. Adipose tissue is an endocrine organ that produces hormones capable of promoting the sexual maturation process. Diagnosis of precocious puberty is necessarily the prerogative of physicians. ‘In a child who shows signs of early pubertal development, an initial paediatric examination should be carried out to highlight any family history, any sudden increases in body weight and height growth rate, the age of onset, as well as the characteristics and speed of progression of the signs of pubertal development’, specifies Prof. Romeo. ‘After assessment, the child may be sent to a specialised paediatric endocrinology centre for a more in-depth specialist examination, which would include blood tests with hormone dosages—even after stimulation with certain drugs—, X-rays to assess bone age, and special ultrasound or radiological investigations based on clinical suspicion’.

Once the diagnosis is certain, the course of treatment will differ depending on the underlying cause. ‘There are drugs that can block the action of the excess puberty hormones produced, thus temporarily halting the progression of the child’s pubertal development’, Romeo continues. In rare cases of precocious puberty related to tumour diseases, surgery must be performed’. In less severe cases, when puberty is only anticipated and has a very slow development, the child only has to undergo endocrinological follow-ups without the need for drugs.

However, beyond the organic and hormonal problems, there can be serious psychological repercussions for children who feel and see themselves as different from their peers. ‘In this regard, it is important to sensitise and train parents in the early sexual and affective education of children. This education must, nonetheless, be endorsed by the school’, Prof. Romeo concludes. ‘Early diagnosis helps to better manage and overcome this condition, but psychological support must continue even after completion of physical development’.