Dr. Jerrold Olshan (Guest): Great question and thanks for having me here to talk about it. So, early onset puberty is a puberty which is from going to being a child to being an adult from a sexual perspective. So, boys go through puberty generally little later than girls. Usually, we consider early puberty if it is happening before roughly eight years of age in a girl or before nine years of age in a boy. There are some thoughts about it happening a little earlier and we can talk more about that later. But that would be early puberty if it's happening, so certainly a five- or six-year-old girl who's having breast development or a seven-year-old girl who starts having her menstrual cycles; that would certainly be considered early. A boy who starts shaving at 12 or 13; that would be considered early. I think the extremes are pretty evident to the general population.
Melanie: Are certain things like hair growth considered a big part of puberty? If, say, an eight- or a nine-year-old girl starts to get some pubic hair or a boy starts to get underarm hair? Do we worry about that or does that sometimes happen first and take a while for rest of the things to happen?
Dr. Olshan: Well, we shouldn't worry right of the bat but it could be the sign of some problems and, therefore, it’s important to discuss with someone who knows what signs of puberty are abnormal and at what age they'd be abnormal. So, it’s certainly something you want to talk about with your pediatrician or family practice doctor, if you are seeing pubic hair or breast development in a boy or a girl before the age that we would normally expect it to happen. Now actually, frequently, it would be something that’s not really concerning. So, we’d have something called benign premature adrenarche, which is some girls will just start having pubic hair a little early at six or seven years of age just because of their genetics and not because there is a disease or a process. The problem, though, is sometimes it's serious, and one of the things that we worry most about in children who go through puberty early is that most people are pretty happy early on because when you start going through puberty, you start accelerating your growth and as they accelerate their growth they start getting taller than their peers. And most people, at least in this country, don't seem to be concerned when their kids are taller than the rest of their peers. The problem comes after they finish puberty, they stop growing and if you start puberty earlier you'll end puberty earlier. If you end puberty earlier, then you stop growing when you are younger and you could lose three or four or five inches of height from going through puberty early. So, that's one of the most important reasons to pick it up early, is so that you don't have problems later on when someone comes in and they are done growing when they are eleven years of age and we say, “What we can do about it now?” And there is really nothing you can do at that point. So, you need to be aware of the concerns of early puberty leading to poor growth so that you could catch it while you could still do something about it.
Melanie: Dr. Olshan, can early puberty set the stage for some emotional or behavioral problems? Is there anything like that as far as ramifications we need to worry about?
Dr. Olshan: Yes. So, most of the studies that have looked at that have been done in women and, in fact, not surprisingly, when girls go through puberty early, they tend to have sexual relationships earlier; they tend to have less education because they are missing those years for education because they are getting involved in more adult type activities. It’s been shown that some of those effects can last through adulthood. So, there are some ramifications but, in general, most kids who go through puberty early will adjust to it, especially if the family is supportive and they are getting good medical support and they'll do just fine.
Melanie: What is your opinion of some of the theories around why this is happening and why you pediatric endocrinologists are seeing more early-onset puberty? What is your opinion on that?
Dr. Olshan: Well, probably it became most popular for people to start thinking about early puberty was back around 1997 when a study came out showing that children were having breast development and pubic hair earlier than all the studies had shown previously. It turns out, we've now looked at that data a lot more and can explain most of that effects from really two factors. One factor is that that was the first time that actually African Americans and Hispanics were included in the data pool and it turns out that African Americans, in particular, have earlier onset of puberty than Caucasians—than whites. Therefore, when they were added into the pool, the average puberty for the whole population in the U.S looks like it’s happening earlier, when, in fact it, at least from that part, it was just the statistical phenomenon because we had more African Americans in the pool of data that we were looking at. So, average breast development was showing, rather than being at 10 ½ to 11, was happening at around 10 and we considered it too early before six rather than in the past we used to think eight was as early as it should be. The biggest explanation for that now, we think, is really the changes in weight in the population in North America and it turns out that as kids gain weight earlier, they also advance through puberty earlier. So, one of the major explanations for why puberty seems to be happening earlier, both pubic hair and breast development in girls and pubic hair in boys, is related to the increased general weight of the population. There's also been a lot of discussion, a lot of research about how the environmental chemicals have effected puberty. So, what do we know about that? We know that, in fact, like BPA--bisphenol A, which is in those clear plastic--does have effects in a body to act like estrogen, to act like the female hormone, and in animal models, certainly can cause early puberty and probably has some effect in humans but most of that effects probably occur in the fetuses, so in babies before they are born. It’s probably not responsible for the earlier age in the general population about why we are seeing earlier breast development or earlier menstrual cycles. We can't say that it's not playing some role but it's certainly not as big of a role as the change in weight in our society.
Melanie: If a parent suspects some of these red flags that you've pointed out, Dr. Olshan, and they come to see you, what are some of the first line of treatments? What do you do? Do you try and slow it down? I mean this is life, you can't stop this progression. But what do you do about it?
Dr. Olshan: Great question. It depends, obviously, how early. So, if I have a four-year-old who is coming in with menstrual periods, that’s obviously something that first of all, we want to say, “Why is this happening?” This is clearly abnormal and we want to make sure that there isn't some serious illness or certain types of tumors in the brain that can cause early puberty. So, in the extreme case, we want to identify what the cause is and what the problem is. The vast majority of those kids, it's a relatively benign process, a relatively benign tumor in the sense, and we can treat with a medication and that turns off puberty. So, what starts puberty is when the brain says to the gonads, “Okay, let's start making those sex steroids,” and the way we treat to stop puberty in those kids is we give them a medicine that turns off the brain and tells the brain to “hold off, don't do this.” It will continue to hold them from going through puberty until we stop that medication and we’ll generally do until they get to an age where they normally supposed to go through puberty. If weight is the cause of the early puberty, which, again, is the most common cause then, really, the only management for that is teaching healthy lifestyles and working on more activity and better food choices.
Melanie: That's great advice. So, just in the last few minutes, really tell parents what you want them to know about the long-term outcomes of early onset puberty and lifestyle modification behaviors and things that might lead to it. So, your best advice on living a healthy lifestyle with your children so that they grow up in the order they are supposed to.
Dr. Olshan: Good question and I think for most of what we know about it in medicine, moderation is always good, healthy lifestyles, eating the foods that are most simple, in a sense; the least modified by humans. Those are always healthy ideas to minimize the risk to exposures to other chemicals and also to have the nutrition that probably will make you maintain a normal weight as well as we can. Probably the most important take home message, I think, about early puberty is that if you see a child that is showing some signs of breast development or pubic hair and it clearly seems earlier than their peers, then it's worth talking with your primary care physician about that concern early on so that they could do the testing to make sure that there is nothing that needs to be treated that could lead to a long-term problem. One of the issues of having early puberty in boys and girls, also, is that it could be the sign of metabolic problems that come on later in life. For example, kids who have early pubic hair development are at a significantly increased risk of developing type-2 diabetes later on in life. So, it's also a marker for other conditions and it’s worthwhile discussing that with your physician so you could then learn how to take appropriate action, whether it's lifestyle or whether it's medication, to reduce those risk as an adult of high blood pressure or metabolic syndrome or type-2 diabetes.
Melanie: What great information. Thank you so much, Dr. Olshan. You are listening to MMC Radio and for more information you can go to mainemedicalcenter.org. That's mainemedicalcenter.org; mmc.org. This is Melanie Cole. Thanks so much for listening.