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Is puberty starting earlier in girls?

The Herman-Giddens study is probably attracting more attention now than it did three years ago when it was published. I wrote a commentary on the study that appeared in that same issue, noting that sexual development has long been far more variable in children than suggested in standard textbooks. That’s something for everyone to keep in mind.

Textbooks v. reality
Conventionally, people have thought of children as maturing close to their teenage years, with girls maturing earlier than boys. Textbooks have long stated that girls begin to develop breasts after age 8 and pubic hair after age 9. The milestone for female sexual development is the first menstrual period, which occurs at about 11 or 12 years old. The average age of the first period has not changed much over time.

What the Herman-Giddens study recorded, however, is that these ages in the textbooks are probably not a reflection of what is actually happening. By age 8, 15 percent of Caucasian girls had started development and almost half of African-American girls had realized stage 2 development. The point is that if something is happening in half of the girls, it is not abnormal. Why there is such a difference between African-American girls and Caucasian girls is not clear, but it’s a gap of about 18 months.

When is medical intervention necessary?
The whole point of this discussion is that parents and physicians need to know at what point is the appearance of sexual development abnormal and worthy of further medical investigation. For example, I would recommend that any child six or younger showing signs of development be evaluated by an experienced specialist in pediatric endocrinology. At any age, if parents are concerned, it is certainly always worth a few simple medical tests to rule out any underlying medical problems.

The connection between obesity and development
We’re not sure why this trend is happening, but we do know that obesity can bring on earlier puberty and there is certainly more obesity in children than ever before. At Yale we are seeing more young female patients who are overweight and have earlier sexual hair development, which is linked to the production of certain hormones. These girls characteristically also tend to be taller for their age. This subset of girls is at risk for polycystic ovarian disease and diabetes later in life and intervention is not easy.

Determining when to act
There has long been a concern that early puberty that progresses too quickly can lead to shortened height in adulthood, but that was not shown to be the case in the Herman-Giddens study. To determine if puberty is advancing too fast, we use a bone age test, which uses X-rays to obtain an image of the bones in a girl’s hand. As children age, the bone plates in the hand begin to close. We compare her hand to the standard for her age.

Ideally, her bone age should be no more than two years more than her chronological age. Otherwise, her growth plates might be closing too rapidly and her adult height might be compromised. If so, we might consider an injection with a modified hormone once a month that stops the progression of puberty until real age catches up with bone age.

There are other types of tests and treatments, but all must be administered under the guidance of an expert in the field with the side effects in mind.

Treating for appearances
Would I treat a child who was otherwise healthy simply to stop early but in all respects normal puberty? You encroach on cosmetic endocrinology when considering treatment simply for the sake of the child’s appearance rather than medical need. I would not preclude that as an option, but it’s something to be considered only after weighing all the options.