Chapter 173 Puberty: Abnormal
THE CHALLENGE
Scope of the Problem: For all patients with precocious puberty (pubertal changes before age 7 or cyclic menstruation before age 10), the possibility of a serious process, either central or peripheral, must be evaluated. (Because of evolving changes in maturation rates, these traditional ages should be adjusted downward by 1 year for African American girls.) Precocious puberty is customarily divided into two classifications: true or gonadotropin-releasing hormone (GnRH)-dependent (70%), and precocious pseudopuberty that is independent of GnRH control. For most girls older than 4 years, no specific cause is discovered for the early development. By contrast, the most common cause of precocious change in girls younger than 4 is a central nervous system lesion, most often hamartomas of the hypothalamus. Even when the sequence of events appears normal, a serious process (such as a slowly progressing brain tumor) must be aggressively sought initially and watched for with long-term continuing follow-up. Delayed puberty is a relatively uncommon problem in girls. When it occurs, the possibility of a genetic or hypothalamic–pituitary abnormality must be considered, along with a moderately large number of other possibilities. Based on the average age and normal variation of puberty, any girl who has not exhibited breast budding by age 13 requires preliminary investigation. Similarly, girls who do not menstruate by age 15 or 16, regardless of other sexual development, should be evaluated. Patients should also be evaluated any time there is a disruption in the normal sequence of puberty or when there is patient or parental concern. Patients with significant abnormalities of either height or weight should be evaluated for chromosomal abnormalities or endocrinopathies.
