Early hair growth, odor isn’t always a sign of early puberty

Premature adrenarche may appear more obvious than other early signs of puberty, but it does not necessarily indicate the onset of sexual maturity.

Adrenarche occurs when the adrenal androgens – sex hormones – that cause pubic and armpit hair, body odor and acne are produced. These androgens alone do not signal the onset of puberty. Instead, this process is measured by the appearance of breast tissue in girls and testicular growth in boys.

The signs of premature or early adrenarche usually do not occur alongside growth spurts unless they appear in rare instances of central precocious puberty – an early entry into the whole process of sexual maturation.

Katherine Kutney, MD, a pediatric endocrinologist at Rainbow Babies and Children’s Hospital in Cleveland, Ohio, said puberty is considered premature in girls under age 8 and boys under age 9. Timing of premature adrenarche may coincide with central puberty, but this is not always the case. In some cases, premature adrenarche may simply occur as a difference in timing and development. However, a specialist can help determine whether a differential diagnosis may need to be considered.

“The main difference for preterm adrenal glands includes benign preterm adrenal glands, congenital adrenal hyperplasia, functional adrenal tumor and exogenous exposure to testosterone,” explained Kutney. “Penis or clitoral enlargement, growth acceleration or very rapid progression are more of concern for pathological causes.”

Some of the diagnostic tools Kutney explained can be used to confirm or rule out alternative diagnoses, including blood tests for:

17-OH levels to check for congenital adrenal hyperplasia (CAH) Blood test for dehydroepiandrosterone sulfate to measure adrenal function Androstenedione to assess for CAH and measure adrenal function Testosterone to rule out hormone-secreting adrenal tumors

It may also be helpful to use an X-ray in addition to blood tests to check bone age.

“If bone age is more than 2 years advanced, or if hormone levels are elevated before puberty, this suggests the possibility of a pathological cause,” Kutney explained.

If all of these tests return to normal — or normal for the child’s Tanner stage — a diagnosis of premature adrenarche alone is usually appropriate, she added. Children with premature adrenarche should see a pediatric endocrinologist, Kutney said, but this step is especially important for children who also have criteria that indicate a differential diagnosis.

Even without a pathological process, research shows that premature adrenarche is linked to a number of long-term metabolic problems such as2,3:

HyperinsulinismInsulin resistanceDylipidemiaLate ovarian hyperandrogenismObesity Increased height during puberty

Few studies have followed cohorts long enough to determine whether these problems persist into adulthood in children who have premature adrenarche. However, a few reports have shown that girls who had premature adrenarche stayed longer, weighed more and reached menarche earlier than their peers at age 12. However, height differences do not appear to be permanent, as most girls with premature adrenarche reached average height in adulthood, regardless of their growth rate through puberty.3

References

1. Kaplowitz P, Bloch C. Evaluation and referral of children with early puberty signs. Pediatrics. January 2016;137(1). doi: 10.1542/peds.2015-3732.

2. Utriainen P, Laakso S, Liimata J, Jääskeläinen J, Voutilainen R. Premature adrenarche – a common condition with variable presentation. Horm Res pediatrician. 2015;83:221-231. doi: 10.1159 / 000369458

3. Liimatta J, Utriainen P, Voutilainen R, Jääskeläinen J. Girls with a history of premature adrenarche have advanced growth and pubertal development at age 12 years. Anterior Endocrinol (Lausanne). 2017;8.291 doi:10.3389/fendo.2017.00291

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