PRECOCIOUS OR PREMATURE PUBERTY

When an individual matures both emotionally and physically and becomes an adult capable of reproduction through the natural development of the reproductive organs, it is expressed as puberty. It happens in stages, both in boys and girls. The age when it happens depends on race, nutrition and

genetics . The normal age of maturation in a girl is about 10 -11 years, in boys it is 9 to 12 years. The girls have their first period about the age of 11. This is called menarche.

To start with if your child is 6 years of age or younger and shows development of breast buds, growth spurt, axillary hair, problems at school and if she has a period; you have to be worried, this is surely precocious puberty.  Please tell your child honestly what is going on. Tell her this is normal as you grow older but for some reason your body has started developing earlier.

The good news is that these children can be treated. To understand what causes premature maturation let us revise what starts maturation in the first place. In the brain (The Hypothalamus) starts the process, how we do not know. The brain secrets a hormone called Gonadotropin- releasing hormone (GnRH). This acts on our main endocrine gland which is the pituitary gland located in the brain, which in turn realeases two more hormones, follicle – stimulating hormone (FSH) and luteinizing hormone (LH). These act on the ovaries in the female, producing oestrogens and small amounts of testosterone. In boys they act on the testicles producing testosterone. The oestrogens and testosterone cause puberty changes in boys and girls. In girls testosterones helps with the growth of axillary and pubic hair. The hormone called LH is involved with ovulation.

When this maturation occurs at a very young age it is called Precocious Puberty. Puberty can also be delayed causing anxiety again. We will discuss this in another blog.

These early developmental changes when they arise in the brain, are called central precocious puberty. This can also happen due to brain tumours, infections of the brain, too much fluid in the brain (Hydrocephalous), radiation to the brainThere are peripheral problems (outside the brain) which can cause precocious puberty. . Congenital problems and congenital adrenal hyperplasia. McCunes – Albright syndrome, is also a congenital disorder which causes hormone problems and finally an under active thyroid gland can also cause precocious puberty

These can be due to tumours of the adrenal glands, ovarian cysts and ovarian tumours.

  

WHAT ARE THE RISK FACTORS

Girls of African American origin, obese girls and exposure to hormones which can be used for treatment of other medical conditions and radiation for tumours or leukemia.

COMPLICATIONS

Initially they grow taller than their age, then they stop once they achieve puberty; because their bones stop growing earlier than usual. Treatment started early will help them to grow taller. The girls whose bodies are changing become very self conscious withdrawn and depressed.

DIAGNOSIS

You must take your child to a Paediatrician or a Paediatric endocrinologist.  They will study your family medical history, the child’s history and do a general examination. They will also do blood tests, mainly hormones, including Thyroid, ultrasound of the Ovaries. X-ray of bones to assess the bone age and magnetic resonance of the brain to see if there are any brain conditions. These tests will help them to know if the precious puberty is of peripheral or central origin.

TREATMENT

The child if of an understanding age, should be explained what is going on. Reassured and praised where possible, such as any achievement in sport, school which will help to build self confidence. Generally no treatment is offered if the child is about 8 years of age. For precocity of central origin GnRH   analogue therapy is offered, named LEUOPROLIDE as an injection once a month until the age of puberty. It suppresses the GnRH activity. 16 months after the treatment is stopped maturation starts again.

Any other peripheral diseases are treated as well, such as an under active thyroid or any tumours, which are removed. This   analysis does not cover precocious puberty in boys.

SUMMERY

Precocious Puberty is when a child’s body develops like an adult at a very young age. It is a very rare condition and occurs once in 5000 children, but once it happens it is frightening. Do not panic.  It is easily diagnosed and treated.

Puberty includes rapid growth of bones muscles and genitals, body shape and size changes and it can reproduce. The cause of this precocious development is often not understood. Sometimes infections, injuries, tumours, brain abnormalities and radiation cause these problems. The treatment includes stopping   any further maturation.

ABNORMAL BLEEDING IN WOMEN IRREGULAR AND HEAVY

Adolescent Girls and Children

In this post I will discuss the causes of abnormal bleeding in women. This can happen in any age group. I will divide this into a number of posts. In the first post I will talk about the causes in children and adolescence. There are 4 reasons for this abnormal bleeding.

1) Vaginal Infections: vulvovaginitis, this is a common infection of the external part of the young girls vulva and vagina.

This is a Comfortable Position for a Child to be Examined

This happens because the young girls have less resistance to infections which may be due to lack of oestrogens (oestrogens only happen in our body when periods start).This is not difficult to treat you can take a swab from outside the vulva and vagina to see what the infection is. Always tell the children and young girls to keep their vulva and vagina clean. Wash it with water if possible. Always use loose cotton under wears as this helps with the soreness and healing.  Applying a bit of Vaseline is a very simple trick. Do not wear very tight undergarments or share them. Do not wear panties to bed. Do not put any antiseptic such as Dettol in the water. Avoid baths if you can have a shower.

You can bath your bottom in a basin. Have a very clean basin on the toilet seat, fill it up with about 15 litres of cooled boiled water, add 2 tablespoons of salt, and sit in the water for 10 to 15 minutes.

It is very soothing. The swabs that where originally taken will show the infection and your GP, will prescribe the appropriate treatment. If the swab shows an infection called tricomonas or gonorrohea, beware. These are sexually transmitted infections. You as a mother will have to explore it further. Constiption should be avoided, as most of these vaginal infections come from the anus.  Threadworms are very common in young girls. When the children scratch the minute eggs of threadworms get transmitted to the vagina and irritate the child, but there no discharge. Please get the stool examined. It is easy to get rid of the threadworms. Always teach your child to wipe their bottom from front to back. Candidiasis is not such a common infection in children unless she has taken antibiotic or she is diabetic a taken bath with her mother who carries an infection.

I started the discussion about vaginal bleeding but got side tracked by vaginal discharge. One of the rare causes of blood stained discharge in children is a foreign body. In my time I have removed a few of these, such as, a safety pin, mother’s hairpin, and a lolly. If the discharge is bloody always try to look inside the vagina. A nasal speculum is a very good tool with a light. These may need to be removed under anaesthesia. I was able to remove a safety pin with a sterilized pair of tweezers.

One of the rare skin conditions that can affect very young girls is called Lichen sclerosis. This occurs at either end of a female’s life. We do not know what causes it, may be immunological. The girls present with intractable pain, itching and difficulty or pain on passing urine. Often there is some bleeding. On looking at it the skin appears dry shiny stretched and pigmented. It is a chronic condition and can last a long time. It has malignant potential.

The Above Picture is of a Normal Vagina

The Vulval Changes in Lichen Sclerosis

               

On looking the skin looks white and shine, pigmented and crinkly. In these cases we should try and exclude any sexual abuse. The diagnosis is confirmed by skin biopsy. The treatment should be started early. In asymptomatic or very mild cases soft emollient is enough. Local Corticosteroids are required in more well defined cases; in more severe cases stronger corticosteroids are used. Rarely immunological suppressants are used in combination with local high potency corticosteroids. Recently cell therapy is being tried by some plastic surgeons. The good news is, in most girls it resolves by puberty. Recurrences can happen; these cases should be followed up after 6 months and then yearly.

Other causes of vaginal bleeding can be due to injury; this can happen in school play grounds, bicycle riding or foreign bodies just being there or when they are sharp and big and sexual interference. If the injury is blunt not bleeding and the vulva is swollen it need reassurance, pain relief and cold compress. If bleeding it needs repair under anaesthesia. Sexual interference can be very traumatic. You have to work out who the offender is, look for sexually transmitted infections, and be very sympathetic to the family. I can never forget a case which I had to deal with of a 6 year old girl in 1968 when I was a very new gynaecologist with no experience in children. This girl was brought in with profuse bleeding on Sunday at midnight after being   assaulted by a big man by sexual intercourse. She was sleeping outside on the street with mum and dad in terrible heat. I called the theatre staff an anaesthetist, blood transfusion services, and the police, I got the terrible man arrested I took the child to the theatre tried to stop the bleeding. The whole area was so damaged could not make out what was what, however 3 hours I was able to stop the pouring of blood, it was still dribbling. I was unable to find a paediatric surgeon. We also gave her 2 units of o negative blood (o negative blood is a universal donor) as that was all I could get. I needed help from other specialists such as a internist or interventionist but these were just fancy words in those days. She ultimately died 2 days later. That was a very sad day in my very new profession. I can still remember her face.

The cause of bleeding can be paediatric malignancies and premature puberty.

Paediatric malignancies of the genital tract are extremely rare say about 5%of the total malignancies in children they are usually referred to tertiary centres where they have a paediatric gynaecologist. They happen both in girls and boys; they often arise in the left over remnants of embryonic tissue, use of diethylstilboestrol during pregnancy to prevent the miscarriage (this used to be practiced long time ago).

The discussion on paediatric malignancy and premature puberty is outside the scope of this blog. I will discuss premature puberty in the next