MUHAMAD REDZUAN BIN JOKIRAM 030.08.

281 FACULTY OF MEDICINE TRISAKTI JAKARTA, JULY 2010

The prevalence of precocious puberty (PP) is difficult to estimate but has been reported at 1 in 5000 children. Gonadotrophin-dependent precocious puberty (GDPP) or central precocious puberty affects girls 10 times more commonly than boys. This may be because activation of the hypothalamo-pituitary-gonadal axis requires a lower dose of GnRH in girls. In the US, the number of girls diagnosed with PP is rising. Several factors affect the age of onset of puberty, although it primarily follows a familial pattern. A similarity in the age at onset of puberty between girls and their mothers, especially with that of menarche, is known. However, the process can be influenced by environmental factors, ethnicity, and chronic disease.

DEFINITION Puberty is the process of physical changes by which a child's body becomes an adult body capable of reproduction. Puberty is initiated by hormone signals from the brain to the gonads (the ovaries and testes). In response, the gonads produce a variety of hormones that stimulate the growth, function, or transformation of brain, bones, muscle, blood, skin, hair, breasts, and sex organs. Growth accelerates in the first half of puberty and stops at the completion of puberty. Before puberty, body differences between boys and girls are almost entirely restricted to the genitalia. During puberty, major differences of size, shape, composition, and function develop in many body structures and systems. The most obvious of these are referred to as secondary sex characteristics.

Normal Puberty Process

brain makes a gonadotropinreleasing hormone (Gn-RH) Gn-RH causes the pituitary gland to release luteinizing hormone (LH) and folliclestimulating hormone (FSH).

LH and FSH cause the ovaries and testicles to produce hormones and The body will also begin to make estrogen and testosterone Produce hormones involved in the growth and development of female sexual characteristics (estrogen) Physical changes occur. The production of estrogen and testosterone causes the physical changes of puberty.

produce hormones responsible for the growth and development of male sexual characteristics (testosterone).

Definition Precocious puberty is when someone's body begins changing from a child into an adult too soon. The process of changing from a child into an adult is known as puberty, and puberty that begins before age 8 for girls and before age 9 for boys is considered precocious puberty.

Central precocious puberty A tumor in the brain or spinal cord (central nervous system) A defect in the brain present at birth, such as excess fluid buildup (hydrocephalus) or a noncancerous tumor (hamartoma) Radiation to the brain or spinal cord Injury to the brain or spinal cord McCune-Albright syndrome a genetic disease that affects bones and skin color and causes hormonal problems Congenital adrenal hyperplasia a group of inherited disorders involving abnormal hormone production by the adrenal glands Hypothyroidism a condition in which the thyroid gland doesn't produce enough hormones

Peripheral precocious puberty In both girls and boys, the following may lead to peripheral precocious puberty: A tumor in the adrenal glands or in the pituitary gland that secretes estrogen or testosterone McCune-Albright syndrome, a rare disorder that also affects the skin and bone Exposure to external sources of estrogen or testosterone, such as creams or ointments In girls, peripheral precocious puberty may also be associated with: Ovarian cysts Ovarian tumors In boys, peripheral precocious puberty may also be caused by: A tumor in the cells that make sperm (germ cells) or in the cells that make testosterone (Leydig cells) Gene mutation a rare disorder called familial gonadotropinindependent sexual precocity, which is caused by a defect in a gene, can result in the early production of testosterone in boys, usually between ages 1 and 4.

Precocious puberty symptoms in girls include: Breast growth First period (menstruation)

Precocious puberty symptoms in boys include: Enlarged testicles and penis Facial hair (usually grows first on the upper lip) Deepening voice

Precocious puberty symptoms that can occur in boys or girls include: Pubic or underarm hair Rapid growth Acne Adult body odor

To diagnose precocious puberty, the doctor will: Review child's and family's medical history Do a physical exam Run blood tests to measure hormone levels X-rays of your child's hand and wrist also are important for diagnosing precocious puberty. These X-rays can help the doctor determine your child's bone age, which shows if the bones are growing too quickly.

DEFINITION Environmental exogenous estrogens, otherwise referred to as xenoestrogens are endocrine disruptors, structurally similar to estrogens. Xenoestrogens are clinically significant because they can mimic the effects of endogenous estrogen and thus have been implicated in precocious puberty and other disorders of the reproductive system. Exogenous estrogens can be found in pesticides, flexible plastics, flame retardants, interior lining of canned foods, various cosmetics and numerous other products. Exogenous estrogens are thought to cause many detrimental health effects such as precocious puberty in girls.

Atrazine used as an herbicide BPA (Bisphenol A) used to manufacture polycarbonate plastic DDT (Dichlorodiphenyltrichloroethane ) used in pesticides for agriculture Dioxin released during combustion processes, pesticide manufacturing and chlorine bleaching of wood pulp Endosulfan insecticide PBB (Polybrominated biphenyls) are chemicals added to plastics Phthalates are plasticizers providing durability and flexibility to plastics Zeronal as an anabolic growth promoter for livestock in the US. Mycoestrogen zearalenone (ZEA) by the Fusarium fungus species.

Xenoestrogens may temporarily or permanently alter the feedback loops in the brain, pituitary, gonads, and thyroid by mimicking the effects of estrogen and triggering their specific receptors or they may bind to hormone receptors and block the action of natural hormones. Thus it is plausible that environmental estrogens can accelerate sexual development if present in a sufficient concentration or with chronic exposure. The similarity in the structure of exogenous estrogens and the estrogens has changed the hormone balance within the body and resulted in various reproductive problems in females The overall mechanism of action is binding of the exogenous compounds that mimic estrogen to the estrogen binding receptors and cause the determined action in the target organs

Precocious puberty has numerous significant physical, psychological and social implications for a young girl. Unfortunately, premature pubertal growth spurt and accelerated bone maturation will result in premature closure of distal epiphysis which causes reduced adult height and short stature. Precocious puberty has also been implicated in pediatric and adult obesity. Some studies have suggested precocious puberty places girls at a higher risk of breast cancer later in life. Precocious puberty is linked with other gynecologic disorders such endometriosis, adenomyosis, polycystic ovarian syndrome and infertility. Precocious puberty can lead to psychosocial distress, a poor self-image, and poor self-esteem. Girls with secondary sex characteristics at such a young age are more likely to be bullied and suffer from sexual abuse Studies indicate that girls who become sexually mature at earlier ages are also more likely to engage in risk-taking behaviors such as smoking, alcohol or drug use, and engage in unprotected sex

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Get Fit- Encourage your children to eat healthy and exercise regularly by setting a good example, preparing food, and getting active with them Steer kids clear of foods laden with hormones and pesticides by serving only organic meat and dairy products, and organic fruits and vegetables whenever possible Chuck the soy products as even organic soy acts as a plant-estrogen that interferes with the bodys natural hormones.

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Eat your veggies still holds true, as vegetarian children reach puberty at the average age of 17. Avoid toxins- including many plastics, personal care products, suntan lotions and drugs that contain hormone-mimicking chemicals Use filtered water- for drinking and cooking to detoxify the bodys systems and avoid exposure to chemicals. Chill Out- Last but not least, stress has proven to be a huge contributor to early puberty.

The current literature is inadequate to provide the information we need to assess the extent to which environmental chemicals contribute to precocious puberty. Gaps in our knowledge are the result of limitations in the designs of studies, small sample sizes, challenges to conducting exposure assessment and the few number of chemicals studied. Unfortunately exposure is inferred and not actually measured in available studies. The ability to detect the possible role of chemicals in altering pubertal development is confounded by many nutritional, genetic and lifestyle factors capable of affecting puberty and the complex nature of the reproductive endocrine system. Other research challenges include shifts in exposure levels among populations over time and simultaneous exposures to multiple compounds. Overall the literature does not with certainty support the contention that environmental chemicals or dietary factors are having widespread effects on human sexual development. However data does not refute such a hypothesis either. Accelerated sexual development is plausible in individuals exposed to high concentration of estrogenic substances. There is a concerning steady increase in exposure to a wide variety of xenoestrogens in the industrial world. Further research is needed to assess the impact of these compounds on pubertal development.

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