Dr. Vaman Khadilkar

Dilemmas in Puberty
Dr. Vaman Khadilkar
MD, DNB, MRCP, DCH (London)
Paediatric and Adolescent Endocrinologist
Ira Clinic, Pune
Jehangir hospital and Bharati Vidyapeeth Medical College
Bombay Hospital, Mumbai
Dr. Vaman Khadilkar
MD, DNB, MRCP, DCH (London)
Pediatric & Adolescent Endocrinologist
• President – Indian Society for Pediatric & Adolescent Endocrinology
• Consultant Pediatric Endocrinologist, Jehangir Hospital, Pune and
Bombay Hospital, Mumbai
• Associate Professor, Pediatric Endocrinology, Bharati Vidyapeeth
Medical College, Pune
• DNB & MD teacher
• PhD (Doctorate) guide University of Pune
• Trained at Great Ormond Street Hospital, London
• Referee for Journal of Pediatric Endocrinology and Metabolism,
London and Indian Pediatrics Journal
• More than 75 Indexed publications in Pediatric Endocrinology and
more than 300 Presentations in State, National and International
Neuro - Endocrine Changes Of Puberty
Cerebral cortex
Hypthalamic Gonadostat
+ve Feedback
- ve Feedback
Sex Steroids
Puberty – Secular Trends
The Average Age of Menarche
Data From Scandinavia
What Is the Mean Age of
Menarche in India Now?
No national Data Available
Dudhe J Y et al (Central India) 2012
Deb R (Meghalaya) 2011
Rao S (Maharashtra) 1998
What Is Precocious Puberty?
• Premature sexual maturation before the
normal age of onset of puberty
• Dilemma - What is normal and should the
age cut off be changed from 8 to 7 or 6 in
What Is Normal Timing of
• Appearance of secondary sexual characters
after the age of 8 years in girls and 9 years
in boys is considered normal at present
• In United States of America especially in
black girls it is seen that signs of secondary
sexual characters appear before 8 years in 57% of the population
What Is Normal Timing of
• Early thelarche is noted in many parts of the
• The time interval between thelarche is
menarche has become longer
• Thus the timing of onset is early but tempo
may be variable and hence observation of the
tempo of puberty is essential
• There is no such evidence in boys – timing of
attainment of testicular volume of 4 ml almost
remains constant
What Is Normal Timing of
• Studies show that for girls between the age of 6
and 8 who had signs of precocity, incidence of
neurological disease is not uncommon
• It is therefore important to retain the previous
cut-off limits of 8 for girls and 9 for boys at
least for the present time
Dilemma - Why Should I Treat
Do I need to treat every
precocious puberty ?
What Are The Reasons To Treat
Precocious Puberty?
• Final height Reduction - Stunting
• Psychosocial problems in coping with the
changing body image, social interactions
and Menarche
Growth Chart of a Girl With Precocious
Bone age is 11 y
Predicted Adult Ht 143
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Who Needs Treatment?
• Precocious physical signs of puberty –
• Significantly advanced BA
• Decreased predicted adult height
• Pubertal response to GnRh testing
The definition of each of
these variable is subjective
and NOT absolute
Precocious Puberty – Who Don’t
Need Treatment
• Girls with slow progressive variety do not
need treatment
• Generally if the bone age advancement is
less than 2 years – Does not need treatment
• If two height predictions at least 6 months
apart do not show progressive reduction in
the predicted adult height – No treatment
Equivocal Cases - Treat or Not?
• Equivocal Cases
CA between 6–8 yr
BA not as advanced
Predicted height still close to MPH
GnRH testing unclear
Equivocal Cases – Treat or Not?
• Adequate follow-up
Rate of progression of physical changes
Linear growth
Bone maturation
Estimates of adult height
Stimulated gonadotropin levels
Dilemma 2 – Delayed Puberty
How long can I wait and watch?
Delayed Puberty Case 1
Stretched Penile Length Norms (CM)
• 15 year
1st child of Cut-off
age old Sanjay
with no signs1.9
of puberty and small
0-6m brought2.9
• His 1-5y
height was on5.2
3rd centile, weight
on 75th centile,
4 75th centile
50th centile.6BMI was above
• Tanner: pubic hair stage 2, axillary hair stage 1,
genital stage 1, buried penis spl 4 cm, testes 4 ml
• Some gynecomastia/ lipomastia
• Am I dealing with CDGP or hypogonadism?
Delayed Puberty Case 1
• Points in favor of delayed puberty (CDGP)
– Short stature
– Some signs of puberty (pubic hair)
• Points in favor of hypogonadism
– Relatively small size of penis
– Small testicular size for age
– Gynecomastia
• How should I proceed?
– Bone age
– HCG stimulation test
– GnRha stimulation test
Delayed Puberty – Case 1
– Bone age
• 12.2 years (delayed)
– HCG stimulation test
• Good testosterone rise – In favor of delayed puberty
– GnRha stimulation test
• Lh rises to above 5 iu/ml
– Diagnosis – Constitutional Delay in Growth
and Puberty
Stretched Penile Length
Prader Orchidometer
Delayed Puberty Case 2
• 16 year old girl living in Pune city from middle
class family
• Mother worried about no breast development or
any other signs of puberty
• Anthropometry:
– Height 95th centile Target height 25th centile
– Weight 50th centile
• Tanner: A1p1b4b4
• Dilemma – should I wait or investigate?
Delayed Puberty – Case 2
• Points in favor of just delayed puberty
– Breast development ++
• Points against
– Too tall
– Well nourished so why late puberty?
– Discordance between breast development and
hair growth
• What should I do?
Delayed Puberty – Case 2
• Bone age
– 14 years
• Pelvic ultrasound
– No uterus, bilateral solid gonads, like testes
• Lh, Fsh, Estradiol, Testosterone
– Lh, fsh very high, testo – male range, e2= 20
• Karyotype XY normal male
Case 3
• 13 year old boy complains of bilateral
breast enlargement of 6 months duration
• On examination
– Bilateral breast development tender 6 cms
– Testes 8 ml, axillary and pubic hair stage 2
– Height 85th centile, weight > 90th centile (MPH
50th centile)
– BMI above 85th centile
• Dilemma - Should I wait or investigate?
Case 3
• Decided to wait for 3 months – reassured
• 3 months later breasts bigger, no progress in
• Investigated
– LH 35 miu/ml, fsh 20 miu/ml (both high),
– Prolactin, TFTs normal
– Testosterone 30ng/ml normal
• Karyotype – 46 XXY
Case 4
• 15 year old girl complaints
– Facial, chin, upper lip hair growth 6 months
– Irregular menses
• On examination
– Hirsutism - FG score 16
– Clitorial hypertrophy
• Dilemma – Is this PCOS or is this CAH?
Case 4
• Investigations
17 ohp 3 ng/dl (not very high)
Testosterone 120 ng/ml (high for female)
LH 15, FSH 5 ( reversed ratio)
PCOS on usg
Synacthen test – more than 5 folds rise in
17ohp and 2 times in cortisol
• Diagnosis - Non classical CAH
• Secular trend is towards early sexual
maturation all over the world and is
particularly marked in areas of the world
that are in rapid economic transition such as
• In equivocal cases longer follow-up to
understand the tempo is essential
• Although there is a trend towards younger
age of maturity the traditional age cut-offs
of 8 years for girls and 9 years for boys for
the beginning of puberty still STAY
• Main reasons to treat precocity in children
are prevention of short stature and
psychological disturbances
• Anthopometry often gives a clue about
whom to investigate, treat and whom not to
• Heterosexual precocity must always be
• With delayed puberty – Discordance in
clinical signs and anthropometry points
towards a non physiological cause
You !
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