Dr. H Reply re Premature Adrenarche

[Guest guest]

Hello Listserve -

I received a reply back from Dr. Madeleine Harbison in response to the email I

sent her where I consolidated Joe Blau's questions on premature adrenarche

with others that came up on the listserve. Here is her reply to each of the

questions. Salem, MAGIC RSS Division Consultant

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a) What exactly is the difference between adrenarche and puberty?

Dr. H Response: Adrenarche is when the adrenal gland switched from making

glucocortcoids and mineralocorticoids to glucocortcoids, mineralocorticoids

and androgens [male hormones].

Puberty is when the brain switches from make LHRH in a linear pattern to a

pulsitile pattern. This changes the response of the pituitary from making

more FSH than LH to more LH than FSH. This starts the gonads to making sex

hormones.

Does premature andrenarche imply that you will likely have premature

puberty?

Dr. H Response: Yes, it sometimes does.

c) How long after andrenarche does puberty typically begin?

Dr. H Response: We do not know what starts adrenarche and we do not know why

adrenarche initiates puberty in some children and not in others. It ssems to

do so in SGA children for sure. It is hard to know when puberty will follow

after adrenarche starts but the more fat the child has the more likely it is

to start because androgens are converted to estrogens in fat. Estrogen is

really what controls puberty in both males and females.

I believe that adrenarche starts when insulin rises. Insulin rises earlier in

SGA children than it does in normal children because they have insulin

resistance.

d) What is your recommended treatment for premature adrenarche?

Dr. H Response: There is no good way to treat premature adrenarche nor is

there a need to treat it because androgens do not cause the problem. Estrogen

causes the problem. If the bone age begins to advance rapidly, giving

Arimidex to prevent conversion of androgens to estrogen is the best

theoretical therapy. This is experimental therapy and not something that most

doctors will or should use.

e) In addition to drugs to forestall puberty, how often should bone age and

hormone levels be checked and which hormones are the most important to watch?

Dr. H Response: Meds that suppress puberty do not help with premature

adrenarche. When children are young, I do a BA yearly along with

testosterone, DHEA, androstenedione, E1 and E2. When they get older, show any

signs of sex hormone secretion, have an advancing BA or have a sudden growth

spurt, I do these tests every 6 mo.

f) With regards to a specific family, what happens if you have a bone age that

is suddenly rapidly advancing, but NO other signs of puberty,

and the blood test hormone levels say that the child is not in puberty yet.

The child's bone age has always been 12-18 months delayed, and this last time

when she is just turning 8 years old, her bone age was only 6 months delayed.

Could it be that the bone age was misread? Or can you she be in " early

puberty " with no visible signs yet?

Dr. H Response: This is likely the start of adrenarche. Young children are

very sensitive to very small amounts, BELOW MEASURABLE, amounts of estrogen.

Like the period of infancy, this is the period of RSS-SGA children's therapy

that requires experience.