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i'm here at stanford medical school

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with Morgan Theis and Dr. Laura Bachrach

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and they're going to teach us some things.

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Okay, so what are we going to learn about today?

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I'd like to talk about precocious puberty

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it seems to be on the minds of many parents these days

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they worry that their child is developing too early,

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they worry their child is going too small as a result,

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they worry their child is going to get picked on,

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and they worry they might have done something wrong.

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Fed the child the wrong food, or exposed them to the wrong videos,

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to cause this all to happen.

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So could we just talk about what precocious puberty means,

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it almost sounds like they've done something too soon,

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is that correct?

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It's exactly true.

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The normal process of puberty, in a girl, we think,

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we used to think, started around the aged of 10,

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with a little bit of breast development.

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And around 6 months later, the girls would get

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a little bit of pubic hair,

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and around the age of 12 and 3/4 to 13

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they'd get their first period.

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Ok.

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In boys, we used to think,

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the process was starting a little later,

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at about 11 and a half.

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The boys would get some enlargement of the testes.

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They'd get some pubic hair about a year later.

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And by age 15 or so, they'd be mature.

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We have a definition of what's precocious,

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uh, when there's signs of puberty before 8, in a girl,

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or before 9, in a boy.

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Ok. So, 8 or less in a girl, would be precocious,

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and that's for the breast development?

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For any signs of puberty:

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the breasts, the pubic hair or the period

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would be precocious if it happened before the age of 8 in a girl.

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And in a boy, before the age of 9.

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Now this has become a little bit controversial

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because there was one very large pediatric study

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that involved over 17 000 girls

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that found that as many as 25% of african american

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girls would have sign of puberty before 8,

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and as many 7% of the white girls had some

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signs of puberty before age 8.

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But we're still basically using these guidelines.

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Not to say that this is definetely abnormal, but

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this is something we're going to evaluate.

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If we see signs of puberty before those age landmarks.

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Ok, so it sounds like there's a lot of variability,

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it's kind of hard to know in any individual case,

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whether it's normal or not, but we have to have

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some kind of threshold for which we're going to

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work someone up to make sure everything is normal.

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You hit on a really important word.

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And that is variability.

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And a lot of this variability, uh, is determined by genetics.

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So part of what we always need to know is

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the timing of development in the family.

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So when did mom get her first menstrual period,

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when did dad get his puberty and growth spurt?

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So that's part of it, genetics,

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and we need to know that, take that into account:

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If mom had her first period at 10 and started

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her breasts at 8

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it might be perfectly normal for her daugher.

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If mom's period were at 14 and her daughter has

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breast development at 7 and a half

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it's more worrysome.

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Ok.

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Ok, the second factor that seems to be contributing,

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potentially,

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is the overnutrition of our young people.

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Oh, yes.

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And in the particular study that I mentioned to you,

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where they looked at over 17 000 children,

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at least for the white population,

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the could explain the earlier signs of puberty

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as an association with a high body mass index.

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So it looked as if, if you overnourish your child

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you may speed along their growth, and eventually,

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potentially, speed along the onset

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of puberty.

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Now, this did not hold up as an association in the

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african american population, so there's other factors

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going on there.

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But that's something that we rtake into account.

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THe bottom line is,

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the child may present with some signs of early puberty,

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mom or dad get worried,

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they go to the pediatrician,

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and the pediatrician has to decide what's going on.

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Ok, now, JUST Backing up a little bit, is this a problem?

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I mean, what's the problem with, say, a 7 year old girl

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starting puberty, or, uh, an 8 year old boy

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starting puberty early?

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I imagine there could be some social implications

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(as you mentionened)

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but what are sort of the things

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we worry about?

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Well, that's an importand question,

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because it comes up not only how far do we go to

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evaluate them, but how far do we go

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to treat them?

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So, one of the concerns parents have,

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relates to their final height.

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So, if they start their growth spurt early in life,

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and close it off early in life,

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are them gonna cheat themselves

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out of some final height?

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Right.

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So height is a concern.

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And its impact really depends upon how young the child is.

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A three year old going into puberty

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is definetely going to end up short

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if we don't do something.

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A seven and a half old girl is

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probably not going to be altered by this

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in terms of height.

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The second concern is definetely what you

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brought up, in terms of social concern.

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Parents worry their child may behave in an older way,

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or be treat in a way that

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they're not quite ready for.

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They mey get unwarranted attention

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from people because they look older.

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And there is even potential concern for abuse,

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sexual abuse.

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Um, right.

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So those are the usual parental concerns

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for why they bring the child in.

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The other concern they have is, often

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"what am I doing wrong".

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There are a lot of questions about

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"should I have fed my child organic food?"

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"what about the soap i was using?"

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"what about the soap operas my child was watching?"

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You know, they're really

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concerned about something they might have done.

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And they worry about these additives in ourplastics,

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in our theeth sealants, etc...

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They worry about evils inour environment.

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Okay.

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So things that you address in the visit that

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you have with them are definetely

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some of the, the concerns that parent have

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about what they could have done differently.

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Exactly. We start out, assessing

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in a sort of a systematic way.

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The first question we want to know, is

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when did this all start?

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And what did they notice.

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And it's really important

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to break down the signs of puberty,

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because different hormones contribute to

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the different signs.

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For example, in a girl, if she is presenting with

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some body odor, some acne, and some pubic hair,

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but no signs of any breast development,

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that leads us down the road to

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worry about what we call her androgens

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or her male hormones.

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If a girl comes in with just breast development

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but none of the body hair

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or body odor, we think, aha! she's been

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exposed to estrogens.

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And so we get a lot from the physical exam in

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terms of thinking what hormones to go after.

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okay, so even though the definitions of precocious

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is just any of these

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different physical developments happening

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too soon, the combination that you see

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is going to direct what yo uthing is going on

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wit hthem clinically.

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Exactly.

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Ok

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It will make us more or less worried

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and it will take us down one avenue or another,

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thinking about what could be wrong,

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what level of abnormality in the hormone system is at work.

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Ok. Can I ask you a question, just curious, so

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what are the most common diagnosis given

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to people coming in with their kids, that are

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concerned for precocious puberty?

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The common diagnosis, is "variations are normal".

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Aha.

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There is a condition called

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"isolated premature adrenarche" which is a

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fancy doctor way of saying

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the adrenal glands producting their

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hormones, we see pubic hair, underarm hair, and acne.

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Uh... We also can see isolated

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breast development in little toddler girls

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that's not concerning.

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So that would just go away, or?

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Yes. Typically that begins between

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six months and two years and

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goes away.

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But even within the more full blown cases,

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where we're seeing breast and the pubic hair

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in a girl, or the enlagrement of the testes

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and the pubic hair in a boy, where's it's full on,

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full blown puberty, it may be idiopathic,

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or not pathological.

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We think that in girls,

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who develop fully, 95% of the time, even if they

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have the full blown puberty,

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it's idiopathic, or not pathological.

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Whereas in boys, about 50% of the time, there is pathology.

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So the condition is less common on boys, but

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when it occurs in boys, it's more worrisome.

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Oh, interesting.

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So it's less common for boys to have any signs of

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precocious puberty, but when it does happen you worry more.

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Exactly.

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Because it's more likeyl to be something bad.

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Exactly.

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Ok.

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So I'm guessing as an endocrinologist,

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once you've sort of ruled out the normal things, then you start th

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then you start thinking more about

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sort of what's going on in terms of all the

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different hormones that are controlling the

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se

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things, which maybe is something that

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we'll talk about in a different

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lecture

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exactly.

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is there any other sort of general things

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that you wanted to adress when

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we'll just talking about...

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I think the general advice I would give to a parent

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if see signs of puberty in their child,

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before 8 in a girl, before 9 in a boy,

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they should at least question their pediatrician

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about it, uh, and the pediatrician should do

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a complete exam, and the

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other factor that needs to be looked at carefully is growth,

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because a child who is truly in puberty will have a growth spurt.

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So, those are things that parents can be

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aware of at home, but I think it's

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important that the parent asks the pediatrician about it,

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if they are concerned.

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Ok, well thank you so much.