I have a six year-old girl with breast buds. How much of an evaluation is necessary?
The onset of breast development in girls less than 8 years of age may be the first sign of precocious puberty or more likely a condition referred to as benign premature thelarche. Benign thelarche is most commonly seen in girls who are under 2 or older than 6 years of age. In those girls under 2 years, breast tissue is thought to be a consequence of infant gonadotropin secretion and ovarian hormone production. History and physical findings that support benign development include presence of breast tissue since birth, waxing and waning size of breast development, absence of other pubertal signs, and no evidence of linear growth acceleration. Additionally, benign thelarche in girls under two years rarely exceeds Tanner stage II development.
What is nonprogressive precocious puberty?
In girls who are 6 years of older, benign thelarche or otherwise known as nonprogressive precocious puberty may be a consequence of temporarily increased ovarian steroid secretion and/or highly sensitive estrogen receptors. When breast development occurs without other signs of puberty in girls older than 6 years, limited work-up is indicated but monitoring of development and growth over subsequent months is necessary. Intervention is considered only if development progresses rapidly and there are psychosocial and final height concerns. Obtaining a bone age at baseline is very helpful for future reference to assess the tempo of pubertal development. If at baseline, there is only a small amount (Tanner II) of breast development and no evidence of bone age advancement, no other evaluation is necessary. Follow-up should occur at 3-4 month intervals. If there is rapid progression of breast development, other signs of puberty, or accelerated advancement of bone age, referral to a pediatric endocrinologist should be considered. Measuring random gonadotropin (FSH/LH) or estradiol levels are rarely helpful as early pubertal values will overlap with prepubertal values.
Rarely a prepubertal aged girl will present with rapid breast development over 1-2 months followed by vaginal bleeding. This history suggests the presence of an ovarian follicular cyst and a pelvic ultrasound performed as close to the episode of bleeding should be obtained.
At what age does benign thelarche occur?
Benign thelarche does not occur as often in girls between ages 2 and 6 years, so onset of breast development in girls within this age range should be referred to a pediatric endocrinologist for evaluation.
Sharon Travers, MD