CENTRAL PRECOCIOUS PUBERTY – CPP

Unusually early puberty (central precocious puberty – CPP)

During puberty, children’s bodies develop and mature into the body of an adult. Girls develop breasts and start having periods, whereas in boys the penis and testicles grow and their bodies become more muscular. Girls usually start showing signs of puberty when they are 8 to 13 years of age, and boys when they are 9 to 14 years old.

The hypothalamus and pituitary are two parts of the brain that control puberty. Together, the hypothalamus and pituitary are called the hypothalamic-pituitary (HP) axis.

When puberty starts, the hypothalamus signals to the pituitary to produce more hormones. These hormones then travel through the bloodstream, telling the body to produce more testosterone (in boys) or oestrogen and progesterone (in girls). Testosterone and oestrogen cause the body to develop and mature.

Damage to the HP-axis can cause puberty to start earlier than usual. When this happens, this is called unusually early puberty, or central precocious puberty (CPP). We speak of CPP when puberty starts before the age of 8 in girls and before the age of 9 in boys. When puberty starts too early, this will cause the child’s final height to be shorter than expected. Most survivors do not develop CPP.

Is my child at higher risk of CPP?

There are some medical conditions and cancer treatments that may increase the risk of CPP.

The following medical conditions can increase the risk of CPP:

  • A tumour near or within the HP axis
  • Hydrocephalus, when too much fluid accumulates in the brain, which may have been treated with a cerebrospinal fluid shunt

The following treatments can increase the risk of CPP:

  • Any dose of radiotherapy to the HP axis or an area that includes the HP axis
  • Surgery near or within the HP axis

You can find out if your child had any of these medical conditions or treatments by looking at your child’s treatment summary. If you do not have a treatment summary or if you have any questions, do contact your child’s treating hospital.

If your child experiences CPP, it does not always mean that this is caused by cancer or its treatment. CPP may have other causes.

What are the symptoms and signs of CPP?

There are symptoms and signs that can tell you if your child might have CPP. These are the same as the symptoms and signs of puberty, but in CPP they occur earlier than usual.

Symptoms and signs of CPP are:

In boys, before the age of 9 In girls, before the age of 8
  • A growth spurt (getting taller)
  • Growth of underarm, pubic and/or facial hair
  • Acne
  • (Adult) body odour
  • Growth of penis and testicles
  • Deepening of the voice 
  • Muscle growth
  • A growth spurt (getting taller)
  • Growth of underarm and/or pubic hair
  • Acne
  • (Adult) body odour
  • Breast development
  • Wider hips
  • Start of periods

If you recognise any of these symptoms or signs in your child (for girls: before the age of 8; for boys: before the age of 9), please contact the general practitioner or follow-up care specialist.

My child is at higher risk of CPP. What tests should I have and when?

If your child is at higher risk of CPP, it is advised to see your general practitioner or follow-up care specialist every 6 months until your child is 8 (for girls) or 9 (for boys) years old. What tests you should have depends on your cancer treatment.

Whenever you visit your follow-up care specialist, they may:

  • Measure growth and progress of puberty. For boys under 9 years who received alkylating agents and radiotherapy to the testes, measuring the progress of puberty by size of testes can be unreliable. Instead, for this group it is advised to measure testosterone levels (early in the morning) in the blood once a year.
  • Ask whether your child has been experiencing symptoms and/or signs of CPP.
  • Do a physical exam.

What happens if my child experiences CPP?

If your child has CPP, your general practitioner or follow-up care specialist will probably refer your child to a:

  • Paediatric endocrinologist (physician specialised in hormones and metabolism in children)

The endocrinologist may discuss different treatment options with you and your child, such as hormone treatment.

What else can I do?

Knowing that your child may be at increased risk of CPP can be difficult. Talking to friends and family can be helpful as well as specialist counselling and/or contact with support groups, such as patient organisations. For more information on taking care of your mental health, please read: Mental health problems.

Although it may not lower your child’s risk of CPP, it is still important to live a healthy lifestyle. Taking care of your child’s mental health may be beneficial; even small changes to your child’s lifestyle can have a positive impact on both your child’s physical and mental health. For more information on taking up a healthier lifestyle, please read: Health promotion.

It is important that you are aware of the possibility of your child developing CPP and that you know the symptoms and signs. If you suspect CPP in your child, please contact your general practitioner or follow-up care specialist soon. Early treatment will help your child to reach their best possible adult height. If you have any further questions or the information in this brochure concerns you, please contact your general practitioner or follow-up care specialist.

Where can I find more information?

You may find more information about CPP online. However, it is important to be aware that this information is not always up to date or accurate.

On this website, you can also find more information related to this topic:

Please note

This PLAIN summary is based on the IGHG* guideline about “Hypothalamic-pituitary dysfunction” [1].

While the PanCare PLAIN information group strives to provide accurate and complete information that is up-to-date as of the date of publication, you can check with your general practitioner or follow-up care specialist if this summary reflects the most up-to-date information available and whether it is relevant for you.

Please do not rely solely on this information. It is best to also seek the advice of a qualified medical practitioner if you have questions regarding a specific medical condition, disease, diagnosis or symptom.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information. PanCare has produced the English version and PanCare is not responsible for the translated versions of this summary.

*International Guideline Harmonization Group for Late Effects of Childhood Cancer

[1] Van Iersel, L. et al. (2022) Hypothalamic-Pituitary and Other Endocrine Surveillance Among Childhood Cancer Survivors. Available at: https://academic.oup.com/edrv/article/43/5/794/6432595