Endocrine Society Issues First Guideline on Central Precocious Puberty

CHICAGO — For kids with central precocious puberty (CPP), there shouldn’t be a one-size-fits-all approach to testing and treatment, according to a clinical practice guideline from the Endocrine Society.

The guideline, the first of its kind from the society, first recommended watchful waiting via periodic physical examinations rather than immediate evaluation with laboratory testing and/or radiologic imaging in girls who present with thelarche, commonly known as breast budding, between the ages of 7 and 8 years.

They also suggested 4 to 6 months of observation to differentiate unsustained or slowly progressive puberty from rapidly progressive puberty before starting diagnostic evaluation in girls younger than 7 years with initial breast development.

The guideline was presented at the organization’s annual meeting, ENDO 2026, here, and published in the Journal of Clinical Endocrinology & Metabolism.

Though there are “many important clinical questions regarding the diagnosis and management of CPP … 10 of the most controversial clinical questions were prioritized,” noted Guideline Development Panel Chair Ana Claudia Latronico, MD, PhD, of the University of São Paulo, and colleagues.

Panel Co-Chair Stephanie Roberts, MD, of Boston Children’s Hospital, told MedPage Today that it was important to issue the guideline now because “children are entering puberty younger than in past decades.”

“Early puberty can affect a child’s adult height and is associated with long-term physical and emotional health risks, including psychosocial stress, heart disease, and some cancers later in life,” Roberts continued. “Children who start puberty much earlier than usual should be carefully evaluated so they receive the right care at the right time — without unnecessary tests or treatment.”

In girls and boys with evidence of precocious puberty, the panel recommended initial evaluation with basal luteinizing hormone concentration by ultrasensitive assay, rather than a gonadotropin-releasing hormone (GnRH) agonist stimulation test to distinguish kids with CPP from those without the condition.

The panel also suggested that brain MRI should not be routinely performed in girls ages 6 to 8 years and boys ages 8 to 9 years with CPP but without central nervous system (CNS) findings. However, they added that the recommendation should not apply to younger kids or those of any age presenting with CNS findings like headaches, seizures, or visual field deficits.

Ultimately, “fewer children need brain MRIs as part of their evaluation for CPP and this can be targeted to certain subgroups,” Roberts emphasized.

The guideline development panel also recommended against routine genetic testing (e.g., to identify loss-of-function mutations in MKRN3, DLK1, and/or MECP2) for kids with CPP. For those with familial CPP, genetic testing should be considered based on shared decision-making with family.

For many kids with CPP, the panel suggested GnRH agonist treatment. However, certain subgroups may not achieve net benefit from this treatment.

“Puberty-pausing medication, which temporarily pauses the brain signals that start puberty, can be an effective treatment and has the potential to increase adult height as well as improve psychosocial and long-term health outcomes among children with early puberty,” Roberts explained. But some subgroups of kids, such as older girls with slowly progressive puberty, “may not need the same level of testing or treatment.”

For kids with CPP expected to use a GnRH agonist in the long term, the panel recommended initiating therapy with long-acting GnRH agonist preparation rather than with a monthly GnRH agonist. Long-acting GnRH preparations are those with at least 3 months duration of action (e.g., 3-month and 6-month injectable formulations and a 12-month subcutaneous implant).

They suggested against routine biochemical testing (e.g., luteinizing hormone and sex steroid concentrations) to monitor pubertal suppression in kids being treated for CPP with a GnRH agonist.

They finally recommended against the routine addition of growth hormone to GnRH agonist therapy in kids with CPP and against the routine continuation of GnRH agonist treatment beyond chronological age 10 to 11 for girls or 11 to 12 for boys and/or bone age 11 to 12 for girls or 12 to 13 for boys.

The guideline was co-sponsored by the American Academy of Pediatrics, the Brazilian Society of Endocrinology and Metabolism, the European Society of Endocrinology, the European Society for Paediatric Endocrinology, the Latin American Society for Pediatric Endocrinology, the Pediatric Pharmacy Association, and the Pediatric Endocrine Society.

To develop the guideline, a systematic review was conducted for each clinical question answered with a recommendation. There were few randomized controlled trials, leading the panel to primarily rely on observational studies and indirect evidence.

The panel also sought evidence relevant to all elements of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence-to-decision framework, including stakeholder values and preferences (based on input from clinical experts and a patient parent representative), required costs and other resources, cost-effectiveness, acceptability, feasibility, and potential impact on health equity. However, the panel did not identify high-quality evidence addressing these evidence-to-decision factors.