A clinical practice guideline on precocious puberty from the Endocrine Society guides clinicians on how to avoid unnecessary testing and treatment, arguing not all children need the same level of testing.

The document, launched at the annual ENDO 2026 scientific meeting in Chicago last weekend, noted older girls with slowly progressing puberty as one group which could benefit from routine observation before moving immediately to laboratory or radiological testing [link here].

The panel of clinical experts used the GRADE approach to answer 10 questions about the treatment of central precocious puberty, defined as the the development of secondary sexual characteristics before age 8 years in girls and age 9 years in boys.

“We give clinicians suggestions that avoid unnecessary or invasive testing and treatment, such as sometimes initially using a period of observation by their health care provider, using simpler testing methods and individualising treatment when indicated,” the guideline’s writing group co-chair and paediatric endocrinologist at Boston Children’s Hospital, Dr Stephanie Roberts, said ahead of the meeting. 

Key recommendations include:

Girls 

• In girls presenting with thelarche (Tanner B2) between seven and eight years of age, watchful waiting via periodic examinations is preferred over lab testing.
• In girls younger than seven with breast development (Tanner B2), a four to six month window of observation is suggested prior to starting diagnostic evaluation.

Labs and radiology 

• In girls and boys with evidence of precocious puberty, initial testing of basal luteinizing hormone concentration by ultrasensitive assay, rather than GnRH agonist stimulation testing is recommended. 
• In girls aged 6-8 and boys 8-9 without CNS findings, the panel recommends against routine brain MRIs.
• Routine genetic testing, ie. for loss of function mutations in MKRN3, DLK1, and/or MECP2, is not recommended.

Treatments

• Puberty-pausing medications (ie. gonadotropin-releasing hormone agonist treatment) is suggested for many patients, but certain groups like girls aged 7-8 with slow progressing puberty may not benefit and shared decision making is important.
• Starting treatment with longer acting GnRH agonist treatments rather than shorter acting therapy is preferred if long-term treatment is anticipated.
• The use of growth hormone therapy in addition to puberty-delaying treatments is not recommended.
• Puberty-delaying therapies should be discontinued by age 10-11 for girls and 11-12 for boys.

Uncertainties remain, shared decision-making key 

The panel weighed available evidence for each therapeutic question, revealing a number of evidence gaps and uncertainties about the benefits of testing and treatment for certain types of precocious puberty.

Guidelines committee co-chair Dr Stephanie Roberts.

For example, the panel judged there was simply insufficient evidence to estimate the benefits of a full evaluation for girls aged 7 to 8 with presenting with early thelarche (Tanner B2).

Meanwhile, girls presenting with Tanner B3 early breast development or higher, and CNS symptoms like persistent headaches, should be more promptly evaluated by an endocrinologist, the guidelines panel said.

Meanwhile the committee had to rely on indirect evidence about when GnRH agonist treatments should be stopped, given “no clinical studies were identified that addressed the impact of different GnRHa-discontinuation strategies on the patient-important outcomes they selected”.

The committee “judged that evidence was insufficient to estimate the desirable effects of routinely continuing GnRHas beyond the specified ages”. However, “that the undesirable effects (eg, pain/anxiety associated with injections, longer exposure to the potential for medication-related adverse events) are likely small but important”.

The role of familial decision making when pursuing the diagnosis and treatment of precocious puberty was emphasised throughout the guidelines.

Parents should be consulted on decisions like genetic testing and the benefits and risks beginning of puberty-delaying treatment.

“In addition to [predicted adult height], factors such as the age of pubertal onset, potential psychological impacts of continued pubertal progression, and attainment of menarche should be carefully weighed,” the panel said.