Lupron Benefits vs. Risks

[momof32b]

My daughter is 6 years old has body odor, some pubic hair and developing breasts.  She's been to a pediatric endocrinologist w/ a full bloodwork up and all is normal (thankfully).  Her bone age scan in July had her w/ the bone age of an 8 year old...now in Feb of that of a 10-12 year old.  Her endocrinologist and I have discussed Lupron but not in any great length (my next appt is in April).  Can you tell me the benefits vs. the risks for this drug.  Thank you!

[Deanna L Aftab Guy, MD]

Your 6 year old with advancing bone age does need treatment, there is one thing that might be tested that I am sure your endocrinologist has done. It is a leuprolide stimulation test to see if her early puberty is coming from early pituitary signalling (central precocious puberty) versus that which may be due to adrenal hormones or just unknown cause, also I image my kids in my workup, that includes a pelvic ultrasound to assess the ovaries and uterus and an mri of the pituitary with and without contrast. Also I am sure they have done this but ruling out other causes of early puberty are important. Even with normal screening labs the leuprolide stim test may show indeed higher pubertal hormones indicating that her tempo is a little earlier and indeed she will do well with Lupron. I have used Lupron in many many of my patients but do go through quite a few steps before getting to that decision. There are relatively few side effects if any really. The medication is a shot and it is in the muscle so ouch! but some kids don't mind and I have used emla cream for others. It has to be mixed up well and given slowly so there are no "knots" which some kids may form, this "sterile abscess" is a concern as it indicates that the child may not respond to further treatment-sort of a rejection of the medication per se. I have only one patient out of maybe 200 just followed by me alone (I have 6 partners) who have developed sterile abscess and we changed her to a medication that is given as a subcutaneous shot daily (not as much med but annoying to be daily).
The lupron works by acting as a copy to the hormone that our brain makes and attaches to the receptor turning on puberty very very briefly and then stopping the signal from acting further, the brain works when the signal is given in a pulse like fashion and when this med acts it is in a continuous fashion so the signal is not readable per se by the brain and it cannot make any more of its own signal nor receive one till the medication is stopped.
I give it monthly and have the pediatrician administer it in the office and the patient comes to see me every 4 months to assess progress. I repeat labs every once in a while to assess that the dose is working and the dose is based on child's weight at first.
Honestly risks besides the shot and the rare but important need to give it right, if we suppress puberty for too long we will miss out on all the important benefits of estrogen like bone density, so I do not treat beyond age 11 unless absolutely necessary, so if your daughter started and with a bone age of 10-12 she more than likely will be on treatment for about 2-3 years.
Once you stop treatment it is not like you get your period the next day, puberty may stay "asleep" for awhile, I am seeing that after 8-9 months in most of my girls that they then see the breast development and other signs of puberty slowly develop.
With treatment some of my girls even had regression of their breast development more like age appropriate findings.
I imagine that at the April appt they will talk about the leuprolide stim testing depending on the exam.
Hope this helps

[momof32b]

Wow!  Thank you so much for all the info.  As far as I know the stim test has not been done..neither has an MRI.  We had discussed doing an ultrasound at the next appt but that's about it.  I'm going to call her endocrinologist the first of the week and discuss these tests.  I got a pamphlet in the mail yesterday about Lupron and it indicated that once she starts treatement that her puberty symptoms may actually increase???   What does that mean exactly??  More pubic hair and more breast development??  That scares me a bit.  I just love her so much and want to do what's best for her and this whole thing is new and frightening.  To me she's still a baby and psychologically not ready for development...esp a period!  Her endo told me that if we didn't treat that she could have her first period by age 8..OMG!  On the flip side I didn't want there to be unknown side effects from the Lupron that we don't know about until it's too late but it sounds like there are none.  Thanks again for all your time and info on this.

[rajcharu]

respected mam, my daugter aged 05 yrs undergoing treatment in deptt endocrinology in referal and research AH delhi. her treatment started when she was 02 yrs . her bone age shows that she is of 05 yrs when she was 02 yrs and again her bone xray at age 03 yrs shows she is 05 yrs agaist chronical age . recently her tst like T3 T4 TSh done T3T4 normal but Tsh.9.1 ul. her ultrascaning  normal bshe is on medication Inj decapeptyl 3.75 mg monthly basis .we are undergoing her treatment frm last04 yrs but bone age shows more than chronological age. doc, told treatment continued up to age 13 yrs pl. advice accordingly requst

[Deanna L Aftab Guy, MD]

even though the bone age is 5 at age 2, it is still 5 at age 3, that is advanced but NOT advancing, that is good news. She is on medication monthly and it is a small dose since she is so young, Treatment should probably continue till age 10 or 11. The TSH sounds a little high but if the free T4 is normal I would repeat it. Or consider discussing this with her doctor cause hypothyroidism can also contribute to early puberty.

[Deanna L Aftab Guy, MD]

As I mentioned the medication attaches to the receptor so at the beginning there is a stimulation but since it acts continously rather than the natural pulse like signal the signal stops, so in a girl with progressive development already there may be a little bleeding at first (like a day or two not to worry). This has happened in exactly 3 of my patients-3! so rare but important to discuss with moms so they don't panic.
Then you see regression.
Hair is not from estrogen, it is from male adrenal hormones, the body odor and pubic and axillary hair will not go away per se so do not expect that. What we treat with lupron is the female hormone signalling that lead to ovulation and periods, that is important as estrogen advances bone age and limits final height and who wants a period in 2nd grade!
Hope this helps with your additional question. Sounds like your doc is working gradually but carefully. Good luck

[momof32b]

Thanks again for all your info!!!  I think my dr is working a little slower than I would like but I'll be patient...for now.  You've given me a lot of info to think about and discuss at our next appt in April.