*10.3.1 Premature adrenarche in girls*

Adrenarche is the puberty of the adrenal gland. Pubarche is denoted by the appearance of pubic hair and or axillary hair. Premature adrenarche in girls is when pubarche occurs before age 8 years in girls and 9 years in boys. The chief hormonal products of adrenarche are DHEA and DHEAS produced from zona reticularis. Premature adrenarche represents an early clinical feature of MetSy (obesity, hypertension, dyslipidaemia, insulin resistance) for some girls. Conceivably the early recognition of these children will permit allow early intervention, such as lifestyle modifications, including dietary, activity level intervention with possibility of using insulin-sensitizing agents in some individuals. Premature pubarche due to premature adrenarche and hyperinsulinemia may precede the development of ovarian hyperandrogenism [81].

Interference with the hypothalamic – pituitary – gonadal axis function may affect follicular recruitment and impact subsequent oocyte quality and affecting overall subfertility in obese women. Studies of women undergoing assisted reproductive technologies (ART) have demonstrated that obesity also has direct effects on the quality oocytes and embryos and on the status of the endometrium. Audit data from retrospective studies demonstrated obesity to be associated with increased risk for miscarriage in spontaneous conceptions [82] as well in pregnancy achieved through donor oocytes after IVF [83]. The pathophysiology underlying this association is complex and likely multifactorial, involving the oocyte, embryonic development, and the endometrium. Apart from fertility and pregnancy problems, female adiposity may influence the timing of onset of puberty, associated with irregular menses, ovulatory dysfunction and ovarian aging [77].
