Puberty

Endo. Puberty L4 prof. Razaq alrubaeeped. department thiqar university

• Physiology of puberty L4
Between early childhood and 8-9 yr of age (prepubertal stage )the hypothalamic –pituitary –gonadal axis is dormant as reflected by undetected level of LH & sex hormones testosterone in boys and Estradiol in girls .1-3 yr before onset of puberty low serum level of LH demonstrate during sleep in pulsatile fashion
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. the pulsatile secretion of gonadotropins is responsible for enlargement and maturation of the gonads and the secretion of the sex hormones
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in mid puberty the level of LH become evident even during day time and occur at about 90-120 minutes intervals
It is clear that GnRH is the primary if not the only , hormone responsible for the onset and progression of puberty
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The effect of gonadal steroid (testosterone and estradiol )on bone growth and osseous maturation are critical , both aromatase deficiency and estrogen receptor defect result in delayed epiphyseal closure and tall stature in affected boys,
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that is mean estrogen rather than androgen are responsible for process of bone maturation and epiphyseal fusion and cessation of growth
Estrogen also mediate the increased production of growth hormone which also responsible with sex hormone for pubertal growth spurt.

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Precedes menarche

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The onset of puberty vary and more correlated with osseous than with chronological maturation age
In female, breast bud(thelarche ) is first sign of puberty (10-11yrs) followed by pubic hair (6-12 months later ), the interval to menarche usually 2-2.5 yrs. peak height velocity usually start early 12 yr of age in girls &always precedes menarche (12.75yr)

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Stages of female puberty

Growth spurt precedes menarche
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In male growth of testes(>2.5 cm) and thinning of scrotum is the first sign of puberty followed by pigmentation of scrotum and enlargement of penis .pubic hair then appeared . axillary hair appear in mid puberty in male unlike female growth acceleration appears after puberty . in male growth spurt usually 2 yrs later than in females .and growth may continue beyond 18 yrs .of age
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Stages of male puberty

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Precocious puberty :

Definition : onset of breast development before age of 8 yrs. In girls & onset of testicular development before age of 9 years in boys .

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Etiology

Central (gonadotropin dependent true precocity )
• Idiopathic
• Brain lesions
• Hypothalamic hamertoma
• Brain tumors
• Prolonged untreated hypothyroidism
Combined peripheral &central
• Treated CAH congenital adrenal hyperplasia
• Familial male precocity
Peripheral (gonadotropin independent precocious puberty)


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• Girls

• Isosexual (feminizing )
• Ovarian tumors
• Teratoma
• Exogenous androgens
• Mc Cune –Albright syndrome
• Heterosexual (masculinizing)
• CAH
• Exogenous androgen
• Adrenal &ovarian tumors

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• Boys

• Isosexual ( Masculinizing)
• CAH
• Leydig cell tumor
• hCG secreting tumors
• teratoma
• exogenous androgen
• heterosexual (feminizing )
• exogenous androgen


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4.5 yrs

Bone ae 9 yrs
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• 6 yrs old female presented at 15 months old age with irregular bleeding .central precocious puberty

نورالزهراء

On decapeptyle GRH analogs injection
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Clinical features
• hair underarm &genitalia &for boys on face
• acne
• adult body odor
• sexual development ( breast & testes )
• emotional changes
• mood swing
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diagnosis

• Hormonal levels(sex hormones )
• Low estradiol level or undetected in girls
• High testosterone (detectable in boys
• Detectable level of LH in girls & boys
• bone age (advance) osseous maturation
• ultrasound for adrenal &uterus size
• MRI or CT scan role out tumors

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• Treatment :
GnRH .analogs are effective in arresting pubertal progression in patient with central precocity like decapeptyle (zoladex ) monthly IM injection .
Medroxyprogesterone acetate some time used to :suppress puberty and arrest menses

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• Peripheral precocity :

• Testolactone which inhibit conversion of testosterone to estrogen
• Ketoconazole  inhibit steroid biosynthesis 200mg tds
• Cyproterone acetate  Potent progestin & antiandrogen, inhibit androgens at the receptor level / supress gonadal & adrenal steroidogenesis : antigonadotrophic
• 100 mg/m2,, 2 divided doses
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Delayed puberty

Will be presented in gynecological course in details by gynecologist lecturer
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Test question

Regarding puberty
• Cyproterone acetate , inhibit androgens at the receptor level
• hypothalamic –pituitary –gonadal axis is active in prepubertal state
• in mid puberty the level of LH become evident even during day time
• Androgen rather than estrogen are responsible for process of bone maturation and epiphyseal fusion and cessation of growth
• Menarche occur immediately after thelarche
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