puberty

Puberty

Definition
is physiological transition from child hood to adolescence with appearance of secondary sexual charectristics
Occur
Between 8-14 yrs in girls
Between 9-14 yrs in boys

endocrine control

stages of puberty

growth spurt

Thelarche
Pubarche
Axillary hair growth
Menarche


Influencing factors

Genetic factor

Enviromental factor
Leptin
Psychological factor

Puberty; girls

Rising level of plasma gonadotrophins....esrtadiol...development of secondary sexual characterestics
Increase ovarian volume
1st ovulation occur 6-9 m after menarche
Uterus increase in length & thickness
Vaginal mucosa become thicker & more pink

Puberty; boys

Testicular enlargement
Penil & scrotal enlargement
Pubic hair
Growth spurt
Voice changes


pubertal stage (Tanner )/female

P1
P2
P3
P4
P5

Precocious puberty

development of secondary sexual characteristics
< 8 yrs in girls
< 9 yrs in boys

*more common in girls.

causes

gonadotrophin dependant

...idiopathic 95%
...congenital (hydrocephalus)
...aquired (irradiation,surgery,sever head injury)
...tumour (glioma)
...Hypothyroidism


gonadotrophin independant
...virilization of female (CAH)
...feminization of boy
...adrenal tumour
...ovarian tumour
...exogenous androgen & estrogen
...HCG secreting tumour
...Mc Cune Albright Syndrome

delay puberty

No breast development by age of 13 in female
No mensis by age of 15

Testicular size <2.5 cm or 4 ml or pubic hair is not present by age of 14 in male.

Hypogonadotrophic
idiopathic
Chronic illness (renal failure, crohns disese)
Malnutrition
Exercise
Tumour of pitutary/hypothalamus(cranio pharyngioma)
Hyperprolactinemia
Cushing syndrome
Isolated GnRH deficiency (kallman's syndrome)


Hypergonadotrophic
congenital (turner's, klinefelter syndrome,complete androgen insensitivity,mixed gonadal dysgenesis)
Aquired
...irradiation/ chemotherapy/ surgery
...testicular torsion, trauma
...infection
...autoimmunity

Eugonadotrophic

Congenital anatomic anomalies
....imperforated hymen
...vaginal atresia.
...vaginal aplasia

**in these cases, secondary sexual characteristics are normal.

treatment
psychological support
GnRH aginist, leuprolide acetate 0.25-0.3mg/kg im once every 4wks.
In gonadotrophin independant
.... in girl, aromatase inhibitor or anti estrogen
.....In boy,combination of anti androgens
Treat systemic disease.
surgery to remove tumour.


Treatment
psychological support
Treat systemic disese
Promote puberty/growth
in male case
Low dose testosterone
HCG

In female case

Estrogen

**Parents

...onset of puberty in parents
...menarche
...parents height
**body changes
...thelarche
...pubarche
...menarche
**past medical history
**activity level
Nutritional habit
**growth history
**review of systems


examination

1-examination of growth

...height
...weight
...BMI
...upper to lower segment ratios
2-pubertal assessment (Tanner staging )
3-neurological assessment

Assessment of puberty

investigation
1-blood test
FBC,LFT,UREA & ELECTROLYTE,FSH,LH,E.,T.,TFT,DHEAS,HCG level.
2-karyotype
3-diagnostic imaging
4-bone age
5-brain MRI

Vaginal bleeding in infancy

Foreign body
Trauma
Genital tumour
Vulvovaginitis
Precocious puberty
Exogenous hormone usage
Condyloma acuminata


Normal menstrual cycle

Follicular phase

ovulation
Luteal phase
Menstruation

secretory endometrium

Basal layer
Functional layer

Clinical features

menarche; 12-13 yrs
Cycle duration; 28+-7dys
Duration of flow; 4-6 dys
Peak flow; dy1-2
Normal menstrual loss; 30-35 ml/cycle
Dysmenorrhoea

History

1-parents
2-body changes
3-past medical history
4-activity level
5-nutritional habits
6-growth history
7-review of systems
8-medication