puperty lec2024ppt

Puberty- Normal & Abnormal
Dr. Thabat J Abd

Asst. Professor
Department of OBG
the objectives of studying
puberty in female
 Understanding the normal sequence of pubertal changes
 study the hormonal changes that drive puberty in females
 identifying and addressing disorders or conditions that may
affect normal development.
PUBERTY
It is a physiological phase lasting

2 to 5 years during which the
genital organs mature
FACTORS INITIATING
PUBERTAL DEVELOPMENT
Increased adrenal
Maturation of neurotransmitt
hypothalamus er activity in androgen
CNS activity
• Nutrition
• Environment
• Genetics
MANIFESTATIONS OF
PUBERTY IN FEMALE
1. Menarche
2. Appearance of secondary sex characters
3. Physical development
4. Psychological changes.
Secondary sex characters
• development of the breast(thelarche)

• appearance of pubic hair (pubarche)
• appearance of axillary hair
Puberty
Adrenarche
Thelarche (Breast
development) Menarche
↑↑ activity of the
suprarenal cortex Onset of
↑↑ androgens menstruation/
Appearance of periods
Pubic &axillary hair
Interval between breast budding &

menarche is nearly 2.5 years
CAUSE OF PUBERTY
During childhood , the hypothalamus is

extremely sensitive to the negative feedback
exerted by the small quantities of estradiol &
testosterone produced by the child's ovaries.
As puberty approaches , the sensitivity of the

hypothalamus is decreased and subsequently, it
increase the pulsatile GnRH secretion .
The anterior pituitary responds by
progressive secretion of FSH and LH
associated with increased secretion of
growth hormone .
The ovaries respond to the increase
Gonadotrophin(LH & FSH) secretion
by follicular development &
estrogen secretion .
Estrogen causes development of genital
organs & appearance of secondary sexual
characters .
With increased estrogen secretion ,

menarche and cyclic estrogen secretion
occurs .
GENITAL ORGANS CHANGES
 Mons pubis, labia majora & minora:

Increase in size
 Vagina:
1. length: increase, appearance of the rugae
2. Epithelium: thick, stratified squamous., containing
glycogen
3. pH: acidic, 4-5
 Uterus:
enlarge, Uterus / Cervix :1/1 then 2 / 1
 Ovaries:
1.Increase in size, oval shape
2.300 thousands primary follicle at menarche ( 2 million
at birth)
BREAST CHANGES
• marked proliferation of duct system

• deposition of fat
• Acini develop under influence of
progesterone
TANNER & MARSHALL STAGES- BREAST
TANNER AND MARSHALL STAGES-PUBIC HAIR
ABNORMALITIES OF
PUBERTY
1 - Precocious puberty .
2 - Delayed puberty .
3 - Growth problems :
FEMALE PRECOCIOUS
PUBERTY
DEFINITION
Appearance of
any secondary sexual characters
<8 years
or
occurrence of menstruation
<10 years of chronological age
TYPES:
1 True precocious puberty

• GnRH Dependent (Central, True or Complete)
• Premature maturation of hypothalamic-pituitary axis (HPO)
2 False (pseudo-precocious puberty)

& Incomplete precocious puberty
• GnRH Independent (Pseudo, Peripheral or Incomplete)
• Gonadotropin secretion independent of HPO axis
Types
• ISOSEXUAL
Features are due to excess production
of estrogen
• HETROSEXUAL
Features due to excess production of
androgen ( ovarian or adrenal
neoplasm)
ETIOLOGY
TRUE PRECOCIOUS PUBERTY
GnRH dependent
• Constitutional – MC
• Juvenile primary hypothyroidism
• Intracranial lesions(TIN) –
Trauma, Infection, Neoplasm
PSEUDO-PRECOCIOUS PUBERTY
GnRH Independent Varieties
OVARY ADRENAL
• Granulosa cell tm • Congenital adrenal
• Theca cell tm hyperplasia
• Leydig cell tm • Tumour
• Mc cune albright
syndrome
LIVER IATROGENIC
hepatoblastoma • Estrogen or androgen
excess
History
•Timing of pubertal developmental signs

• Normal tempocentral cause
• Rapid tempoTumors
•Family history
•Medications- hormones, psychostimulants.
•ROS: pain, neuro symptoms, headaches, visual
change
Exam
• Height and weight plots are CRITICAL!

• Visual fields
• Skin abnormalities?
• Thyromegaly?
• Tanner stage
• External genitalia normal?
Labs
• Labs
•LH, FSH,Estradiol
•HCG
•TSH
•DHEAS, testosterone, 17OHP
Useful Imaging Studies
•X ray wrist-Bone Age
•Rule out tumor
• MRI Brain
• Pelvic Ultrasound
• CT scan abdomen
Treatment
•Explanation & Reassurance
•Following drugs which inhibit the secretion of
gonadotrophins till appropriate age is reached
(a)Gonadotrophin releasing hormone analogues which
are given as daily nasal spray, intramuscular, or subcutaneous
injections every 4 weeks.
• GnRH agonist therapy - administration for GnRH dependent
cases
• Consult Endocrinologist
• Weight-based-Intramuscular, subcutaneous or intranasal
• Effects: can stop when reaches appropriate height, menses occur
1-2 years after cessation, puberty occurs at normal pace after
cessation, no BMD(bonemarrow density) diminishment, fertility
unchanged
Treatment
(b)Medroxyprogesterone acetate tablets (Provera
tablets) or intramuscular injection (Depo-Provera);
(c) Danazol capsules;
(d) Cyproterone acetate tablets (Androcur).
Calcium & Vitamin D supplements

Isolated Pubertal Signs
•Precocious Thelarche
•Precocious Adrenarche
•Precocious Menarche
Precocious Thelarche
• Isolated development of breast tissue before age

of 8 yrs
• Commonly idiopathic
• Unilateral or bilateral
• Requires no treatment
Precocious Adrenarche
•Due to early androgen activation

•Seen in certain ethnic groups, children with
neurological sequelae, obese kids
•Increased risk for PCOS
Precocious Menarche
• A diagnosis of exclusion!
• Rule out: infection, trauma, tumors, foreign
body
• True cases thought to be idiopathic
similar to precocious thelarche
DELAYED PUBERTY
No Secondary Sexual Characters 14y

or
No menstruation till age of 16y
DELAYED PUBERTY
• 3 classifications
•Hypergonadotropic hypogonadism
•Hypogonadotropic hypogonadism
•Eugonadism
HYPERGONADOTROPIC HYPOGOANDISM
•LH & FSH are raised .

•What causes it?
• Ovarian failure
• Gonadal dysgenesis
• Karyotypic abnormalities-Turner(XO)=MC
• Chemotherapy
• Radiation
• Surgery
• Galactosemia
HYPOGONADOTROPIC HYPOGOANDISM
•LH & FSH are decreased

•Reversible
• Constitutional delay (most common)
• Central suppression
• Weight loss, chronic disease, anorexia
• Prolactinoma
• Primary Hypothyroidism
• CAH
HYPOGONADOTROPIC HYPOGOANDISM
• Irreversible
•Kallman’s syndrome ( most common)

•Hypo pituitarism
•CNS lesions
EUGONADISM
• Normal levels of LH & FSH
• Structural abnormalities
•Mullerian agenesis
•Transverse Vaginal Septum
•Imperforate Hymen
• Karyotypic abnormalities
•Androgen Insensitivity syndrome/testicular
feminization synd.
History
• Age of pubertal initiation, if any

• Neonatal history
• Medical conditions
• Surgical history
• Medications/chemo/radiation
• Family history
• ROS: ie., inability to smell, rapid weight change,
athlete, neuro symptoms, pain
Exam
• Presence of neck webbing?

• Tanner stage-breasts and genitalia
• Galactorrhea?
• Normal external genitalia?
• Rectal-e/o mass or bulging effect
• Thyromegaly?
Labs and Imaging
•Labs
• FSH (if high, need a karyotype)
• TSH
• PRL
•Imaging
• Pelvic ultrasound( ovary, uterine malformation)
• MRI +/-
• Bone Age
Evaluation
• High FSH (>10)

•Send Karyotype, then address underlying
cause
•If Turner’s, may need HRT to enter puberty
Evaluation
•Low to Normal FSH (<5)

• Exclude systemic condition
• Rule out CNS Tumor (MRI Brain)
• May need GnRH stim. test for confirmation
• May include watchful waiting
• Beginning hormones to enter puberty may be
necessary ( cyclic estrogen)
TREATMENT OF DELAYED
PUBERTY
Constitutional : Reassurance .
•Treatment of the cause (if treatable)
•or cyclic estrogen-progesterone hormone
replacement therapy if the cause is not treatable ,
•for 3 cycles: Norethistrone acetate 5 mg twice daily
for 21 d or OCP
* Patient with Y chromosome cell line : Gonadectomy
+ hormone replacement therapy
THANK YOU

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Puberty- Normal & Abnormal

Dr. Thabat J Abd

It is a physiological phase lasting

• development of the breast(thelarche)

Interval between breast budding &

During childhood , the hypothalamus is

As puberty approaches , the sensitivity of the

With increased estrogen secretion ,

 Mons pubis, labia majora & minora:

• marked proliferation of duct system

1 True precocious puberty

2 False (pseudo-precocious puberty)

•Timing of pubertal developmental signs

• Height and weight plots are CRITICAL!

Calcium & Vitamin D supplements

• Isolated development of breast tissue before age

•Due to early androgen activation

No Secondary Sexual Characters 14y

•LH & FSH are raised .

•LH & FSH are decreased

•Kallman’s syndrome ( most common)

• Age of pubertal initiation, if any

• Presence of neck webbing?

• High FSH (>10)

•Low to Normal FSH (<5)

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