Wk: 6

Lecture 2 Obs/Gyne: Male and Female Puberty

Done By: Shareefah Khaleefah & Nora AL-Towaijri
Slide 1:
-Puberty = sexual maturation normally ready to be a father/mother
from the psychological reproductive aspect.
-We’ve discussed about abnormality (Primary Sex Differentiation) will
have a problem with puberty.
Slide 2:
-Know the definition, onset its range, so at 5 yrs its abnormal and after
the age 14-16yrs (delayed).
-Dr. gave ex. Of a mother with her daughter at the age of 14 with no any
secondary sexual characteristics [ no pubic & axillary hair, no breast, no
menstruation] ABNORMAL!
-That’s why its imp. To take 1) medical history 2)directed physical
examination 3)appropriate diagnostic tests.
-Some of these conditions are treatable.
-The problem of Delayed puberty is that reason is unknown yet by the
Doctors!
Slide 3:
-Peak height velocity = there is a period in life where we have
accelerated growth in height.
-Menarche= First menstruation, its NOT painful b/c NO ovulation.
-During ovulation= the Corpus Luteum produce Prostaglandins and
make the uterus to contract and have pain during menstruation
[Dysmenorrhea]
-The periods are NOT regular till after year or 2 yrs after onset.
-Heterosexual instincts= put an ex: as in the LT Females are sitting next
to each other and so the males due to instinct (aggressive attitudes of
puberty).
Slide 4:
-Those the Secondary sexual characteristics don’t come at once and the
chart is from a British Study.
Ex: A mother worried about her 6year old daughter whose having a
pubic hair → Don’t worry, she will grow NORMALLY.
-Menarche occur about 12.5 yrs, BUT 10 years ago, it was 14.5 yrs.
50 years ago it was at 16 yrs, so its coming down due to environment
and better nutrition.
-Menstrual pain due to ovulating, NOT every women have it. But in
some women the PAIN may be cruciating and as painfull as it can be.
Slide 5&6:
-Stage 1 = areola’s there and behinds it like a nodule.
-Stage 2 = areola pops out.
-Stage 3 = different areola’s position.
-Stage 4 = areola totally out.
-Stage 5 = adult breast.
* Used to classify the pubertal stages. And relate Slide 6# with the pic in
the Slide 5#.
-Staging puberty in Males = testicular volume.
Slide 7:
**What initiates puberty ?!! Hypothalamic-Pituatry-Gonadal axis with
negative feedback.
1) Highly sensitive –ve feedback system of steroids (Estrogen-
Testosterone) → SUPRESSING the axis.
2) Intrinsic CNS inhibitory mechanism
1) & 2) are acting on GnRH neurons inhibiting them.
-GnRH neurons act to release LH & FSH.
-These 1) & 2) will NOT make a girl of 9 or 10 to start puberty.
**What act to inhibit the TWO –ve feedback systems & so activate the
axis, initiating the puberty?!! A PROTEIN called KISSPEPTIN that act
with its receptor [G protein receptor 54].
-The gene of KISSPEPTIN is Central and imp. To activate GnRH neurons
and release LH & FSH to act on the gonads.
-There is –ve feedback (if Estorgen is ↑ it affects @ THREE levels)
1_ Pituitary release of LH & FSH.
2_ GnRH neurons.
3_ Gene of KISSPEPTIN.
Take Home Message: 1) protein Kisspeptin. 2)Its receptor G-P54.
3) Its gene.
**ALL THREE are imp. For Puberty ( if any one is absent → Puberty
will NOT take place.)
Slide 8:
-This is imp. The Dr. emphasizes on the 3rd &4th points.
-Kisspeptin signaling is an imp. Target for Fertility managing.
Slide 9:
-With the Kisspeptin, you are going to have the Pulsatile release of
GnRH every 90 minutes to the system & so you will have the LH & FSH
and will be able to reproduce.
Slide 10:
-BOTH men & women will have Stimulatory and Inhibitory effects. And
Kisspeptin will enhance the Stimulatory effect to initiate puberty & the
Reproductive Function.
Slide 12:
-If you have Menarche, then Kisspeptin, GnRH, LH &FSH are working
NORMALLY.
- If the ovaries are working to produce Estrogen that cause Endometrial
Hyperplasia in the Uterus.
-When the level of Estrogen goes ↑, there is –ve feedback & then the
woman is going to shed the Endometrium.
-Studies found that the amount of blood loss by the woman is imp. If its
more than 80ml → you are going to have CLOTS and so you are going to
change the sanitary towels more frequently. (eg: if you are using 3-4 a
day, you’re gonna double it b/c of heaving bleeding).
Slide 13:
**What determine Menarche?!!
-Genetics → eg: if your sister menstruate at age 14, most probably
you’re gonna menstruate around this age.
Slide 14:
-Woman that is obese is MORE likely to start menstruating EARLY (fat
deposition).
-Malnutrition will DELAY the Menarche.
-Exercise: *IF its Normal, NO effect.
*IF its excessive &daily, will have problems in the ONSET of
Menarche.
-Bulimic patients (they eat & then vomit) and Anorexia nervosa →
POSTPONED the onset.
-Environmental factors_eg: smoking and endocrine disturbing chemicals
[Displace the Normal Hormones –eg: Estrogen and Estrogen will NOT be
affective] so they will have problems.
-Depending on the previous factors, in the past few years, there has
been a PLATUE of the Age of Menarche between 12-12.5 yrs.
Slide 15:
-Evaluate problems with Menarche:
1_History → can tell you about the Risk Factors_eg: Changing the
environment like travelling from Villages to Cities will have
problems(environmental factors).
Slide 16:
**DD is imp. [DD=Differential Diagnose]
1. A women brought her 5 yr old daughter b/c she has pubic hair
BUT that’s NORMAL & they didn’t do anything for her. (This is
Benign Premature Adrenarche)
2. Benign Premature Thelarche = early breast development. If it is on
one side & NOT progressive, Don’t worry about it.
3. If she has bleeding, First thing you have to do is to MAKE SURE
that she don’t have TUMOR in the ovaries that is producing ↑
levels of Estrogen b/c if it’s there, you should REMOVE it.
Slide 17:
 Problems w\ puberty:
1. Primary amenorrhea → could be 18 yrs old and she never
menstruate.
2. Cryptomenorrhea (aka: cryptic amenorrhea) → everything in
anatomy is normal, but the hymen is closed, so the blood is
not coming out and there will be blood back up in the
vagina, uterus, and the fallobian tubes. So you have
hematometria and hematosaloinges.
3. Dysmenorrhea (pain during menstruation – the woman is
running in the ground because of the pain) → this pain is
caused by prostaglandins released from the corpus lotium,
so they give them NSAIDs to manage the pain as they inhibit
prostaglandins production).
4. Adolescent pregnancy → he gave an example of a 14 yrs old
girl who got pregnant & her mother said go & look for the
father of your child.
Slide 18:
 Central or true / complete isosexual (result of premature
initiation of the hypothalamus-pituitary axis).
 The treatment of feminizing tumor is removal of the tumor
surgically or use MBA injections.
Slide 19:
 Treatment depends on many things: the tumor & the facilities you
have around.
 Exogenous sex hormones injections can be a problem & these of
course have to be stopped.
Slide 21:
 Suppose at 18, & the girl did not menstruate, history chart is imp.
& also the physical examinations & the hormone profile.
 The hormone profile divide the patients into 3 groups:
1. Normal FSH & LH.
2. High FSH & LH (hypergonadotropic hypogonadism).
3. Low FSH & LH.
 In karyotype, 45 XO is turner’s syndrome or mosaic.
Slide 22:
 Constitutional delay –eg: in athletes & in refugees (due to
malnutrition).
 Kallmann’s syndrome is a deficiency in GnRH.
Slide 23:
 Hypergonadotropic hypogonadism could be congenital or result
from a chemotherapy or radiotherapy:
→In males: you can have ONLY sertoli cells in the testes & no
germ cella & no lydig cells.
→In females: you might have premature menopause.

Slide 24:
 Skipped & said already talked about.
Slide 25:
 He put this slide which was already there in the previous lec., he
put it again to emphasize that the diagnosis can be on a well-
developed lady at age of 22-23 yrs.
Slide 26:
 The principle of treatment is that you should discuss everything
w/ the woman & her parents.
 You should be working as a team with the endocrinologist,
psychologist, obst., surgeon, & his or her parents.
 But if this starts at the delivary & you noticed ambiguous genitalia,
do a full investigations, so that the individual doesn’t present w/
this problem as an adult. Once you do all that, then choose the
appropriate sex of the reare & exclude congenital adrenal
hyperplasia.
Slide 27:
 Psychoeducation is difficult.
  If the problem was only breast development & everything is
normal, the breast is very easy to develop → you give only
estrogen & the breast will develop.
Slide 29:
 If the testes are undescended, you should remove them because
they have a 30% chance of malignancy.