Puberty

Dr. Mohammed EL-Shafei

Prof. of Ob. & Gyn.
Faculty of medicine
Mansoura university
Egypt
 Puberty
Definitions:
Puberty: is the period of life (a transitional period
between childhood and adulthood) 4-5 years during
which secondary sexual development occurs, the sex
organs mature, menstruation commences and
reproductive capacity is attained (includes
maturation of the hypothalamic-pituitary & gonads).
Girls reach puberty 2 years before boys.
Adolescence: is the period of transition from
childhood to the maturity stage during which both
somatic and psychic changes occur. (includes the
physiological, social, behavioral & personal
independence → the development of adult
identity
 Puberty
Menarche is an event in puberty and indicates the beginning of
the menstrual function (first menstruation).
The age of menarche vary between 10 -16 years (mean 12.5
years) and is influenced by several factors including
hereditary predisposition, nutrition, geographic location,
psychological and socioeconomic factors.
Adrenarche: the increase in secretion of androgens by the
adrenal gland, occurring from about age 5 to age 20
Gonadarche: the initiation of production of significant
amount of sex steroids by the ovary related to
stimulation by gonadotropins
Theories of pubertal initiation
 The exact cause of initiation of pubertal
changes is not finally understood
 The Gonadostate theory
 During childhood →low level of E
(severity of –ve feedback to sex steroids
↑) → inhibits the Hypothalamus
 With age → severity ↓→↑FSH &LH
 Later on → +ve feedback between LH & E
receptors develops → start LH surge
2- Critical weight & body fat mass
Leading to ↓ sensitivity of –ve feedback loop:
– At 30 kgs → growth spurt begins
– At 39 kgs → peak height velocity
– At 47.5 kgs → menarche occur
3-Onset of adrenal activity
– Adrenal androgen ↓ the sensitivity of the –ve
feedback loop
4- Sleep mechanism
– Changes in the neurotransmitters during sleep cycle
→ might play a role in releasing from inhibition
– 1st events in puberty → nocturnal release of LHRH
during sleep
5- CNS maturation
 Physiology of puberty
In summary:
1- Hypothalamus is activated by:
– Decreased sensitivity of negative (inhibitory) feed back mechanism to small amount
of estrogen present in the prepubertal girl.
– Suppression of intrinsic CNS inhibitory mechanism independent of sex steroids.
– Increased production of leptin ( peptide produced by fat cells) which stimulate
GnRH cells
This leads to production of GnRh and the release of pituitary gonadotropins (FSH
& LH)
2- Gonadotropins stimulates female development & estrogen secretion by
the ovaries
3- Estrogen causes:
– Development of genital organs
– Appearance of secondary sexual characters
– Endometrial proliferation & menstruation (Menarche)
Hormone changes at puberty (The role of the H-P-O axis)
 Stages of pubertal development or pubertal
changes (the sequence of events at the time of puberty)
 The changes associated with puberty occur in an orderly sequence over a definite time
frame which averages 4.5 years.
 Beginning of roundness of the body contour (trunk and limbs) by selective deposition of
fat after the age of 12
 Thelarche: prominent nipple (9.8) years then formation of conical breast bud under the
effect of gonadal estrogen, it is completed over 3 years
 Adrenarche: appearance of pubic hair (10.5 years) and axillary hair 2 years
later under the effect of adrenal androgen. May be the 1st sign of puberty in up
to 20% of girls
 Premenarchal growth spurt during the year preceding menarche under the
effect of growth hormone (G.H) and insulin growth factor 1 ( IGF.1). It passes
in 3 phases:
– Minimum growth velocities : 5 cm / years
– Peak height velocities 805 cm/year
– Stages of ↓ velocity
 Menarche (12.8 years) is a late event occurring after the peak growth is passed
 Stages of pubertal development or
pubertal changes (cont.)
 Anatomical maturation of the genital tract
 Behavioral changes & psychic maturation
 Roundness and further growth of the
breast which have a rounded lower margin
(adult breast)
 Slowing of gain of height (closure of
epiphysis of long bones )
 Acquisition of adult type of pubic hair
with the characteristic female pattern
Pubertal stages
 Tanner had classified puberty
into 5 stages
depending on the degree of breast development and distribution of pubic hair.

Stage 2 sparse Stage 3 darking,

Stage 4 Stage 5
long pigmented coarsing, curling
Stage 1 no hair unlimited to Hair spread to the
hair along the labia of hair w extend
pubic hair majora upward & laterally medial aspect of
mons
the thigh

Adult configuration with

Elevated papilla only (no Enlargement of breast & Areola & nipple form a
breast tissue) Breast bud areola without septum mound on top of
areola &breast having
smooth contour
underlying breast tissue
Changes occurring at puberty
Somatic changes:
1- Growth of the breast
2- Female configuration
3- Fat deposition on the pelvic girdle
4- Appearance of pubic and axillary hair
5- Closure of the epiphysis in late puberty
 Genital changes (estrogen dependent):
1- Growth of the labia majora and decrease in size of labia minora (deep vulva)
2- Thickened vaginal mucosa with deposition of glycogen in the vaginal epithelium
3- Increase in size of uterine body
4- Fallopian tubes become thicker, longer with development of cilia and peristalsis
5- Menstruation occur→ factors affecting the age of menarch
12.5 years (Egypt)
Factors: - socio-economic - Environmental
- Racial & geographical
- Medical & endocrinological disease
- Blindness - Deafness
- Epilepsy - Obesity
- Diabetes
Psychological changes
1- Sexual desire ( heterosexual inclination)
2- Imagination
3- Shyness of girls
 Management of puberty
Duty of the parent & school
 Knowledge about reproductive health
 Psychological preparation of the girl will ensure that she is not
taken by surprise by the beginning of the menstruation & other
changes. This girl should be encouraged not to abstain from
daily function (other than those religiously determined) e.g.
socializing, sport activity and bathing.
 The symptoms of puberty may need reassurance
 Menstrual irregularities are common in post-menarchal years
and usually need reassurance
 Attention to physical activity to enhance fitness by ensuring
physical exercise.
 Adequate & balanced food is needed
 Abnormal puberty

Classification:
I- Precocious puberty: defined as pubertal development beginning
before the age of 8 years
II- A synchronous pubertal development: pubertal development
that deviates from the normal pattern of puberty.
III- Delayed or interrupted puberty: defined as
 Failure to develop any 2ry sex characters by the age 13
 Have not had menarche by the age 16
 5 or more years have passed since the onset of pubertal
development without attainment of menarche
So, delayed puberty may involve either delay in onset or progression
 I-Precocious puberty:
- Means the onset of the female menstruation,
which is usually associated with pubertal
changes, before the age of eight years .
- It may occur as early as the age of 2 years.
- It may occur towards the same sex (isosexual)
or towards the other sex (heterosexual)
- Girl is usually shorter than normal
(premature closure of epiphysis
Isosexual precocious puberty:
- May be:
1- Complete →all manifestation of puberty
- central (ovulation + true sexual hormone production)
early activation of Hyp-Pit Ovarian axis
- Peripheral (false) with sex hormone production only
Causes:
- Feminizing ov. T - Adrenal t.
- Mc Cune Albright syndrome
- Iatrogenic exogenous drugs
- Ectopic Gonadotropin production
- !ry hypothalamic disease
2- incomplete → one or more manifestation occur
- 50% have organic brain disease
- may be isolated thelarch or adrenarche
 Heterosexual precocious puberty It means virilization
– Congenital adrenal hyperplasia
– Adrenal ovarian tumour
– Adrenal tumours
– Exogenous androgen ingestion
Diagnosis of precocious puberty

 US, CT scan & MRI to rule out neoplasm

of ovary, brain and adrenal
 Observe the velocity of changes
 Exclude hypothyroidism (Thyroid
function tests)
 FSH, LH and estrogen assays
 DHEA-S (heterosexual)
 Gn Rh challenge test
 Management of precocious puberty
A) Treatment of the cause e.g. surgical
removal of tumors (localized brain tumors
& ovarian tumors)
B) Treatment of constitutional precocious
puberty:
The aim of treatment is to:
 Prevent emotional problems by special parental
care for psychological support & protection
 Prevent premature closure of the epiphysis
 Prevent pregnancy in girls
Management of precocious puberty (cont.)

 Preserve future fertility

 Arrest premature sexual maturation until the
normal pubertal age, by the use of several drugs
including, medroxyprogesterone acetate
(depoprovera), danazol and Gn Rh analogues
The treatment is continued until:
 Bone age matches the chronological age
 Epiphyseal closure occur
 To the age of 12 years
 II -Asynchronous pubertal development

Defined as pubertal development that deviates from the

normal pattern of puberty (testicular feminization
syndrome.
III-Delayed or interrupted puberty:
 Absence of breast development by the age of 14 years
 If more than 3 years elapsed between onset of breast
development and menarche
 Absence of menses by the age of 16 years in presence of
good 2ry sex characters
 Delay of onset of menstruation after the age of 16 years
is considered as having primary amenorrhea
 Etiology of delayed puberty
A) Normogonadotropic normogonadism: (anatomic
abnormalities of genital tract or end organ defect)
1] Rokitansky – Kauster – Hauser syndrome
2] Imperforate hymen
3] Transverse vaginal septum
B) Hypergonadotropic hypogonadism: includes conditions in
which the ovaries or gonads are not functioning and are
unable to respond to GnH as a result gonadotrophin level
are high
FSH > 30 m IU/ml
1] Turner’s syndrome
2] Pure gonadal dysgenesis: refers to 46 XX or 46 XY phenotypic females
who has streak gonads
3] Early gonadal failure: primary ovarian failure may occur due to radiation
therapy, chemotherapy or galactosemia
Etiology of delayed puberty (cont.)
C- Hypogonadotropic hypogonadism
The ovaries is normal, however signals from hypothalamus is
abnormal
FSH < 10 mIU/ml
1- Constitutional delay: these have normal progress of the stages of
puberty but the initial of the process is simply delayed
The most common cause of delayed puberty
Psychological: stress & anorexia & nausea
2- Isolated gonadotropin deficiency
- Kallaman’s syndrome: (olfactogenital dysplasia)
- Laurence – Moon – Bardet – Biedl syndrome
3- Multiple pituitary hormone deficiencies
4- Neoplasms of the hypothalamus and pituitary
5- Infiltrative process
6- Irradiation of CNS: for treatment of neoplasms
Etiology of delayed puberty (cont.)
C- Hypogonadotropic hypogonadism (cont.)

7- Other hypothalamic / pituitary dysfunction

a-Malnutrition and malabsorption
b-Anorexia nervosa and bulimia
c- Hyperprolactinemia
d- Primary hypothyroidism
e- Cushing’s syndrome
f- Severe chronic illness
Diagnosis of delayed puberty (cont.)

A) History:
1- Pubertal milestones of the mother and sister
2- Disorders of pregnancy, labour, delivery, birth weight and
birth trauma
3- Nutrition
4- Poor linear growth
5- Systemic medical disease
6- Neurogenic symptoms
7- Family history of:
 Disorders of puberty
 Anosmia or hyposmia in relatives ( Kallaman’s syndrome) and
delay in age of onset of puberty
 B-Examination of delayed puberty (cont.)
 Weight, height
 Upper: lower segment ratio, arm span: height ratio
 Evaluation of Turner stigmata
 Tanner staging of breast and pubic hair
 Exclude genital malformation
 Neurologic examination: (visual fields, fundoscopy,
sense of smell)
C- Investigations of delayed puberty
1- FSH, LH, prolactin, TSH
2- Radiologic (hand and wrist for bone age, skull x ray)
3- Karyotype
 Treatment of delayed puberty
1] Essentially correction or removal of the 1ry cause
when possible : e.g
 Thyroxin for hypothyroidism
 Growth hormone for isolated G.H. deficiency
 Treatment of chronic illness as malabsorption syndrome
2] In constitutional delay: reassurance that
development will occur