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

pubertal stage (Tanner )/female

Puberty; boys Testicular enlargement Penil & scrotal enlargement Pubic hair Growth spurt Voice changes

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

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.

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 Treat systemic disese Promote puberty/growth in male case Low dose testosterone HCG In female case Estrogen

Assessment of puberty

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

examination 1-examination of growth ...height ...weight ...BMI ...upper to lower segment ratios 2-pubertal assessment (Tanner staging ) 3-neurological assessment

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