1. Puberty

2. 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

3. endocrine control

4. stages of puberty growth spurt Thelarche Pubarche Axillary hair growth
Menarche

5. Influencing factors
Genetic factor
Enviromental factor
Leptin
Psychological factor

6. 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

7. pubertal stage (Tanner )/female

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

10. Precocious puberty development of secondary sexual characteristics
< 8 yrs in girls
< 9 yrs in boys
*more common in girls.

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

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

14. treatment psychological support
GnRH aginist, leuprolide acetate mg/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.

15. 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.

17. 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)

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

19. Eugonadotrophic Congenital anatomic anomalies ....imperforated hymen
...vaginal atresia.
...vaginal aplasia
**in these cases, secondary sexual characteristics are normal.

20. Treatment psychological support Treat systemic disese
Promote puberty/growth
in male case
Low dose testosterone
HCG
In female case
Estrogen

21. Assessment of puberty

22. 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

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

24. 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

25. Vaginal bleeding in infancy
Foreign body
Trauma
Genital tumour
Vulvovaginitis
Precocious puberty
Exogenous hormone usage
Condyloma acuminata

26. Normal menstrual cycle

28. Follicular phase
ovulation
Luteal phase
Menstruation

33. secretory endometrium
Basal layer
Functional layer

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