1. Puberty and the Menstrual Cycle

2.  Adrenarche  Regeneration of zona reticularis  Production of androgens (DHEAS, DHEA, androstenedione)  Gonadarche  Pulsatile release of GnRH from hypothalamus →  Anterior pituitary releases LH + FSH →  Ovaries produce estrogen Adrenarche and Gonadarche learnobgyn.com

3.  Thelarche:  ↑ estrogen → breast development (10 yo)  Pubarche:  ↑ androgens → pubic and axillary hair development (11 yo)  Menarche:  ↑ estrogen → first menses (12 yo)  Typically 2.5 years after thelarche  Concerning if does not occur by age 15 or 3 years after thelarche  Growth spurt:  ↑estrogen → ↑ GH and somatomedin c Thelarche, Pubarche and Menarche learnobgyn.com

4.  Onset of secondary sexual characteristics <8 yo  Central (gonadotropin-dependent) precocious puberty  Premature activation of HPG axis  Appropriate sexual characteristics (but early)  ↑ linear growth, ↑ bone age, ↑ FSH, LH and estradiol  80-90% idiopathic in girls; some due to CNS lesions Precocious Puberty learnobgyn.com

5.  Peripheral (gonadotropin-independent) precocious puberty  Excess secretion of sex hormones from peripheral source  Eg adrenal glands, ovaries, exogenous source, germ cell tumor  Possible normal sexual characteristics or virilization  Causes include:  Ovarian cysts or tumors (granulosa theca cell)  McCune-Albright Syndrome  Primary hypothyroidism  Congenital adrenal hyperplasia  Adrenal tumor Peripheral Precocious Puberty learnobgyn.com

6. Precocious Puberty Management learnobgyn.com

7.  Premature thelarche  Isolated breast development  Premature adrenarche  Isolated male-hormone mediated sexual characteristics  Possibly just variant of normal puberty  Continue to monitor Isolated precocious puberty learnobgyn.com

8.  Breasts  I: prepubertal breasts  II: palpable breast buds  III: enlarged breasts / areola  IV: areola forms mound on breasts  V: adult breasts and areola recesses to contour of breast  Pubic hair  I: no pubic hair  II: minimal hair mostly on labia majora  III: hair becomes coarser and darker, continues to spread  IV: hair is adult like, has spread but spares thighs  V: hair extends to medial surface of thighs Tanner Scale learnobgyn.com Illustration by Michał Komorniczak; This file has been released into the Creative Commons 3.0. Attribution-ShareAlike (CC BY-SA 3.0) http://creativecommons.org/licenses/by-sa/3.0/deed.en

9.  Average cycle: 28 ± 7 days  Average menses: 4 days, 40 mL, 3-6 ppd  Menorrhagia: >7 days or >80 mL  Metrorrhagia: frequent irregular intervals  Menometrorrhagia: prolonged + irregular  Oligomenorrhea: >35 days  Polymenorrhea: <21days Menstrual Cycle learnobgyn.com