Puberty and its disorders
Ob/Gyn .
INTENDED LEARNING OBJECTIVES (ILO)
By the end of this lecture the student will be able to:
1. Define puberty , precousious and delayed puberty
2. Describe pathophysiology of puberty onset.
3. List the causes for puberty disorders.
4. Outline the diagnostic steps and management
Ob/Gyn .
Normal
Puberty
Definitio
• Age of transition n
• from childhood to adulthood
• physically ending in full sexual & reproductive
development.
Age of onset of
puberty
Gir ls boys
Mean age 10.5 years 11.5 years
Rang 8 - 12 years 9 - 14 years
Changes of
puberty
Before
puberty
There is no / very little estrogen secreted
due to:
1. GnRH suppression (unknown, 2. Very sensitive
mostly controlled by a gene in HPO axis to –ve
GnRH nucleus/ melatonin feedback of
secretion from pineal glands) steroids
Normal
1. Adrenarche (before the puberty 2.Gonadarche:
onset of puberty): activation of the
activation of the adrenal gonads by the pituitary
cortex adrenal FSH and LH
androgensis the appearance
3.Pubarche Estrogen
4.Thelarche is the
of pubic hair appearance of breast buds
In most girls, the earliest 2ry sexual ccc is
Thelarche, although minority have Pubarche at first
5. Menarche: It is the last event
• Occurs 2.6 years after onset of breast and 0.5 years after peak height velocity.
• Usually the initial cycles are anovulatory
Pubertal
Abnormalities
Delayed
Puberty
Definitio
• n
Absence or incomplete development of 2ry sexual ccc
• At age at which 95 % of children of that sex & culture
• Have initiated sexual maturation
No menarche by 16 No 2ry
Or for 5 years after sexual ccc
completed thelarche by 14
Etiolog
y
A. Secondary hypogonadism - Low FSH
/ LH Delayed in GnRH pulse
a) Constitutional delayed puberty
generator (50% of causes)
b) Diseases
Congenital diseases of the Hormone Neoplasm
hypothalamic-pituitary deficiencies
• Hypothyroidism s
e.g. pituitary
axis (rare)
Hypothalamic • Cushing adenomas
- Frolich $ • Hyperprolactinemia
- Laurance Moon Beidel $ • DM
- Kallmann $
Pituitary (rare): Levi-Lorain
$
Severe Extensive Severe Acute
• malnutrition
Starvation training
as athletes stress illness
• Anorexia
nervosa
Etiolog
y
B. Primary hypogonadism - High FSH /
Gonadal
LH
dysgenesis
(Turner $ – 45XO) PO
F
C. Normo–
gonadotrophic
Uterine: Cryptomenorrhe
Mullerian a
agenesis - Outflow(
TFS )obstruction
Precocious
Puberty (PP)
Definitio
• n earlier than its mean by 2.5 SD
Appearance of any pubertal changes
Approximately
< 8 years for thelarche < 10 years for menarche
Etiolog
y
A. Isosexual (
E2)
• Normal ovulation occurs
a) True (central) PP
• Pregnancy can occur
Gonadotrophin
dependent
I. Idiopathic/ II. Organic brain
constitutional
Early maturation of HPO axis lesion
that stimulation of HPO axis
(Commonest cause (80%) ) trauma / tumors / meningitis
Etiolog
y
A. Isosexual (
E2)
b) False (peripheral) PP • No stimulation of HPO axis
Gonadotrophin
• No ovulation (only feminization)
independent
E2 secreting ovarian Iatrogenic
tumors (exogenous drugs)
McCune Albright $ a triad of: Primary
hypothyroidism
- Precocious Puberty
- Café-au lait patches
- Polyostotic fibrous • TRH FSH/LH
dysplasia
Etiolog
y
B.
Heterosexual
(excess androgen) [very
rare]
Androgen secreting Iatrogenic
tumors (exogenous drugs)
• Ovarian
• Adrenal
Adreno-genital $ Cushing syndrome
Congenital
adrenal
hyperplasia
Etiolog
y
C. Isolated
(incomplete)
Normal hormonal levels, but end organ sensitivity e.g.
• Isolated premature thelarche (unilateral or bilateral)
• Isolated premature pubarche
..Let’s sum it up
Normal Puberty
• Puberty is age of transition from childhood to adulthood with full
maturation at a proper genetically determined age.
• Pubertal changes starts at an earlier stages in girls than boys. (10.5 vs
11.5 years)
• Pubertal changes occurs due to activation of hypothalamic GnRH pulse
generator under the influence of central and peripheral mediators as
leptin.
• Tanner staging is used to describe pubertal breast and pubic changes.
..Let’s sum it up
Pubertal Abnormalities
• Pubertal abnormalities can be:
1. Delayed puberty
2. Precocious puberty:
A. Isosexual:
I. True (central)
II. False (peripheral)
B. Herterosexual (Contrasexual)
C. Isolated (incomplete)
3. Others (DONOT FORGET):
A. Congenital
B. Inflammatory
C. Neoplastic
D. Traumatic
SUGGESTED TEXTBOOKS
1. Essentials in Obst. &Gyn.
2. Williams in Gynaecology.
Ob/Gyn .
Thank You
Ob/Gyn .
