UNIT 3: A review of the applied physiology of

female reproductive system - Puberty,

Menstruation and its disorders including,
amenorrhea, dysmenorrhea, menorrhagia,
metrorrhagia, epimenorrhoea, AUB,
Postmenopausal bleeding and menopause with
related ailments and its scope and
management in Homoeopathy and integrate
wherever necessary with other disciplines.
PUBERTY
PUBERTY:
Definition:
1. Puberty in girls is the period, which links childhood to
adulthood.
2. It is the period of gradual development of secondary sexual
characters.
3. There are profound biological, morphological, and
psychological changes that lead to full sexual maturity and
eventually fertility
The Profound changes occurs are
BIOLOGICAL,
MORPHOLOGICAL and
PSYCHOLOGICAL changes which lead to
full maturity and eventually fertility.
The development of secondary sex traits and an increase in size are the
two most obvious changes that occur throughout puberty.
Alterations in body composition, fertility, and most body systems
(such as bone, with accelerated growth and mineralization), as well as
the development of the brain and cardiovascular system, are all
profound changes (with greater aerobic power reserve,
electrocardiographic changes, and blood pressure changes).
The bodies of both boys and girls, grow taller and resemble adult
bodies the most during puberty.
Morphological changes:
1. As described by Tanner and Marshall, five important physical
changes are evident during puberty.
2. These are breast, pubic and axillary hair growth, growth in
height, and menstruation.
3. Most of the changes occur gradually but only the menarche can
be dated.
4. Moreover, there is a lot of variations in the timing of the events.
5. The most common order is beginning of the growth spurt →
breast budding (thelarche) → pubic and axillary hair growth
(adrenarche) →peak growth in height → menstruation
(menarche).
MORPHOLOGICAL
CHANGES Breast Pubic and
Axillary hair Height
Menstruation Completed
between the age of 10 to 16
years
MENARCHE
1. First menstruation in life 10 –
16 years 
2. peak time 13 years
3. First period is usually anovular
4. Ovulation may be irregular
during variable periods
following menarche and may
take 2 years for regular
ovulation to occur
5. GROWTH Increase in the height
due to the hormones ( GH,
estrogen, insulin like growth
factor)
 ENDOCRINOLOGY IN PUBERTY

1. The levels of gonadal steroids and gonadotropins are low until the
age of 6–8 years. This is mainly due to the negative feedback effect
of estrogen to the hypothalamic pituitary system (Gonadostat).
2. The gonadostat remains very sensitive (6–15 times) to the negative
feedback effect, even though the level of estradiol is very low
during that time.
3. As puberty approaches this negative feedback effect of estrogen is
gradually lost
Hormones of hypothalamous
Hypothalamopituitary gonadal axis
• The GnRH pulses from hypothalamus results in pulsatile gonadotropin
secretion (first during the night then by the day time).
• GnRH → FSH, LH → Estradiol
• The tonic and episodic secretion of gonadotropins in prepubertal
period is gradually changed to one of cyclic release in postpubertal
period
Thyroid gland plays an active role in the hypothalamopituitary-gonadal
axis.
♦ Adrenal glands (Adrenarche) increase their activity of sex steroid
synthesis (androstenedione, DHA, DHAS) from about 7 years of age.
Increased sebum formation, pubic and axillary hair and change in voice are
primarily due to adrenal androgen production.
♦ Gonadarche: Increased amplitude and frequency of GnRH → ↑ secretion
of FSH and lH → ovarian follicular development → ↑ estrogen.
Gonadal estrogen is responsible for the development of uterus, vagina,
vulva and also the breasts
♦ Leptin, a peptide, secreted in the adipose tissue is also involved in
pubertal changes and menarche
Menarche
1. The onset of first menstruation in life is called menarche. It may occur
anywhere between 10 and 16 years, the peak time being 13 years.
2. There is endometrial proliferation due to ovarian estrogen but when the
level drops temporarily, the endometrium sheds and bleeding is visible.
3. It denotes an intact hypothalamo-pituitary-ovarian axis, functioning
ovaries, presence of responsive endometrium to the endogenous ovarian
steroids and the presence of a patent uterovaginal canal.
4. The first period is usually anovular. The ovulation may be irregular for a
variable period following menarche and may take about 2 years for
regular ovulation to occur.
5. The menses may be irregular to start with.
1. The vaginal changes are more pronounced: A few layers of thin
epithelium in a child become stratified epithelium of many layers. The
cells are rich in glycogen due to estrogen.
2. Doderlein’s bacilli appear which convert glycogen into lactic acid; the
vaginal pH becomes acidic, ranging between 4 and 5.
3. The vulva is more reactive to steroid hormones.
4. The mons pubis and the labia minora increase in size.
5. Breast changes are pronounced: Under the influence of estrogen, there
is marked proliferation of duct systems and deposition of fat. The breast
becomes prominent and round. Under the influence of progesterone,
the development of acini increases considerably.
COMMON DISORDERS OF PUBERTY:
CPrecocious puberty
1. Delayed puberty
2. Menstrual abnormalities (amenorrhea, meno_x0002_rrhagia,
dysmenorrhea)
3. Others (infection, neoplasm, hirsutism, etc.)
 CONDITIONS AND DISORDERS:
1. Nutritional deficiencies, including eating disorders.
2. Environmental exposure to hormones.
3. Tumors affecting hormone production.
4. Genetic conditions.
 TANNER PUBERTIAL STAGES:
1. Tanner Staging, also known as Sexual Maturity Rating (SMR),
is a classification system that healthcare providers use to
document and track the development of secondary sex
characteristics of children during puberty. It’s a tool that
outlines the stages of puberty for your child and when they’re
likely to occur.
2. It’s important to note that there’s a wide range of “normal” in
the timing and stages of puberty. Every child develops at their
own rate. Tanner Staging functions as a general guide, not a
strict rule.
Stage 1 is prepubertal. In this stage, girls haven’t experienced any visible
changes. But their adrenal glands are maturing and their ovaries are
growing.
In Stage 2, physical changes begin. Between the ages of 8 and 13, girls
typically experience:
1. Budding breasts and enlargement of areolas (pigmented area around
their nipple).
2. Scant pubic hair along their labia.
3. Height increases by about 2 3/4 inches per year.
4. Enlargement of their clitoris.
5. Growth of their uterus.
6. They may start having body odor. Deodorant can help.
In Stage 3, physical changes speed up. Between the ages of 9 and 14:
1. Breasts continue budding.
2. Armpit (axillary) hair begins to grow and pubic hair continues to grow. Pubic
hair is coarse, curly and forms in the shape of an upside-down triangle.
3. A growth spurt of more than 3 inches per year occurs.
4. Oilier skin leads to acne.
In Stage 4, puberty hits full stride. Between the ages of 10 and 15:
5. Breasts continue growing, and their areola (the part that’s red or darker at the
nipple) forms a separate mound over the mound of breast tissue.
6. Pubic hair is still in a triangle, and there are now too many hairs to count.
7. Growth may continue at the rate of about 2 3/4 inches per year.
8. Acne may continue.
1. Periods (menstruation) begin in Stage 4, typically around age 12 (usually
around the same age their biological mother’s and sisters’ periods
began). Some girls start earlier or later than this age. Periods usually start
around two years after breasts start to bud or pubic hair starts to grow. If
periods haven’t started three years after puberty began, make an
appointment with your child’s healthcare provider.
2. Stage 5 is the final phase:Development typically ends in this stage. Girls
reach physical adulthood. Pubic hair may extend out to their thighs, and
some girls may have a line of hair up to their belly button. Most girls
reach their peak height by age 16, but some may continue growing
through age 20. Some girls never have pubic hair reach Tanner Stage 5;
that may be their “normal.”
Tanner stages for boys
1. There are separate Tanner stages for changes in genitalia and
pubic hair. Other physical changes happen, too. For parents, the
Tanner stages can serve as an excellent guide to the changes you
can expect to see in your son. There are five stages of puberty for
boys.
2. Stage 1 is prepubertal: In this stage, boys haven’t experienced
any visible changes, but their adrenal glands are maturing.
3. In Stage 2, physical changes begin. Between the ages of 9 and 14,
boys typically begin to experience:
1. Genital development (growth of their testicles and scrotum).
2. Growth of sparse hair around their penis and under their arms.
3. An increase in height (typically about 2 to 2 1/2 inches per year),
which could bring growing pains.
4. Changes in body composition with a decrease in body fat (adipose
tissue).
5. They may start to have body odor and may need deodorant.
In Stage 3, physical changes speed up. Between the ages of 10 and 16 years,
boys experience:
1. Continued growth of their penis and testicles. Nocturnal emission (“wet
dreams”) may happen as well.
2. Darkening, coarsening pubic hair in the shape of a triangle in their genital
area.
3. Continued increase in height (about 2 3/4 to just over 3 inches per year).
4. More sweating, which can lead to body odor.
5. Vocal changes (and cracking in the process).
6. Increased muscle mass.
7. Some breast development, or gynecomastia, occurs in about 50% of all boys
in Stage 3. But it typically resolves by the end of puberty. It’s most common
between the ages of 11 and 15 years. If this becomes an issue physically or
socially, you should talk with your child’s healthcare provider.
In Stage 4, puberty hits full stride. Between the ages of 11 and 16 years, boys experience:
1. Growth in penis size and darkening of the skin on their scrotum and testicles. Red ridges
on their testicles called rugae will begin to develop.
2. Body hair growth that reaches adult levels. Pubic hair remains in a coarse triangle.
3. A peak growth spurt that averages nearly 4 inches per year.
4. Development of acne.
5. Continued cracking of their voice.
Stage 5 is the final phase. Puberty ends in this stage. Boys finish their growth and physical
development.
6. Many may not develop facial hair until this step in the process. Pubic hair may extend
out to their thighs, and some boys may have a line of hair up to their belly button. Most
boys finish growing by age 17, but some may continue growing through their early 20s.
PRECOCIOUS PUBERTY:
DEFN:
1. The term precocious puberty is reserved for girls who
exhibit any secondary sex characteristics before the age of
8 or menstruate before the age of 10.
2. Precocious puberty may be isosexual where the features
are due to excess production of estrogen. It may be
heterosexual where features are due to excess production
of androgen (from ovarian and adrenal neoplasm)
Precocious puberty is when children's bodies begin to change into adult
bodies too soon. This change is known as puberty. Most of the time,
puberty occurs after age 8 in girls and after age 9 in boys. However,
Black, Hispanic, and Native American children might naturally reach
puberty earlier. Precocious puberty is when puberty begins too early
for the child who's going through it.
In puberty, muscles and bones grow quickly. Bodies change shape and
size. And the body becomes able to have children.
The cause of precocious puberty often can't be found. Rarely, certain
conditions, such as infections, hormone issues, tumors, brain issues or
injuries, may cause precocious puberty. Treatment for precocious
puberty usually includes medicines to delay puberty.
ETIOPATHOLOGY
constitutional :
1. It is due to premature activation of hypothalamo -pituitary
ovarian axis.
2. There is secretion of gonado tropins and gonadal steroids
due to premature release of GnRH.
3. Bone maturation is accelerated, leading to premature
closure of the epiphysis and curtailed stature.
4. If menstruation occurs, they may be ovulatory. The changes
in puberty progress in an orderly sequence.
Premature thelarche
1. It is the isolated development of breast tissue before the age of 8
and commonly between 2 and 4 years of age.
2. Either one or both the breasts may be enlarged
3. There is no other feature of precocious puberty.
4. It generally requires no treatment.
Premature pubarche
Premature pubarche is isolated development of axillary and or pubic
hair prior to the age of 8 without other signs of precocious puberty.
Premature menarche:
Premature menarche is an isolated event of
cyclic vaginal bleeding without any other signs of
secondary sexual development
Precocious puberty :
Constitutional type is the commonest one but the rare one is to
be kept in mind.
The diagnosis is made by:
♦ History of early menarche of mother and sisters
♦ The pubertal changes occur in orderly sequence
♦ Tanner stages
♦ No cause could be detected.
The basic investigations, to confirm or to exclude some pathologic lesions,
include:
♦ X-ray hand and wrist (non-dominant) for bone age. Acceleration of growth
is one of the earliest clinical features of precocious puberty
♦ Pelvic sonography to exclude ovarian pathology
♦ Skull X-ray, CT scan, or MRI brain—to exclude intracranial lesion
♦ Serum hCG, FSH, lH
♦ Thyroid profile (TSH, T4)
♦ Serum estradiol, testosterone, 17 OH proge_x0002_sterone,
dehydroepiandrosterone (DHEA).
♦ Electroencephalogram.
Premature thelarche
♦ Somatic growth pattern is not accelerated
♦ Bone age is not advanced
♦ Nipple development is absent
♦ Vaginal smear shows negative estrogen effect
 Causes:
1. The causes of precocious puberty in some children, it's helpful to
know what happens at puberty. The brain starts the process by
making a hormone called gonadotropin-releasing hormone
(GnRH).
2. When this hormone reaches the small, bean-shaped gland at the
base of the brain, called the pituitary gland, it leads to more
estrogen in the ovaries and more testosterone in the testicles.
Estrogen makes female sex traits. Testosterone makes male sex
traits.
3. There are two types of precocious puberty: central precocious
puberty and peripheral precocious puberty.