Gynecology [PUBERTY]

Precocious Puberty
Puberty is a series of events that culminates with menarche. This Hypothalamus
signifies the maturation of the HPO axis and termination of GnR NONE Development Normal Age
growth, fusion of the growth plates. If she bleeds then she’s H Breast 8 years
done growing. It’s a good thing to catch that condition before it Anterior Pituitary Axillary Hair 9 years
happens. Therefore, since secondary sex characteristics develop Growth Spurt 10 years
FSH/LH Tumor Menarche 11 years
first (before the growth plates fuse), we use that as a marker for
disease. Development of axillary hair or breast buds < 8 years old Ovary
warrants investigation (there is a trend to earlier age, 7 for girls, Estrogen Cyst
6 for African American girls, but still use the traditional age of 8). Progesterone Granulosa-Theca
The first step is to determine bone age with a Wrist X-ray. If it’s Endometrium BLEED
2 years greater than her chronological age it’s positive. The next DHEAS Adrenal Tumor
step is a GnRH stimulation test. If it stimulates LH, she has Testosterone CAH
central precocious puberty and needs to be evaluated with MRI Adrenals
to rule out a tumor. If there’s a tumor, remove it. If no tumor, it’s
considered constitutional (i.e. idiopathic) and she gets Breast Buds or Axillary Hair at < 8 years old
continuous leuprolide for 2-4 years. But if the stim test was
negative, she has estrogen coming from somewhere else; the
source has to be found. Get an ultrasound of the ovaries (cysts) Wrist X-ray
and adrenals (CAH, Tumor) while getting estradiol (ovarian),
DHEAS (adrenal), and 17-OH-Progesterone (CAH). Resect
tumors, treat CAH with corticosteroids, and leave cysts alone. GnRH Stimulation Test

Delayed Puberty LH ↑ LH no change

The definition of delayed puberty is absence of secondary sex
characteristics by age 13 or the absence of menses by 15. The Central Peripheral
majority of cases are constitutional delay (normal, it’s going to
happen, it just hasn’t yet). But the other causes need to be broken
down into hypergonadotropic hypogonadism (the axis is active MRI U/S Adrenal
and is producing FSH and LH but the ovaries aren’t listening) and U/S Abdomen
hypogonadotropic hypogonadism (the pituitary hasn’t turned on + - Testosterone
the Axis, so the ovaries are just waiting for the signal). DHEAS
Tumor Constitutional 17-OH-Progereterone
The workup beings with a bone age and assessment of Resection Continuous
biochemical state: FSH and LH. Leuprolide

If the FSH and LH are elevated, the problem is with the ovaries. Tumor CAH Cyst
This is going to be primary ovarian failure, Turner syndrome, and
resistant ovarian syndrome. The diagnosis is primarily made with Resection Steroids Reassurance
a karyotype. See primary amenorrhea for more details.

If the FSH and LH are normal, unfortunately the door is wide Delayed Puberty
open. Start by ruling out common diseases and chronic diseases
with TSH, FT4, Prolactin, ESR, and LFTs. An MRI is the last Bone age,
step. Consider things like CAH, systemic illness, Hypothyroid, ↑FSH, ↑LH FSH, LH Normal
bulimia, and pituitary disorders.
Hypergonadotropic Hypogonadotropic
If the workup is negative, it’s constitutional. The most important
thing is to look at family history and reassure if the girl’s parents
Karyotype
had a late puberty. Growth Hormone is never the right answer. Prolactin
TSH, T4
CBC
We talk more about the specific diseases in primary Found the disease ESR
amenorrhea. The workup and framework is provided here. LFTs
Treat the disease MRI

Constitutional Delay

Wait

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