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characteristics y Adolescent growth spurt y Attainment of fertility Pubertal development takes place over a period of 4 years Tanner staging of puberty (sexual maturity rating SMR) Female Male Breast maturation Genital development Pubic hair growth Pubic hair growth Physical signs of puberty Marshall & Tanner (Fairly regular sequence of events between ages of 10-16 y/o in girls) Growth spurt Breast growth (thelarche) Pubic hair (pubarche) Axillary hair (adrenarche) Menstruation (menarche) Growth Spurt IGF-1, GH Peak serum IGF-1 reached about 1 year after peak growth velocity (remain above normal adult lvl up to 4 years thereafter) Sex steroids, either y Indirectly through GH y Directly stimulate IGF-1 production in cartilage Estrogen y Stimulate maturation of chondrocytes y Stimulate maturation of osteoblasts (maturation of bone age) y Lead to epiphyseal fusion
Pubertal Growth Spurt Girls Boys Begins in early pubertal Occurs toward end of puberty Completed by menarche (2 years older than in girls) Average difference in height (male, female) = 10 cm (2 additional years of prepubertal growth)
Changes in Body Composition Prepubertal (boys, girls) start with equal y Lean body mass y Skeletal mass y Body fat Matured Men Lead body mass Skeletal mass Muscle mass
Women Body fat
Male Changes Testes size (> 2.5cm) (equivalent to testicular volume > 4ml) Due to seminiferous tubular development (FSH stimulation) Pubic hair development (due to adrenal, testicular androgens) Appearance of spermatozoa in early morning urine (spermache) at 13.4 y/o Stages of Pubic Hairs Development (Boys) Stage Description 1 Preadolescent, no pubic hair 2 Sparse, long pubic hair, chiefly at base of penis 3 Hair darker, coarser. Hair spread sparsely over pubic junction 4 Hair adult-type, but area covered is less than adult 5 Adult hair texture, quantity Hair is distributed as inverse triangle of feminine pattern Spread occurred to medial surface of thighs
Female Changes Growth velocity Breast development y Stimulated by ovarian estrogen y Size, shape determined by genetic, nutritional factors Estrogen actions y Enlargement of labia minora, majora y Dulling of vaginal mucosa (from prepubertal reddish hue) y Production of clear/ slight whitish vaginal secretion (prior to menarche) y Change in uterine size, shape y Change in ovarian size Stages of Breast Development (Girls) Stage Description 1 Preadolescent (only papilla elevated) 2 Breast bud, papilla elevated Small breast mound present Areola diameter is enlarged 3 Enlargement of breast mound Palpable glandular tissue No separation of their contours 4 Areola, papilla project to form 2° mould (above breast level) 5 Adult breast Only papilla projects
Stages of Genital Development (Boys) Stage Description 1 Preadolescent 2 Scrotum, testes enlarge Change in scrotal skin texture No enlargement of penis 3 Growth of penis in length Further growth of testes, scrotum 4 Growth of penis in legth, girth Further enlargement of testes, scrotum Darkening of scrotal skin 5 Adult-sized genitalia
Stages of Pubic Hair Development (Girls) Stage Description 1 Preadolescent (no pubic hair) 2 Slight growth of fine pubic hair 3 Hair darker, coiled, denser 4 Adult-type hair (area covered is less than adult area) 5 Adult-type hair (with triangular-shaped distribution)
Pubertal Stage (Tanner)
Adrenarche Stage of maturation of adrenal cortex Adrenal androgens (dehydroepiandrosterone, DHEA sulphate) Starts around y Girls 6-7 y/o y Boys 7-8 y/o y Continued rise in secretion (of adrenal androgens) until late puberty Functions y Promote pubic hair growth y Promote axillary hair growth Age at adrenarche does not significantly influence age at gonadarche Mechanisms of Puberty Gonadostat Hypothesis -ve feedback regulation of gonadotropins operate at threshold (sensitive to low steroid levels) At puberty, threshold (less sensitive) LH, FSH levels Puberty involves a change in set point (but not driving force for puberty) Timing of Puberty Genetic/ Environment Genetic 50% variation of timing of puberty Association mother, daughters Hypothalamic Maturation Hypothesis Maturation of hypothalamus GnRH is driving force for puberty
Hormones & Puberty Hypothalamus stimulates pituitary gland y GH causes growth spurt y Ovaries, testes release gonadotrophins (sex hormones) Male testosterone Female estrogen, progesterone
Hypothalamus-Pituitary-Gonadal Axis Fetal (1-2 years) GnRH pulse Active generator LH, FSH Sex Steroids - Girls E2 Sex Steroids - Boys E2 (until birth) T
Environment Body fat (weight) Delay puberty vegetarian diet ( protein, plant fiber)
Prepubertal Frequency Amplitude
Ovulation, Menarche Last stage of HPG development onset of +ve feedback (ovulation, menarche) Estrogen (after mid puberty) stimulate, suppress gonadotropin secretion GnRH Stimulate ovary to produce estrogen LH (mid cycle) Ovulation st 90% of menstrual cycles anovulatory in 1 year after menarche 4-5 years after menarche, <20% anovulatory cycles Menstrual Cycle, Uterine Endometrial Responses
Physical activity Exercise (delay puberty) Amplified by body fat mass Physical illness Chronic illness (delay puberty) Environmental chemical/ drugs Pharmaceutical sex steroids (early puberty) Polychlorinated biphenyls (PCBs) (bind, trigger ER) Stress, Social Factors Stress (early puberty) Wartime (nutrition) (delay puberty)
Abnormalities of Puberty Delayed Puberty Girl 13 y/o Boy 14 y/o No signs of pubertal development (falls > 2.5SD below mean) Sex Boys Genital stage (Tanner) 1 after 13.7 yrs (childlike phallus, testicular V < 1.5ml) Girls Breast stage (Tanner) 1 after 13.4 yrs (no glandular tissue) Pubic hair stage 1 (>14.1 yrs) Failure to menstruate before 16 y/o > 5 yrs from initiation of breast growth to menarche Sexual maturity ratings lag in expected durations (breast, pubic hair stages) Precocious Puberty Appearance of secondary sexual development (>2.5 SD below mean at onset of puberty) y Girls <6-7 y/o y Boys < 9 y/o Types True Precocious Puberty Pseudoprecocious Puberty Sex glands (ovaries, testes) mature Outward appearance becomes more adult Child s outward appearance becomes more adult Sex glands remain immature Pubic hair grows Child s body shape changes 2-5X more common in girls (than boys)
> 5 yrs from initiation to completion of genital growth Sexual maturity ratings lag in expected durations (genital, pubic hair stages) Causes Physiological hypogonadotrophic hypogonadism (constitutional delay of growth, puberty) Malabsorption celiac/ inflammatory bowel disease Underweight dieting, anorexia nervosa, over-exercise Chronic illness asthma, malignancy, -thallasaemia major, cranial trauma/ tumor/ irradiation Congenital deficiency (rare) y Kallmann s syndrome y Prader-Willi syndrome Hypergonadotrophic hypogonadism (ovaries do not respond) y Turner syndrome (XO) y Ovarian damage irradiation, chemotherapy y Autoimmune addisons, vitiligo, hypothyroid y Rare CAH - 17 hydroxylase deficiency (21 hydroxylase causes virilisation/ salt wasting at birth)
Gonadotrophin Gonadotrophin-dependent (true/ central) Idiopathic Family history Overweight/ obese 74% of girls Intra-cranial lesions y Tumours y Hydrocephalus y CNS malformations y Irradiation y Trauma Gonadotrophin secreting tumours
Gonadotrophin-independent CAH Sex steroid secreting tumours y Adrenal, ovarian y Peutz-Jeghers syndrome McCune-Albright syndrome y Irregular areas of skin pigmentation y Polyostotic fibrous dysplasia y Ovarian functional cysts (due to autonomous ovarian activation) (absent nocturnal pulses) Gonadotropin secreting ovarian/ adrenal tumours Estrogen ingestion
Classification Hypogonadotropic hypogonadism CNS disorders tumours Isolated gonadotropin deficiency Kallman s syndrome Gonadotropin deficiency (with normal sense of smell) Multiple pituitary hormonal def. Prader-Willi syndrome Laurence-Moon Bardet-biedl syndrome Chronic disease Weight Anorexia nervosa Physical activity Hypothyroidism
Hypergonadotropic hypogonadism Male Klinefelter syndrome Other primary testicular failure Cryptorchism Female Turner syndrome Other primary ovarian failure Pseudo-Turner syndrome Noonan syndrome XX, XY gonadal dysgenesis
Classifcation Central (complete/ true) precocious puberty y Constitutional y Idiopathic y CNS disorders y Following androgen exposure Incomplete precocious puberty y Male gonadotrphin secreting tumours, excessive androgen production, premature leydig cell maturation y Female ovarian cysts, estrogen secreting neoplasm y Both sexes severe hypothyroidism, McCune-Albright syndrome Sexual precocity due to gonadotrphin/ sex steroid exposure Variation in pubertal development y Premature thelarche y Premature menarche y Premature pubarche y Adolescent gynaecomastia
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