Puberty

GROUP D

Supervised by: Dr Khairulnisa

Table of Contents
INTRODUCTION PRECOCIOUS
PUBERTY

PHYSICAL DELAYED
CHANGES PUBERTY

HORMONAL DISORDERS OF SEXUAL

CHANGES DEVELOPMENT

PSYCHOLOGICAL
ISLAMIZATION
CHANGES
 Muhammad Irfan Hakim Bin Amri
2111229

Introduction
The maturation process that leads to a female being
sexually developed and able to reproduce.
Through
the release of sex hormones
development of secondary traits
maturation of reproductive organs
onset of menstruation

Occurrence of menarche: 9-16 years old

Average age: 12.8 years old

Precocious vs delayed pubirty?

 Presentation overview

Factors :
Nutritional and genaral health
Genetics (family,ethnicity)
Environment (exposure to chemicals, socioeconomic
background, physical and psychological stresses)

Physical changes?
Hormonal changes?
Psychological changes?
Pathologies?
 Physical
Changes
Amiratul Hasanah Binti Mohd Hakimi (2116028)
 Physical Changes
The physical changes occurring in puberty are breast
development (thelarche), pubic and axillary hair growth
(adrenarche), growth spurt and onset of menstruation
(menarche)
Thelarche
Adrenarche

dependent of adrenal androgen hormone,

usually after thelarche Tanner staging
 rapid changes in body features; height and weight
GROWTH SPURT average 9-10 years for females, but varies between individuals
occurs in different stages, adolescents stage is the most prominent one

the first occurence of menstruation

occurs between age 10-16, with mean age of 12.4 years
MENARCHE tends to be painless, first cycles usually anovulatory with varied length and flow
signals the reproductive abilites, occurs with ongoing secondary sexual characteristic
development
 Hormonal
changes
Amiratul Hasanah Binti Mohd Hakimi (2116028)
 Hormonal changes
Involve maturation of hypothalamus and secretion of releasing hormones
Internal urogenital system and external genital organ remain inactive during
preadolescent

Gonadarche Adrenarche

activation of the gonads by the

Adrenarche is the increase in
pituitary hormones follicle-
production of androgens by the
stimulating hormone (FSH) and
adrenal cortex
luteinizing hormone (LH)
Decrease repression of ‘gonadostat’
Gradual amplification of GnRH-gonadotropin
interaction
Activation of HPG axis

increase in the pulsatile secretion of gonadotropin-

releasing hormone (GnRH) from the hypothalamus.
GnRH stimulates the gonadotroph cells of the anterior
pituitary gland to secrete follicle-stimulating hormone
(FSH) and luteinizing hormone (LH), with increases in
frequency and amplitude of both FSH and LH pulses (but
more so the latter), which in turn stimulate sex
steroidogenesis and eventually gametogenesis in the
gonads.
 Hypothalamus
-> Vasopressin
-> Corticotropin- releasing hormone (CRH)
Anterior pituitary gland -> Adrenocorticotropic
hormone (ACTH)
Maturation of adrenal gland

when the zona reticularis of the adrenal gland begins to

synthesize the adrenal androgens dehydroepiandrosterone
(DHEA), androstenedione, and 11-ketotestosterone.
induce androgenic changes including growth of pubic and
axillary hair, maturation of the apocrine sweat glands
(leading to adult-type body odor), and development of
acne.
 Psychosocial
Changes
Muhammad Farid Bin Hisham
(2110735)
References : https://www.researchgate.net/publication/5280557_Psychosocial_Development_and_Puberty
 Independence

Early Start to have different interest and pull away from family activities
Adolescense Crave privacy and want to control personal information

Rebellious and may act hostile to parents

Middle Wanting independence from adult supervision
Adolescense Adults may be frustrated at their lack of self-control
The stereotypical teenager

Family comfortable with teen’s decision making and individuality

Late
Teen gains confidence and mature enough to seek adive from parents for
Adolescense
decision making
 Body Image

Early Going through changes in their physical body

Adolescense Worrieed of being abnormal and compare to others

Middle More accustomed with their body

Adolescense Dieting, maintaining hygiene, body care and trying new clothing became
important in gaining confidence of their body

Late
Comfortable with changes of body
Adolescense
 Peer relations

Early starting to turn to peers for guidance as they pull away from family
Adolescense

Middle Peer groups becomes dominant in influencing the teen

Adolescense Fear of being excluded so tend to follow their group
Wrong peers may lead to risky behavior

Late
Peer relationships become less intense
Adolescense
 Precocious
Puberty
Aqif Ilhan Bin Khairul Hazman
(2116401)

References : 10 Teachers, UpToDate, Medscape, RCOG

 Definition
Onset of puberty before the age of 8 in a girl or 9 in a
boy

Classifications

Central Precocious Peripheral Precocity Benign or

Puberty (CCP) Nonprogressive Pubertal
Gonadotrophin
Variants
Gonadotrophin independent
dependent Always
pathological
Etiologies of Precocious Puberty
How to Diagnose?
 Managements
GnRH Agonist Therapy
depot Leuprolide acetate, Histrelin implants, depot triptorelin
Possible A/E :
Central
transient pain and local reactions at the injection sites & sterile abscess formation
Precocious (Uncommon)
Puberty (CPP) Systemic hypersensitivity (<4%)
Pseudotumor cerebri (idiopathic intracranial hypertension) - rare
Risk of prolonged QT interval

Surgery
Peripheral McCune Albright Syndrome (MAS)
Precocious Aromatase inhibition (Letrozole)
Oestrogen receptor blockade (Fulvestrant)
Puberty

Benign
Clinical reexamination and follow-up
Variants
 Delayed
Puberty
Noorshafikah Alia Binti Romaina
(2115402)

References : 10 Teachers, NCBI,MSD Manual

 Definition
No sign of secondary sexual characteristics by the age of
14 years

Central defect Failure of gonadal

(Hypogonadotrophic function
Hypogonadism) (Hypergonadotropic
Hypogonadism)
 Central defect Failure of gonadal function
(Hypogonadotrophic
Hypogonadism)
Constitutional
General:
1.anorexia nervosa
2. excessive excercise
3. chronic illness
4.pituitary tumour
Congenital :
1.Kalmans Syndrome
Acquired
1.chemotherapy or trauma
(Hypergonadotropic
Hypogonadism)
Congenital :
1.Turner syndrome
2. XX gonadal dysgenesis
3. premature ovarian
failure
Acquired
1.chemotherapy or trauma
 Diagnose

medical history and physical exam

any history of chemotherapy/radiotherapy

any blurry vision or headache
any family history of delayed puberty
the history of eating disorder or excess excercise
fatigue/weight loss

BMI
assess tanner staging
 Diagnose
In addition to a complete medical history and physical
exam, diagnosis of delayed puberty may include:

1. Blood Test
serum LH, FSH, estradiol in females(elevated in hypergonadotrophic
hypogonadism)
prolactin(brain tumour secrete prolactin)
2. Karyotype(Turner, Klinefelter, Kallman’s syndrome)
3. Abdominal Ultrasound(absent uterus need chromosomal evaluation)
4. XRay (remaining growth potential)
5. MRI (in the case of suspicious for brain tumour)
Management
 Disorders of Sex
Development
Siti Maisarah Binti Anuar
(2118826)
Izyani syahirah binti alfian
(2119490)
References : DISORDERS OF SEX DEVELOPMENT - PMC.pdf, https://youtu.be/-UrwHPXIZdY?feature=shared,
https://youtu.be/MrXIHQ11gD4?feature=shared, https://youtu.be/CCBQIpg5yLs?feature=shared,
https://www.healthychildren.org/English/health-issues/conditions/genitourinary-tract/Pages/Explaining-Disorders-of-Sex-Development-
Intersexuality.aspx#:~:text=What%20is%20a%20Disorder%20of,were%20called%20%22intersex%22%20conditions.
 What is DSD?
Disorders of sexual development (DSD) a group of congenital conditions associated
with atypical development of internal and external genital structures.
Causes: can be associated with abnormality in genes, developmental problems , and
deficiency @ excess of hormones.
1.XX DSD- 21-hydroxylase deficiency
2.XY DSD -
a) AIS
b) Swyer Syndrome
c) 5 alpha-reductase deficiency
3. Sex Chromosome DSD
4. Mullerian Anomalies
1. XX DSD
 21-hydroxylase deficiency
other CAH :
most common form of virilizing congenital adrenal hyperplasia 11 - hydroxylase
due to mutations in the 21-hydroxylase (CYP21A2) gene deficiency
17 alpha hydroxylase
deficiency
lab findings - blood serum test

male precocious puberty (under 9 y/o)

 2. XY DSD
Androgen Insensivity Syndrome (AIS)

internal organ is male (have testis but not descend), external organ is female.
 Complete Gonadal Dysgenesis (Swyer Syndrome)
individuals with 46, XY karyotype
due to mutations of SRY gene (of Y chromosome), MAP3K1 gene etc
no gonadal differentiation bcs SRY is inactive > bipotential gonad cannot develop into
testis > no male gonad(testis) to produce testosterone and AMH > develop female
reproductive structures (uterus, tubes, cervix, vagina) instead.
+ no XX chromosome so cannot develop into ovaries either > streak gonads.
DX
AMH inhibit dev of tubes, uterus, cervix, upper vagina

1. Ultrasound ; missing ovaries

2. karyotype test: 46, XY chromosome
3. hormone testing : low testosterone
Tx
fetus cannot respond testosterone > Wolffian structure (epididymis,
vas deferens, seminal vesicles) cannot form 1. HRT: to induce menstruation + develop 2ndary
female characteristics + increase bone density
DIFFERENCES BETWEEN SWYER AND AIS
 5 alpha reductase deficiency
TX:
DHT ; responsible for depends on desirable
development of male gender:
external genitalia 1. HRT
2. surgical procedures
to restore external
genitalia
(vaginoplasty)
 3.SEX CHROMOSOME DSD
A)TURNER SYNDROME
-A condition affecting female, due to partially or completely missing sex
chromosome.
A girl with Turner syndrome only has 1 normal X sex chromosome, (44+XO)
What are 3 characteristics of Turner syndrome?
-Features of Turner syndrome may include a short stature, a short neck with a webbed
appearance, low hairline at the back of the neck, low-set ears, hands and feet that are
swollen or puffy at birth, and soft nails that turn upward.
LAB INVESTIGATIONS TREATMENT
prenatal- -no cure
- ultrasound shows fetal hydrops, cystic -can improve physical development
hygroma, or cardiac defects (growth hormone theraphy and estrogen
after birth therapy)
-with karyotype testing.
https://www.google.com/search?client=avast-a-
3&q=turner+syndrome+lab+findings&oq=TURNER+SYNDROME
+&gs_lcrp=EgZjaHJvbWUqBggAEEUYOzIGCAAQRRg7MgYIAR
BFGDsyBAgCEAAyBAgDEAAyBAgEEAAyBAgFEAAyBAgGEAAy
BAgHEADSAQg0OTEyajBqMagCALACAA&ie=UTF-8
 B)KLINEFELTER SYNDROME
- where boys and men are born with an extra X chromosome(44+xxy).

-Klinefelter syndrome may adversely affect testicular growth, resulting in

smaller than normal testicles, which can lead to lower production of
testosterone. The syndrome may also cause reduced muscle mass, reduced
body and facial hair, and enlarged breast tissue,decreased libido

investigation
treatment
karyotype analysis. A blood sample is sent
-testosterone replacement therapy
to the lab to check the shape and number of
chromosomes. -breast tissue removal

https://www.mayoclinic.org/diseases-conditions/klinefelter-syndrome/diagnosis-
treatment/drc-20353954
c)triple XXX syndrome
-Trisomy X, also called triple X syndrome or 47,XXX, is characterized by the
presence of an additional X chromosome in each of a female's cells.

PRESENTATION
1)very long leg and above average height
2)early ovarian failure and fertility problem
3)developmental,psychological and learning problem
4)malformed kidneys and ovaries
5)hypothyroidism and autoimmune condition

treatment
investigation
-no cure
karyotyping
-depends on signs and symptoms
 4.MULLERIAN ANOMALIES
A)MULLERIAN OBSTRUCTION
-Failure of complete canalization of the mullerian structures which can lead to
menstrual obstruction
-PRESENTATION:imperforate hymen with Increasing abdominal pain in early
adolescence(10-14),
haematocolpus

TREATMENT
1)surgical incision of hymen
2)drainage of retained blood
B)MULLERIAN DUPLICATION

-It may be complete duplication of the uterus,cervix and vagina

-may also present a midline uterine septum
investigation-ULTRASOUND
Treatment-SURGERY
C)MULLERIAN AGENESIS
-Mullerian system does not develop resulting in absent or rudimentary uterus
and upper vagina
-known as Rokitansky-syndrome
common presentation;
1)primary amenorrhea
2)normal pubertal development

investigation TREATMENT
Creation of
1)ultrasound:presence of
a vagina
ovaries,but no functioning uterus
will be present
BLIND POUCH VAGINA
ISLAMIZATION
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