Female Puberty

Topic #1
By:

Alex Qader
 Puberty
• What is it?
– Development of secondary
sexual characteristics and
the acquisition of
reproductive capability
• Onset
– Genetic factors / race
– Geographic location
– Nutritional status
– Excessive exercise
• >48Kg
– Psychological factors
Endocrinologic Changes of Puberty
• Fetal & Newborn period
– Peak number of oocytes
• 20wks gestestion (LH, FSH)
– Peak level of gonadotropins by 3 month  decline until nadir
(4yrs)
• Childhood
– H-P-G axis suppressed
• Low Estradiol  negative feedback on gonadostat
• Intrinsic CNS inhibition of GnRH secretion
• Late prepubertal period
– ↑ Androgen production/ differentiation
• Zona reticularis
• ↑Axilary and pubic hair (adrenarche/pubarche)
 Endocrinologic Changes of Puberty
(continued)
• Pubertal onset
– ↓ sensitivity by gonadostat
to negative feedback
• GnRH pulses  LH, FSH
 Follicular maturation, Sex
steroid production
» Secondary sexual
characteristics
 Somatic Changes of Puberty:
• Stage 1
Stages of Breast development
– Preadolescent
• Elevation of papilla only

• Stage 2
– Breast bud stage
• Elevation of breast and papilla
(small mound), areolar
enlargement
• Stage 3
– Further enlargement

• Stage 4
– Secondary mound
• Projection of areola and papilla

• Stage 5
– Mature stage
• Projection of papilla only
• Recession of areola
 Stages of Pubic Hair development
• Stage 1
– Preadolescent
• Absent of pubic hair

• Stage 2
– Sparse hair
• Downy, sparse, slight pigment

• Stage 3
– Hair over junction of pubes
• Darker and coarser

• Stage 4
– Adult-type hair

• Stage 5
– Adult-type hair
• Spread to medial surface of
thighs
 Growth Spurt
• Adolescent growth spurt
– Seen ~2 yrs earlier than
boys
• Body comp and bone
age
– Correlates with onset of
2ndary sexual
characteristics and
menarche
• Radiographs of non
dominant wrist, elbow,
knee
 Precocious puberty
• Definition
– Development of any sign of
2ndary sexual maturation
earlier than 2.5 standard
deviation of expected age of
pubertal onset
• Female – age 8 or younger
– Incidence ~ 1/10,000
» Female 5X more
common
» 75% idiopathic
» Tall as children, short
as adult Fun fact
Lina Medina: 5 years, 7
months, 21 days
 Heterosexual precocity
• Definition
– The development of secondary sexual characteristics opposite those of
the anticipated phenotypic sex
• Causes
– Virilizing neoplasms
• Types
– Ovarian
» Sertoli-Leydig cell
– Adrenal
• Diagnosis
– Abdominal/ physical/ radiologic exam
• Treatment
– Surgical removal
– Congenital adrenal hyperplasia
• Most common cause
– 21-hydroxylase deficiency
• Treatment
– Replacement of cortisol
– Surgical correction of anatomical abnormalities
– Exposure to exogenous androgens
 Isosexual Precocious Puberty
• Definition
– appearance of phenotypically appropriate
secondary sexual characteristics before age 8
years in girls
• Secondary sexual characteristics
• Increased levels of sex steroids
– Types
• True Isosexual
– Involves H-P-G axis
• Pseudoisosexual
– Exposure to estrogen (no HPG axis involvement)
 True Isosexual Precocity
• 75% constitutional
– Diagnosis by exogenous GnRH administration
•  rise in LH
• 10% due CNS disorder
– Including:
• Tumors
• Obstetric lesions
• Granulomatous diseases
– Innterfere with normal inhibition of GnRH release
– Exhibit neurologic symptoms before apperance of premature
sexual maturation
• Treatment
– Long term GnRH agonist (leuprolide) therapy
• Final stature influenced by chronologic age at diagnosis and initiation of
treatment
– If untreated only 50% will reach 5 feet
 Pseudoisosexual Precocity
• ↑ estrogen w/t no HP axis involvement
– Causes
• Ovarian tumors
– Diagnosis- radiology
– Treatment – surgical
• McCune-Albright syndrome
– Precocity, cystic bones, café au lait spots, hypercortisolism
• Hypothyroidism
 Increased pitiutary gonadotropin release in
response to ↑ TRH
• Peutz-Jeghers Syndrome
– Associated with rare sex cord tumor (may be estrogen secreting)
 Delayed Puberty
• Evaluation required for failiure of thelarche by age 14.
• Causes
– Hypogonadotropic hypogonadism (FSH + LH < 10 mlU/ml)
• Anorexia nervosa / extreme exercise
• Kallmann syndrome
– No GnRH migration into hypothalamus
• Mutations of GnRH receptor gene
• FSH β-subunit / receptor gene mutations
• Aromatase deficiency
• 17-hydroxylase deficiency
 Delayed Puberty
– Hypergonadotropic hypogonadism (FSH > 30 mlU/mL)
• Chromosomal abnormalities
– Turner syndrome
• Injuries to ovaries
– Surgery, Chemotherapy, radiation

• Treatment
– Estrogen therapy
• Low dose OCP after establishment of 2ndary sexual characteristics to
avoid menopausal symptoms and prevent osteoporosis
• 1500 mg Ca+ and 400 mg Vit D with exercises
Reference