Pubertal disorders
Dr Olcay Evliyaoğlu
Pediatric Endocrinology Department
Puberty
Sexual differentiation begins on 4-5th week of gestational age.
ADOLESENCE Physical, sexual, physcological
development. Transition to adulthood from childhood
Not an adult nor child Time of transition Establishment of individualism.
PUBERTY
Secondary sex characteristics are developed
Includes Physical growth Sexual development Psychological development
Growth spurt, disturbution of muscle and fat
bone maturation and fusion of epiphysical centers
Adult height At the end of this period
spermatogenesis in boys, ovulation in girls occur
STRESS
MATURATİON NUTRİTİON+ +CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM
++ - - +
+ +
- - -
- -
- -
+ +
--
-- --
GLUTAMAT GABA ENDROFIN
HYPOTHALAMUSHYPOTHALAMUS
GnRHGnRH
PİTUİTARYPİTUİTARY
PRLPRL
LHLH FSHFSH
TEKA TEKA OVARYOVARYGRANULOZA GRANULOZA
ANDROGENANDROGEN ESTROGEN INHIBINESTROGEN INHIBIN
-
LEPTIN
What makes HHG axis work
Hypothalamus GnRH pulse frequency and amplitude increase
LH pulse frequency and amplitude increaseAt early stages at nights With progression of puberty pulses occur during day
Pituitary
Gonadarche
LH
Granulosa cellsFSH
Estradiol (E2)
androstenedionTeca cells
Gonadarche
LH Leydig cells
testosteron
Gonadarche
Adrenarche
Increase in the secretion of adrenal androgens
Appearance of pubic hair (pubarche) Axillary hair
CRH
ACTH
Adrenal androgens
Hypothalamus
Pituitary
Adrenal cortex
Adrenarche
Genetic and environmental conditions effect timing of puberty
Environmental factors: Socioeconomic factors Nutrition General health Geographical place lived
Nutrition and puberty
Menarche is earlier in obese girls
Malnutrition , chronic diseases, and excessive physical activity delay puberty and menarche
LEPTİN
Codes Ob gene Synthesized in adipose tissue. Leptin signals stimulate central
nervous system Leptin levels are decreased in
excessive physical activity, anorexia nevrosa and amenorea.
hypothalamus
LHRH secreting neurons
Leptin LHRH
pituitary gonadotrophs
Leptin mRNA Adipose cells
LH, FSH
Timing of puberty is related to bone age rather than chronological age
BA< CY ------------- delay in puberty BA = CA ------------- puberty on expected age BA>CA -------------- early puberty (puberty
precocous)
In girls the first sign of puberty is telarche, generally observed on 10 - 11 ages, menarche is observed 2-3 years after telarche.
In girls growth spurt occurs 2 years earlier than boys. Growth spurt in girls is at the time of telarche,
In boys growth spurt occur at the time when testes volumes are 10 ml.
Telarche Pubarche Menarche
Pubertal development in girls
breast development (tanner staging)
1. Prepubertal
2. Palpation of breat bud
3. Palpation of breat tissue with out
any changes in contures
4. Development of breast tissue
5. Adult type breast
Pubic hair1.No hair
2. Appearance of short hair on labium majora
3. Black and thic hair on mons pubis
4. Adult type hair but not spread to inguinal area
5. Adult type with the shape of inverted triangle
Tanner stagingGirls pubic hair
Stage 1: no pubic hair
Stage 2: lightly pigmented localized on labiums
Stage 3: coarser, darker , more curved, increased in amount spread to pubis
Stage 4: curved and increased still less than an adult.
Stage 5: adult women triangle spread to thighs
Tanner stagingBreast development
Stage 1: prepubertal
Stage 2: breast budding
Stage 3: enlargement of breast tissue and areola
Stage 4: Areola and papilla forms secondary mound .
Stage 5: Mature
Tanner stage 42-3years after telarche
Menarche
Tanner stage 42-3years after telarche
Menarche
FSH secretion Dominant follicule
estrogen
LH secretion
Ovulation
corpus luteum
Progesterone
Endometrium prepared
If no implantation uterine bleeding
Follicular phase
Luteal phase
Pituitary hormones
Ovarian hormones
ovary
Endometrium
İstihdam Seçim
dominant istihdam
Follicular /proliferative phase Luteal /secretuary phase
folliculeovulation
corpus luteumcorpus albicans
LHestrogen
-
+
estrogen +
Ovulation
corpus luteum Progesterone
endometrium is prepared for implantation
Luteal phase
If no implantation occurs
Corpus luteum regression
Progesterone levels decline
Endometrium can not hold itself-desquamation
Spiral arteriols in the functional and basal layers of endometriumun contracts and approx in 7 gün days bleeding stops
Luteal phase14+2 days
In boys initial finding of puberty is enlargement of testes. This is followed by scrotum pigementation and thinning of scrotal skin. Penis enlarges. Pubic hair develops. Growth spurt occurs at 14-16 years and usually continues until 18 years.
Pubertal development in boysTanner staging
Testes volumes 1-3 ml P1 4-9 ml P2 10-14 ml P3 15-20 ml P4 > 20 ml P5
Prepubertal testes diameter < 2.5 cm= 4 ml
Tanner stagingPubic hair
stage 1: no pubic hair
Stage 2: little pubic hair
Stage 3: pubic hair on pubis
Stage 4: adult type hair but no invasion on tighs
Stage 5 : adult type hair spread to thighs
