13 - Puberty Flashcards
What is puberty and at what age does this happen?
Stage where secondary sexual characteristics develop in a child so they have the ability to reproduce
Girls: 8-14, on average starting at 10.5
Boys: 9-15, on average starting at 11.5
Takes 4 years to complete on average
What signals the end of puberty?
Closure of epiphyseal growth plates
What are the stages of female puberty?
- Therlarche: breast bud growth
- Adrenarche: hair growth
- Menarche: usually coincides with Tanner stage 3, average age 12.9
- Growth: 5-10cm/year after menarche
What are the different Tanner stages for girls?
BREAST AND PUBIC HAIR (know both)
- B1 Prepubertal
- B2 Breast bud
- B3 Elevate breast
- B4 Areola and papilla project above breast
- B5 Adult
What are the stages of puberty in boys?
- Growth of testes
- Pubic hair growth and change in voice
- Growth between age 14-17
What are the different Tanner stages for male puberty?
Male genital changes
- G1 Prepubertal, testicular volume <1.5ml
- G2 Penis grows in length only, testicular volume 1.5-6ml
- G3 Penis grows further in length and circumference, testicular volume 6-12ml
- G4 Development of glans penis, darkening of scrotal skin, testicular volume 12-20ml
- G5 Adult genitalia, testicular volume >20ml
Pubic hair changes
- PH1 Pre-adolescent no sexual hair
- PH2 Sparse, pigmented, long, straight, mainly along base of penis
- PH3 Dark, coarser, curlier
- PH4 Filling out towards adult distribution
- PH5 Adult in quantity and type with spread to medial thighs in males
What are some common complications that occur during puberty?
Acne: due to increased sebaceous gland activity
Gynaecomastia: just reassure will eventually resolve
What is precocious puberty and what are the complications of this?
Puberty before the 8 of age in girls and 9 in boys
- Short stature
- Psychological disturbance
- Safeguarding concerns
What hormones drive pubic hair growth, breast enlargement, penis enlargement and testicular enlargement?
Pubic Hair: adrenal androgens (DHEA, DHEAS)
Breast enlargement/Penis enalrgement: sex steroids (oestrogen and testosterone)
Testicular enlargement: pituitary gonadotrophin (LH, FSH)
What are the causes of precocious puberty?
Think of causes as central or peripheral
Gonadotrophin-dependent precocious puberty (GDPP) (true)
- Idiopathic (>90%)
- Brain tumours
- Cranial radiotherapy
- Cranial disability e.g hydrocephalus, cerebral palsy, meningitis
- Traumatic head injury
- Associated with child adoption and sexual abuse
Gonadotrophin independent precocious puberty (GIPP) (false)
- Ovarian and Testicular tumours
- Congenital Adrenal Hyperplasia
- McCune-Albright syndrome (MAS)
- Hypothyroidism
What is primary amenorrhea?
Absence of menstruation by the age of 16 OR
Absence of breasts by the age of 14
Who is precocious puberty pathological in?
(image is important)
BOYS
Girls it is often familial
Pathological if discordance between Tanner stages e.g full pubic hair but little testes volume
What is the main difference between gonatrophin dependent and independent precocious puberty?
Independent is usually just one sexual characteristic but dependent is full puberty
What investigations need to be done for a child undergoing precocious puberty?
- Growth charts and Tanner charts
- Brain CT/ MRI
- Bone age (skeletal X-ray)
- Karyotype
- TFTs
- LH, FSH, GH
- AFP and HCG
- Oestrogen and Testosterone level
- Gonad US
- Virilizing 21-hydroxylase deficiency: 17hydroxyprogesterone on ACTH stimulation
How is precocious puberty managed?
GDPP: GnRH analogues e.g goserelin so continuous high levels rather than pulses to stop pituitary responding with FSH/LH.
Treat any brain tumours
GIPP: treat underlying condition e.g remove ovarian tumour, hydrocortisone for CAH
Reassure parents that their child will develop normally
What does precocious puberty look like in CAH?
- Pubic and axillary hair
- Cliteromegaly
- NO breast development
What is the definition of late-onset puberty?
- No signs of puberty by age 13 in girls and 14 in boys
- No menstruation by the age of 16 in girls
What are some of the causes of delayed puberty in both boys and girls?
Most common cause is constitutional delay
Hypogonadotropic Hypogonadism (deficiency of LH and FSH so leads to deficiency of testosterone and oestrogen)
- Damage to the hypothalamus or pituitary, e.g radiotherapy or surgery
- Growth hormone deficiency
- Hypothyroidism
- Hyperprolactinaemia
- Serious chronic conditions e.g CF and IBD
- Constitutional delay in growth and development
- Kallman syndrome
Hypergonadotropic Hypogonadism (gonads fails to respond to LH/FSH)
- Damage to gonads (e.g. testicular torsion, cancer, mumps)
- Congenital absence of the testes or ovaries
- Kleinfelter’s Syndrome (XXY)
What are some causes of delayed puberty in just girls?
- Turner’s Syndrome
- Anorexia Nervosa
- Low body weight/athletic lifestyle
- Autoimmune failure- premature ovarian failure
What investigations should be for delayed puberty?
Initial investigations can be used to look for underlying medical conditions:
- FBC and ferritin for anaemia
- U&E for chronic kidney disease
- Anti-TTG or anti-EMA antibodies for coeliac disease
Hormonal Blood tests:
- Early morning serum FSH and LH (the gonadotropins)
- TFTs
- Insulin-like growth factor I: screening test for GH deficiency.
- Serum prolactin
Karyotyping (XXY and XO)
Imaging
- Xray wrist to assess bone age and diagnose constitutional delay
- Pelvic US in girls to assess the ovaries and other pelvic organs
- MRI of the brain to look for pituitary pathology and assess olfactory bulbs
How is delayed puberty managed?
- Observation and reassurance for constitutional delay and that they will reach normal height
- Sex hormone replacement
- Treat underlying abnormality e.g treat CF optimally, weight gain, GH for Turner’s
What is Kallman’s syndrome?
- Genetic condition with hypogonadotrophic hypogonadism
- Anosmia
What is short stature and some causes of this?
Height below 2.5th centile
ANY CHRONIC DISEASE
- Familial
- Constitutional delay in growth and puberty
- Psychological neglect
- Hypothyroidism
- Cushing’s
- Turner’s
- Noonan
- Down’s
- Chronic inflammatory diseases e.g IBD, Coeliacs, Asthma
- Heart failure
- Achondroplasia (AD dwarfism) and Hypochondroplasia
- Malnutrition