. Physiology of puberty.

Question 1

the mean age when puberty starts has lowered and menarche has stayed the same what does this mean ?

Answer 1

women stays more in their puberty

Question 2

what are the features of puberty in females ?

Answer 2

estrogen dependant :

breast development - a palpable breast disc first sign between 8.5-12.5 years

pubic hair growth and rapid height growth immediately after breast development

enlargement of the ovaries , uterus , vagina , labia

fat redistribution in hips and breast and bone maturation

Question 3

what are the pubic hair changes in males

Answer 3

sparse and pigmented , long and straight and mainly along the base of the penis

getting darker and coarser and curlier and spread in the medial thighs

Question 4

what are the male genital changes in puberty ?

Answer 4

seminiferous tubules develop under FSH causing testicular enlargement over 4ml volume and measured using and orchidometer - which is the FIRST CLINICAL SIGN of puberty (earlier than pubic hair growth) = occurs between 10-14 years of age

long standing pulsation of LH causes the interstitial cells to differentiate into lydia cells - giving negative feedback fro lh secretion

there is the lengthening of the penis and it circumference

then there is development of gland penis , darkening of the scrotal skin

Question 5

menarche occurs how many years after puberty ?

Answer 5

on average 2.5 years

Question 6

menarche signals what ?

Answer 6

growth coming to an end an only 5 cm left to gain in height

Question 7

when the testicular volume is around 12-15ml what occurs ?

Answer 7

rapid height growth with a delay of 18 months

Question 8

what is the difference in growth spurts in puberty in males and females

Answer 8

the growth spurt in males occur later than to a women and of greater magnitude

MALE VOICE PITCH CHANGES

Question 9

what are the there signs of puberty in both sexes ?

Answer 9

development of acne , axillary hair 13YEARS F AGE , body odour , mood changes

Question 10

if puberty is early or late it can be further assessed by what ?

Answer 10

bone age measurement from a hand and wrist to determine skeletal maturation

pelvic ultrasound in females to asses the uterine size and endometrial thickness

Question 11

what are the is the normal period cycle

Answer 11

cycle of 21-45 days is normal with a optimum of 28 days (+- 7 days)

and the menstruation length is on average 5 days (between 3-7 days)

Question 12

what is the average blood loss per cycle ?

Answer 12

less than 80ml

Question 13

what are the signs which imply heavy bleeding ?

Answer 13

passage of blood clots or are than 6 pads daily

Question 14

amenorrhea is split into ?

Answer 14

primary and secondary

Question 15

what is primary amenorrhea

Answer 15

patients who have no secondary sexual characteristics and no menarche by the age of 14 - delayed puberty

normal secondary sexual characteristics but no menarche by age of 16

Question 16

what is secondary amenorrhea ?

Answer 16

absence of menstrual periods for more than 3 months who has previously been regular

Question 17

what are the causes for primary amenorrhea ?

Answer 17

unbroken hymen 
vagina without cervix 
absence of vagina 
non perforated cervix 
asherman syndrome 
hypoplastic uterus 

turner syndrome - ovarian dysgensisis , increased fsh and LH , congenital cardiac defects

androgen insensitivity- atresia o vagina , ovaries or fallopian tubes
clitorial hypertrophy
testicles inguinally
increased estrogen and LH bt normal FSH

Kallmann syndrome -olfactory genital dysplasia

anorexia nervosa

hyperprolactinemia - Ahumada-Del Castillo syndrome include the abnormal production of breast milk (galactorrhea) without childbirth and nursing
prolactinoma

hypopituitarism tumors , infection , radiation

hypothyrodism
low T4 –> inc TRH (hypothalamus)/ TSH (anterior pitutory)–> dec dopamine (inhibitor of prolactin) –> inc prolactin –> dec GnRH –> dec LH + FSH

addison disease

frolic syndrome -Adiposogenital Dystrophy

congenital adrenal hyperplasia

TRUNER SYNDROME -gonadal dysgenesis
increased fsh and LH , congenital cardiac defects

Question 18

reason for secondary amenorrhea ?

Answer 18

anorexia nervosa
-Weight loss can cause elevations in the hormone ghrelin which inhibits the hypothalamic-pituitary-ovarial axis

hyperprolactinemia - chiari frommel syndrome - affects women who have recently given birth (postpartum) and is characterized by the over-production of breast milk/ excessive stress / pills

premature ovarian failure - genetic
Autoimmune diseases
smoking

pregnancy

sheehan’s syndrome - postpartum pituitary gland necrosis,
schemic necrosis due to blood loss and hypovolemic shock during and after childbirth

adrenal / ovarian tumors

PCOS

Question 19

how to diagnose primary amenorrhea ?

Answer 19

US to visualise normal uterus and ovaries and vagina

check all the blood hormones

congenital adrenal hyperplasia - 17-hydroxyprogesterone checked

Question 20

how do we diagnose secondary amenorrhea ?

Answer 20

pregnancy test

progesterone test performed - once you cease it bleeding occurs meaning normal endometrium
if bleeding does not occur oestrogen’s are applies followed by progesterone test - still no bleeding - asherman syndrome suspected

T3,T4,TSH measured

serum FSH- increased levels show ovarian insufficiency

if LH:FSH ratio over 3 = PCOS

prolactin tested

testosterone levels tested
increased testosterone but normal DHEAS = ovarian tumor

increase testosterone and DHEAS = PCOS , adrenal hyperplasia or neoplasia

abdominal US

CA125

Question 21

what is precocious puberty?

Answer 21

Precocious puberty occurs when children younger than 8 in males and younger than 9 in males experience changes indicative of puberty, including development of breast buds (thelarche), pubic hair, menstruation,and a growth spurt.

Question 22

cause of precocious puberty

Answer 22

central precocious puberty - 
gonadotropin dependant and premature activation of 
the hypothalamic-pituitary-ovarian axis
eg - hypothalamic hamartomas 
brain tumours
infections  - most common tuberculous meningitis 
radiation 
hydrocephalus 

Peripheral precocious puberty are GnRH independent
from gonads such as ovarian cyst , ovarian tumors (sex chord gonadal tumors that produce estrogen - granulose cell tumor /thecoma)
adrenals - tumors , congenital adrenal hyperplasia
germ cell tumor - producing ectopic hCG
exogenous sex hormone exposure
primary hypothyroidism

Question 23

diagnosis of precocious puberty and treatment

Answer 23

media history - start of menstruaton usually before 10 years in girls

physical examination - hieght , weight
tanner staging - breast formation , pubic hair

blood tests - for LH and FSH , estradiol , testosterone , TSH and free t4

bone age and skeletal maturation

treatment continuous use of GnRH agonists decreases gonadotropins

Question 24

what affects the time when puberty occurs ?

Answer 24

GENETICS 
ETHINICITY
malnutrition 
chronic diseases 
socioeconomic condition environmental factors

Question 25

1-3 years before the onset of puberty what are the clinical signs evident ?

Answer 25

nocturnal LH levels increase inpulsatile fashion showing the GnRH release - releasing gonadotropin
mid puberty the lh surge becomes evident
FSH stimulates the follicles
and LH stimulates the leading cell
lydig cells release testosterone
while the follicular cells generate estrogen

secretion of sex hormones

Question 26

what begins to increase in 6-8 years of age ?

Answer 26

DHEA and sulphated DHEAS - adrenarche

precede menarche b 2 year’s

Question 27

what ar the 3 critical changes in prepubertal period

Answer 27

adrenarche

increase gonadostat

gradual amplification of GNrh - gonadtropin interaction

Question 28

is the mechanism initiating gonadarche the same as the mechanism initiating adrenarche ?

Answer 28

NO -
demonstrated by kallman syndrome -no gonadarche but adrenarche occurs

addison disease - gonadacrhe occurs even in the absence adrenarche

Question 29

what causes the adrenals to mature and release sex hormones ?

Answer 29

pitutory adrenal androgen stimulating factor

local steroid inhibitors of key enzymes within the adrenals

Question 30

which hormone is uncharge for the timing of the puberty ?

Answer 30

leptin - inhibits neuropeptide y gene expression

leptin levels increase in puberty - higher the leptin earlier the menarche and girls with precocious puberty has higher levels of leptin produced from the adipose tissue

also IGF-1

Question 31

describe tanner staging

Answer 31

stage 1 - elevation of papilla only and no pubic hair

stage 2 - elevation for breast and papilla , areola diameter enlarged
age 9
sparse long , pigmented along labia major
age 10

stage 3 - further enlargement without separation of breast and areola
age -11
dark coarse and curly hair
age 11

stage 4 - secondary mounds of areola and papilla above the breast
age 12
adult type hair , abundant but limited to mons
age - 12

stage 5 - recession of areola to contour the breast
age : 14
adult type spread os pubic hair in quantity and distribution
median age 17

Question 32

when does the average peak of growth occur ?

Answer 32

2 years before breast budding and one year prior to menarche

limited growth potential after menarche -

Question 33

puberty is over when ?

Answer 33

sexual characteristics are fully developed

Question 34

what is the median age for MENARCHE?

Answer 34

12-13 YEARS

RANGE OF 10-15 YEARS

Question 35

WHEN DOES SPERMARCHE occur in men ?

Answer 35

14 years of age