Puberty

Question 1

How is puberty defined

Answer 1

Growth acceleration
Primary sexual growth genitals grow and ovulation/ spermatogensis
Secondary sexual characteristics. Hair breast voice oily skin

Question 2

What is Thelache and when does it normally occur in girls

What is pubarche

Answer 2

Breast development girls first sign of puberty girls 10.8y ( 8-13.5)
Pubic hair development
Gonadarche onset of gonads working testicular vol >4mls
Menarche av 12.7 years
Growth spurt max spurt about 11.5 girls early in puberty
Spermatogenesis 13.5-14 y av in boys middle puberty boys

Question 3

True precocious puberty ( pubertal levels of FSH/LH and sex hormones ) causes and are they different in girls and boys?

Answer 3

Causes 1 neurogenic - tumors/CNS disease/ TRAUMA
2 Idiopathic
Boys 75 % caused by neurogenic CNS lesion
Girls about 90% idiopathic

Question 4

Precocious pseudo puberty. What is this ?

What are the causes

Answer 4

Raised sex steroids levels but low FSH and LH

CAUSES

CAH
Gn independence (Mc cure Albright/ testosterone)
Ad tumor
Normal variations

Question 5

What are the lower limits of normal sexual development in girls
Is early puberty common in girls /boys

Answer 5

Girls
Breast development <8years (10.9yrs is normal)
Pubic hair <8yrs
Menache <10years. (Normally 12.7)

Boys
Testicular enlargement <9 years ( 11.5 =normal)
Pubic hair <9 y ( 11.5yrs =normal)
These have family /ethnic background effects them
Girls have early puberty more than boys

Question 6

What blood tests are useful in early puberty

Answer 6

FSH /LH/Testosterone/Oestrogen/

17OHP AND DHEAS (helps pick peripheral causes)

Question 7

Consequences of percousious puberty

Answer 7

Tall in childhood. Short in adult hood
Psychological impact
?increased risk of sexual abuse
Early menopause
Treatment if needed needs to be individualized

Question 8

Treatment of percousious puberty

Answer 8

1 treat the underlying cause in males (75% neurogenic eg brain tumor
2pubertal suppression GnRH agonists depo infection 4-12/52

Question 9

Mccune-allbright syndrome. Features

Answer 9

Peripheral PP. (girls&raquo_space;> boys)
Low FSH /LH high DEAS and 17OHP
Clinically PP peripheral
Bone polyostotic fibrous dysphasia
Irregular pigmented lesions
Other endocrine oversecretion Hyperthyroidism/Adredal /pituitary

Question 10

Premature thelache

Answer 10

Common during first 2 years of life
Can be B2/B3 without other signs
Growth vel normal /bone age normal
Can be present from birth
Regresses by about 2years 
2nd peak about .6yrs
Important can be the first sign of Central PP follow up is needed 
Ask about exogenous oestrogen

If ATYPICAL /PROGRESSIVE. Bone age/ pelvic USS /FSH/LH O/PROLACTIN /GnRH test

Question 11

Premature adrenache. What is it and is it serious?

Answer 11

Adrenache without gonads usually benign
Oily skin/acne/ adult body odor. No associated changes in gonads

Girls <8 years. Boys <9years
RARE <6yrs think CAH 17OHP and a bone age

Question 12

Ovarian cysts

Answer 12

Normal at any age <6mm usually can be up to 10mm
Can get larger cysts in puberty bery in girls
Solid /complex masses. Germ cell tumors / ovarian neoplasms

Question 13

Gynicomastica

Answer 13

Common mid puberty about 50% males 14-15years ( testicular size 8-15 mm)
Bilateral/Assam
Resolves spontaneity 
Investigation if exaggerated
Check testicular vol >4mm

Other causes 
Marijuana/drugs
Sex steroid secreting tumor PAIS
Hypogonadism Klienfelters syndrome XXY
Systemic illness

Question 14

Delayed puberty definition

Answer 14

No changes in girls by 13years
No changes in boys by 14years
No periods in girls 15.5-16 years
Arrested pubery

DD delayed puberty. VS pathological ( needs treatment )

Question 15

Classification of delayed puberty pathological (3 classes )

Answer 15

Primary. Hypogonadism. Gonadal problem
2ary pituitary
3ar hypothalamus

Question 16

Primary hypogonadism features

Answer 16

High FSH/LH low testosterone/oestrogen
Chromosomal. 45XO. 47XXY
Trauma/torsion testicle
Radiation/ chemotherapeutic damage

Question 17

2ary hypogonadism

Answer 17

Causes. Tumors trauma radiation
Genetic pit def

Low FSH/LH LOW oestrogen/testosterone
No rise in FSH/LH after GnRH trail

Question 18

Tertiary hypogonadism features on blood tests and causes

Answer 18

Normal variation
Following sickness in childhood eating disorder/ sport
Tumor/infection/ radiotherapy

Low FSH/LH/O/T/ rise in FSH/LH after a GnRH trial

Question 19

What features are important in the HISTORY wiht delayed puberty
8

Answer 19

1 growth velocity plot the growth and velocity on charts
2 testicular descent ( bilaterally absent testicles
3 medical illness /eating disorders
4 sport
5 endocrine (TSH )/neuro he
6I head injury
7 family hx
8 ANOSMIA no smell Kellmans syndrome delayed pubery

Question 20

Examination in delayed puberty

Answer 20

Growth /growth velocity
Pubertal staging
Genital staging in males
Neuro fundi and smell ( kellmans syndrome and 2/3ary causes of delayed puberty)

Question 21

Investigations of delayed puberty

Answer 21

Bone age X-ray ( left wrist)
FSH/LH and O/T
SEX steroid levels

Others chromosomes XO XXY
TSH
Growth hormone if short
GnRH
?MRI of head
Pelvic uss

Question 22

Maturation delay in growth and puberty

Features

Answer 22

Commonest causes of delayed puberty (boys&raquo_space;>girls)
U assoc with short statue and delayed growth
Bone age affected by about 2 yrs
NO pathological cause
Normal adult height prediction
Growth hormone NOT indicated
+ve family history of delayed growth common

In boys can give a low dose of androgen oral/I I
Primes the HPG
Growth spurt and safe and predictable

Girls rare need intervention

Question 23

Treatment of primary /secondary/tertiary Hypogonadism

Answer 23

Long term treatment needed for both M/F

Males. Get to full adult height
Testicles will remain small
Fertility specialist ( difficult if primary hypogonadism

Women
Oestrogen alone initially and later P
If primary damage poor fertility