Puberty ☺️

Question 1

Describe the HPO axis in females

-what are the effects of O, P

Answer 1

GnRH => FSH => follicle development => inhibin release
LH => theca cells => androgens => granulosa cells (via aromatise) => oestrogen

-ve FB

Oestrogen

• breast dev
• growth
• skeletal maturation

Oestrogen + progesterone
-menstruation

Question 2

Describe the HPT axis

-what are the effects of testosterone and oestrogen

Answer 2

GnRH => FSH => Sertoli cells => inhibin
LH => Leydig cells => testosterone => Sertoli (via aromatase) => oestrogen

-ve FB

Testosterone

• increased muscle
• penile, hair growth
• deep voice

Oestrogen

• breast development
• growth
• skeletal maturation

Question 3

When would puberty be delayed in females

• thelarche
• pubarche
• menarche, 2ndary characteristics
• thelarche, menarche gap

Answer 3

13, no thelarche
14, no pubarche
16, no menarche or 2ndary characteristics
5 year gap between thelarche and menarche

Question 4

When would puberty be considered delayed in males

• testes volume <4ml
• pubarche
• testes, penile growth

Answer 4

14, testes volume <4ml
15, no pubarche
5+ years to finish penile, testes growth

Question 5

Describe the timeline for reproductive hormones

Which stage marks the start of puberty

Answer 5

Prenatal
-GnRH v active but suppressed 6months postnatally

Adrenarche
-increase in androgen production => 2ndary sex characteristics => pubarche

Gonadarche (START OF PUBERTY)
-GnRH reactivated => pulsatile FSH, LH => gonadal development => sex steroid FB

Menopause
-gonads fail but GnRH, FSH, LH increases due to low O, P

Question 6

When does puberty occur in females
What is the order
Describe each Tanner stage
What are the consequences of puberty

Answer 6

8-13
Adrenarche => gonadarche => thelarche => growth spurt => pubarche, menarche

T1, prepubertal
T2, breast bud, some pubic hair
T3, increased breast size, dark coarse hair
T4, 2nd mound areola, increased area
T5, 2nd mound lost, thigh spread

Anaemia, low Fe due to periods

Question 7

When does puberty occur in males
What is the order
Describe each Tanner stage
What are the consequences of puberty

Answer 7

9-14
Adrenarche => gonadarche => pubarche => growth spurt => facial hair, spermarche

T1, prepubertal
T2, 4ml testes, some pubic hair
T3, 10ml testes, increased penis length, dark coarse hair
T4, 16ml testes, increased penis length and width, increased area
T5, 25ml testes, adult penis, thigh spread

Gynecomastia
-13, imbalance of O and T

Acne
-increased A, DHEAS, scarring

Question 8

What is True Central Precocious Puberty
What are the causes
How would you manage this
-idiopathic
-genetics
-CNS lesions
-GnRH tumours
-sex steroid exposure

Answer 8

GnRH dependent

Idiopathic
-more common in females

Genetic
-KISS, MKRN

CNS lesions
-affects HPG axis, damage to inhibitory system

GnRH tumours
-increased FSH, LH

Sex steroid exposure
-premature adrenarche => increased A => TCPP

Block with GnRH analogue => pause pituitary

Question 9

What is Female Peripheral Precocity
What are the causes
-ovarian cyst
-ovarian tumours
How would you manage this

Answer 9

GnRH, pituitary independent

Ovarian cyst (common)
-increased O => breast dev, early menarche

Ovarian tumour/Gonadoblastoma (rare)

• granulosa cells => isosexual, more O
• sertoli/leydig cells => contrasexual, more T

Anti A/aromatase inhibitor

Question 10

What is Male Peripheral Precocity
What are the causes
-Leydig cell tumour
-Germ cell tumour
-Testotoxosis
How would you manage this

Answer 10

GnRH, pituitary independent

Leydig cell tumour

• increased T
• benign testicular enlargement

Germ cell tumour
-increased hCG acts on LH receptor on Leydig cell => too much T => shrunken testes, low sperm count

Testotoxicosis
-LH receptor excessively activated

Anti A/aromatase inhibitor

Question 11

What is primary hypogonadism
What are the causes
-congenital
-acquired

Answer 11

High GnRH, low sex steroids

Congenital

• chromosomal (Turners, XXY)
• testes regression

Acquired
-surgery, trauma, infection, AI

Question 12

What is secondary hypogonadism
What are the causes
-congenital
-acquired

Answer 12

Normal, low GnRH
Congenital
-craniofacial defects
-GnRH deficit (Kallmann)
-idiopathic

Acquired

• functional (ED, chronic illness)
• physical activity

Question 13

How can primary hypothyroidism induce precocious puberty

What are the consequences

Answer 13

Cross reactivity of increased TSH/FSH

Premature thelarche, menarche, testes growth

Question 14

What are the consequences of adrenal pathology on precocious puberty

• CAH/androgenoma
• oestrogen tumours

Answer 14

CAH/androgenoma
-virilization

Oestrogen tumours
-feminisation

Premature epiphyseal fusion

Question 15

What are the main signs and symptoms of McCune Albright

What are the consequences

Answer 15

Peripheral precocity
Irregular cafe au slit spots
Fibrous bone dysplasia

Leads to abnormal pubertal progression => vaginal bleeds

Question 16

What are the signs and symptoms of premature thelarche

Answer 16

No 2ndary characteristics
Normal height velocity/bone age
Normal LH, FSH

Question 17

What are the signs and symptoms of premature adrenarche
Which population is this common in?
What are the risk factors
What can this lead to

Answer 17

Pubarche, acne, BO
Mild increased growth, bone age, DHEAS

Afro Caribbean, obesity, insulin resistance

Can lead to PCOS, TCPP

Question 18

How would you diagnose constitutional delay

How would you manage constitutional delay

Answer 18

Rule out other causes
Paternal FHx
Normal birth length, weight
Delayed bone age
Growth below 3rd centipede

Wait
Anabolic steroid
Testosterone