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
What makes HHG
axis work
MATURATİON
+
GLUTAMAT
+
+
CENTRAL NERVOUS SYSTEM
GABA
+
LEPTIN
ENDROFIN
-
-
+
HYPOTHALAMUS
-
-
GnRH
-
-
+
+
PİTUİTARY
PRL
-
LH
-
-
-
FSH
-
+
TEKA
+
OVARY GRANULOZA
ANDROGEN
ESTROGEN
INHIBIN
NUTRİTİON
Gonadarche
Hypothalamus
Pituitary
GnRH pulse frequency and amplitude increase
LH pulse frequency and amplitude
increase
At early stages at nights
With progression of puberty pulses occur
during day
Gonadarche
LH
Teca cells
FSH
androstenedion
Granulosa cells
Estradiol (E2)
Gonadarche
LH
Leydig cells
testosteron
Adrenarche



Increase in the secretion of adrenal
androgens
Appearance of pubic hair (pubarche)
Axillary hair
Adrenarche
Hypothalamus
Pituitary
Adrenal cortex
CRH
ACTH
Adrenal androgens
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
Leptin
LHRH secreting neurons
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 hair
1.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
staging
Girls 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 staging
Breast 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 4
2-3years after telarche
Menarche
Tanner stage 4
2-3years after telarche
Menarche
FSH secretion
Dominant follicule
estrogen
Follicular phase
LH secretion
Ovulation
corpus luteum
Progesterone
Endometrium prepared
If no implantation uterine bleeding
Luteal phase
Pituitary hormones
Ovarian hormones
ovulation
follicule
corpus luteum
corpus albicans
ovary
İstihdam
Seçim
dominant
istihdam
Endometrium
Follicular /proliferative phase
Luteal /secretuary phase
Luteal phase
+
LH
+
estrogen estrogen
-
Ovulation
corpus luteum
Progesterone
endometrium is prepared for implantation
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
phase
14+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 boys
Tanner staging
Prepubertal testes diameter < 2.5 cm= 4 ml

Testes volumes





1-3 ml  P1
4-9 ml  P2
10-14 ml P3
15-20 ml P4
> 20 ml  P5
Tanner
staging
Pubic 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