Normal Female Pubertal Development

Additional Changes

- Widening of the hips, enlargement of the ovaries, labia, and clitoris, and thickening of the endometrium and vaginal mucosa. - Doubling heart size and lung vital capacity, Rise in blood pressure, blood volume, and hematocrit. - Androgen stimulation of sebaceous and apocrine glands (acne and body odor) - Physiologic changes in sleep patterns and requirements (increased amount and daytime)

Tips for working with the adolescent patient

-Physical maturation correlates with sexual maturity, psychosocial development correlates with chronological age. -Early adolescents typically need reassurance that the somatic changes they are experiencing are common and normal. -Always ask social history questions with the parent/guardian out of the room. - Do not assume heterosexuality. -Intention to have sex & whether close friends are sexually active- indications that a youth may be initiating sexual activity shortly. -Similarly involvement of friends in other risk taking behaviors (smoking, drugs, alcohol)- indicator that the patient may be engaging in these behaviors.

Menarche

-The onset of menstrual periods. -Typically 2-2 ½ y after Thelarche and 1 year after the growth spurt, during Tanner stage 4. Avg age in Caucasian females is 12y (9-16y). Before menarche occurs, the uterus enlarges, vaginal lubrication increases, and a clear vaginal discharge appears = physiologic leukorrhea. -Primary Amenorrhea if no menses by 16yo

Endocrine changes that cause puberty

1) Adrenal Gland increases production of androgens particularly DHEAS. 2) Rise in LH & FSH 3) Increased sensitivity of the pituitary to GnRH 4) Pulsatile release of GnRH, LH, and FSH and a corresponding increases in gonadal androgens and estrogens cause the more dramatic changes of puberty.

Puberty Sequence

1. Thelarche 2. Pubarche and Adrenarche 3. Growth Spurt 4. Menarche 5. Development of adult breasts and pubic hair distribution.

Pubarche and Adrenarche

2nd sign of puberty. Pubarche = The beginning of pubic hair development Adrenarche = Adrenal maturation which leads to acne, oiliness of skin, body odor, axillary hair and pubarche (pubic hair) development.

By what Tanner Stage will most girls have menarche?

4

Does Ethnicity Make a Difference in Onset of Puberty? (Ages)

Caucasian: Breasts 10.3, Pubes 10.5, period 12.7 African-Amer: Breasts & pubes 9.5, period 12.3 Mexican: Breasts 9.8, pubes 10.3, period 12.5

The Final Changes

Development of adult breasts and adult pubic hair distribution. Pubertal changes typically occur over 4.5 years.

Self-Concept

Early on: External physical changes & increased self consciousness. Girls who develop earlier than their peers have higher rates of school difficulty, body dissatisfaction, and depression. Middle: More introspective and Self concept is very strongly tied into peer groups. Media has a big impact. Late: Adolescence identity is less tied to peer group and more based on their job goals and emerging place in society.

Cognitive Development

From concrete operational thinking to formal logical thinking (abstract thought). Start to question and analyze things. Develop the ability to see beyond themselves, and to begin to understand their own actions in a moral and legal context. Later develop ability to act on long-term plans, delay gratification, compromise, set limits, and think independently. Differs by gender & girls developing earlier than boys.

Growth spurt

Peak Height velocity. Occurs 2 years earlier in girls then in boys. Occurs 1 year before menarche; after Menarche there is limited linear growth because gonadal steroids promote fusion of the growth plates.

Tanner Staging of Pubic Hair

Stage 1 - Preadolescent Stage 2 - Sparse, lightly pigmented, straight, medial border of labia Stage 3 - Darker, beginning to curl, increased amount Stage 4 - Coarse, curly, abundant, but less than in adult Stage 5 - Adult feminine triangle, spread to medial surface of thighs

Tanner Staging Breasts

Stage 1 - Preadolescent -elevation of papilla only. Stage 2 - Breast Bud -Breast and papilla elevated as small mound Stage 3 - Breast and areola enlarged, no contour separation Stage 4 - Areola and papilla form secondary mound. Stage 5 - Mature - nipple projects, areola part of general breast contour.

Thelarche

The first sign of Puberty- Breast budding. Between 8-12y, avg age in Caucasian females 10 ½ y. Unilateral breast development can be normal.

Relationships With Others (1)

Throughout adolescence teens become less interested in activities with parents and focus on peer groups and an increased need for privacy. Shift towards separation from family- change behavior and dress to mirror that of their peer group and choose role models outside of the family. Adolescent girls relationships first involve one-on-one same sex friends with whom they share secrets. Adolescents with obvious differences will have more difficulty w/ these relationships and their sense of self confidence. Later progress to exploration of sexual identity and developing dating relationships- first are more superficial and based on attraction and sexual experimentation, then progress to intimate relationships.