Female Puberty
what is definition of delayed puberty in female?
1. absence of sex maturation by age 13 2. no evidence of menarche by age 15-16 3. menses not beginning 5 years after thelarche
what factor accounts for the majority of variability with the onset of puberty and age of menarche? what other factors play a role?
1. genetics = main 2. overall health (nutritional status), 3. social environment/family stress 4. environmental exposure
when does pubarche occur in females?
11 pubic hair/then axillary circulating androgens
when is average age of menarche?
12-13 2.5 years after develop breast buds.
between what ages of female does adrenarche occur?
6-8
who is precocious puberty more common in? what are risk factors?
AA girls AA, girl, obesity, exposure sex hormones, CAH, Mccune Albright
onset of puberty in females (thelarche, pubarche, menarche) can vary based on race. what is different racial times in AA, Mexican Americans, White?
AA early >>Mexican Americans>>white
delayed puberty can be caused by hypogonadtropic, hypergonadotropic, or eugonadism causes. what are examples of hypergonadotropic hypogonadism?
FSH > 30 ovarian insufficiency gonadal dysgenesis (Turner) iatrogenic (sx, cancer)
delayed puberty can be caused by hypogonadtropic, hypergonadotropic, or eugonadism causes. what are examples of hypogonadotropic hypogonadism?
FSH and LH <10 constitutional delay (physiologic) Kallman syndrome anorexia exercise = extreme pit. disorder or tuor drug use hyperprolactinemia Chronic dx CNS
how is GnRH dependent precocious puberty vs independent tx?
Gn-RH tx = give monthly injection of medicine to inhibit HPO axis Gn-RH indep- treat underlying condition and remove exposure
what are tanner stages for girls?
Stage 1- prepubertal flat appearing chest with raised nipple, no pubic hair Stage 2- breast bud/mound forms; pubic hair appears (adrenarche) Stage 3- pubic hair darkens and becomes course; breast enlarge (thelarche) Stage 4- pubic hair across pubis but spares thigh; breast enlarges and raised areola Stage 5- adult breast; pubic hair on medial thigh; areola flattens
delayed puberty can be caused by hypogonadtropic, hypergonadotropic, or eugonadism causes. what are examples of eugonadism?
anatomic causes (mullerian agenesis) outlet obstruction like imperforate hymen or transvaginal septum androgen insensitivity
what is unique about the first 2 years of menarche?
anovulatory cycles = irregular
what is premature thelarche?
appearance of breast development (unilateral or bilateral) that occurs in girls younger than 3 with normal growth rate
what is precocious puberty?
appearance of physical/hormonal signs of pubertal development earlier than normal (2-3 STD)
precocious puberty = appearance of physical/hormonal signs of pubertal development earlier than normal. what age = considered precocious for AA/white females?
breast or pubic hair development <7 Caucasian <6 AA
in girls, 90% of total body mineral content appears to be accrued by 16.9 yrs and rates of calcium absorption and bone formation decrease significantly following menses. what should be encouraged for girls to increase peak bone mass?
exercise vit D calcium
what is abnormal skeletal maturity seen on bone xray of child with precocious puberty?
greater than or equal to 2 yrs the chronologic age
precocious puberty can be dx with physical findings of puberty at a pre pubertal age, growth spurt, skeletal maturity> chronologic age, or pubertal range hormone levels (estradiol >5pg). it can be caused by GnRH dependent mxns where there is early normal maturation of HPG, idiopathic, or CNS related. in addition, it can be caused by GnRH independent processes wehre there is excess secretion of sex hormones from gonads/adrenal glands or exogenous sex steroid exposure. how do you tell difference?
measure LH and FSH GnRH dep- FSH and LH are high GnRH-ind- FSH and LH are suppressed and estrogen increased
after adrenarche, gonadarche occurs when there is increased pulsatile GnRH secretion from hypothalamus leading to production of FSH and LH. in females this begins around age 8. what time of day do these increases initially occur?
night--> eventually occur throughout the day leading to increased stimulation of ovary
if early development of secondary sexual characteristics is noted but x ray of bone age confirms growth is not accelerated, what are next steps?
no further testing probably normal variant close monitoring
growth spurt is characterized by an acceleration in growth rate in females around 9-10 with peak velocity around 12. when does this occur in relation to menarche? why does this occur?
occurs half a year before menarche and before reach Tanner 3 in breast and 2 in pubic hair due to increased GH due to increased estrogen
what is the MCC of GnRH independent precocious puberty in females?
ovarian cysts others: ovarian tumor, exogenous estrogen, androgen tumor, CAH
what is premature adrenarche/pubarche?
premature appearance of pubic hair without signs of puberty in children less than 7-8
adrenarche in female occurs between ages 6-8. what does it include?
regeneration of adrenal cortex zona reticularis and increased DHEA and steroid hormones that increase until age 13-15
Puberty = endocrine process that involves physical, emotional, and sexual transition from childhood to adulthood. what is the order that female puberty occurs in (from fertility, secondary sex characteristics, and growth spurt?)
secondary sex characteristics (breast bud then pubic hair) growth spurt menarche Adult breast Adult pubic hair
after adrenarche, gonadarche occurs when there is increased pulsatile GnRH secretion from hypothalamus leading to production of FSH and LH, which stimulate the ovary to produce estrogen. what does this trigger?
thelarche- development of breasts pubarche- development of hair in axilla/pubic area growth spurt menarche
what is the first phenotypic sign in puberty in females? what hormone causes this?
thelarche- development of buds around 10 (note that pubarche can be first sign in AA) circulating estrogen