PUBERTY

ENDOCRINOLOGY DIVISION
DEPARTMENT OF CHILD HEALTH
MEDICAL SCHOOL
UNIVERSITY OF SUMATERA UTARA
 What is Puberty?
Puberty, from the Latin word: Pubertas
 age of maturity  refers to the stage of transition from the
sexually immature child to the potentially fertile adolescent, during
which secondary sexual characteristics appear and the ability to
procreate is established.

Close interaction between the hypothalamic-pituitary-gonadal axis

(HPG axis) & adrenal cortex.
 HPG axis  Sexual characteristics (breast, increase
in testicular and penile size, menarche.
 Adrenal androgen  Sexual hair (pubarche), acne,
axillary odour

Understanding of regulation and progress of puberty is

crucial for evaluation and management of pubertal disorders
Timing of Puberty

Endocrine Reviews, 2003

Endocrine Reviews, 2003
Ontogeny of Puberty
How Puberty Begins
HYPOTHALAMIC-PITUITARY-GONADAL (HPG) AXIS
Central signals Peripheral signals
(GABA, NPY, Glutamate) (Leptin, Ghrelin)

Kisspeptin

GnRH

Pituitary

LH FSH
LH

Testis Ovary

Ley Ser Gran The

Testosterone Inhibin Estradiol

Nutritional theory
 Weight gain & %age body fat prerequisite to puberty →
critical weight for activation of HPG axis
 47-48 kg / 17% fat
 Slightly obese ( 30% ideal BW) begin puberty earlier
 >30% fat → delayed puberty
Gonadostat Hypothesis
 Prepubertal: negative
feedback regulation of FSH /
LH secretion → low
threshold & sensitive to low
levels of steroids
 Puberty: sensitivity  
gonadotrophins & sex
steroids 
Hormonal changes at puberty
 Adrenarche (“mini puberty”)
2-3 yrs before gonadarche → age 6 - 8 yrs
 cortex adrenal activity →  adrenal androgens production
(DHEA, DHEAS & androstenedione) → pubic and axillary hair
 Gonadarche
Pulsatile GnRH secretion leads to stimulation of FSH/LH →
activation of gonad →  sex steroids & completion of
gametogenesis → maturation reproductive organs
development of H-P-G axis

 HPG axis functions during fetal life & during first few weeks
following birth, then becomes quiescent
 Puberty: reactivation of HPG axis
 HORMONAL CHANGES IN PUBERTY

 Increased GnRH secretion  the first identifiable event of

puberty.
 At the onset of puberty  LH pulse secretion are evident only
during the night, approximately 1-3 years before any external
signs of puberty are manifest. Mid puberty  LH pulse
secretion appears during the day. Adulthood  The day/night
pattern disappears
 Increase LH levels as much as 25x during puberty as compared
to FSH (2,5 fold)  LH level  Better indicators of pubertal
status compared to FSH levels.
Hormonal changes at puberty
 Prepubertal
 LH/FSH levels low →
insufficient to initiate gonadal
function
 Onset of puberty → 
activity GnRH pulse
generator
  frequency & amplitude
GnRH pulses, especially
during sleep → progressive 
LH/FSH→ initiate gonadal
function
 nocturnal gonadotropin
pulses (onset) → daytime
gonadotropin pulses
Serum Gonadotropin and sex steroid levels in relation to Sexual
Maturity Rating (SMR)

BOYS
SMR Stage 1 2 3 4 5
LH (IU/L) 0,1 – 0,3 0,4 – 2,3 0,5 – 1,8 0,3 – 1,6 1,5 – 6,3
FSH (IU/L) 0,1 – 0,9 0,1 – 2,8 0,3 – 3,0 0,4 – 5,0 0,6 – 5,0
Testosterone <3 – 10 18 – 150 100 – 320 220 – 620 350 – 970
(ng/dL)
GIRLS
SMR Stage 1 2 3 4 5
LH (IU/L) 0,1 – 0,2 0,1 – 4,1 0,5 – 4,3 1,0 – 4,0 0,8 – 12,1
FSH (IU/L) 0,1 – 2,1 0,4 – 2,8 0,8 – 4,6 1,0 – 8,8 0,1 – 6,7
Estradiol 5 – 20 10 – 24 7 – 60 21 – 85 34 – 170
(pg/mL)
Influencing factors
1. Genetics : 50 – 80% of variation in pubertal timing
2. Environmental factors e.g. nutritional status
3. Leptin  Regulates appetite and metabolism
through hypothalamus. Permissive role in
reegulation of timing of puberty.
4. Adrenarche : development of pubic and axillary hair,
body odour, and acne
 Hormonal changes..

Hormones: Physical:
-Gonadotroin -Reproductive system
-Sex Steroid -Secondary sex characteristics
-Growth hormone -Growth spurt

Final Height
Maturation reproductive system
Fertility
DISORDER of PUBERTY
Female Puberty
What is the age of onset of puberty ?

Females : 8 – 13 years
Female hormonal changes
 Estrogen induces secondary
sex characteristics:
growth of pelvis
deposit of subcutaneous fat
growth of internal
reproductive organs,
external genitalia
 androgen release by adrenal
glands increases > growth
of pubic hair, lowering of
voice, growth of bone,
increased secretion from
sebaceous glands
Physical Changes of Puberty *GIRLS*
Estrogen
 Stimulates growth of the uterus
- Corpus/Cervix ratio ↑
Pepubertal < 1  Pubertal = 1
- Endometrium proliferation
 Stimulates endometrial growth
 Stimulates cervical mucus secretion
 Labia Majora : Pigmentation, vascularisation, ↑ erotisation
 Enlargement of clitoris
 Vagina: - Mucosal thickening
-Changes in Epithelial cell ratio (superficial, intermediate,
parabasal)
-↑ glicogen deposit  pH ↓, fungal infection
 Sequence of Sexual Maturation

Age
Event
(years)
Thelarche 10-11
Pubarche 10.5-11.5
Growth Spurt 11-12
Menarche 11.5-13
Adult Breast
12.5-15
Development
Adult Sexual Hair 13.5-16
 LH, FSH and E2 - PUBERTAL STAGE
Hormonal changes Secondary sexual characteristic
changes (tanner stage)

1 2 3 4 5
Female Puberty landmark
 Breast budding –
 1st sign of puberty
 Menarche –
 2 yrs > onset of puberty
 Ovulation-
 2 yrs > menarche
 Growth spurt –
 early Tanner stage
 Final Height -
Male Puberty
Physical Changes of Puberty *BOYS*

Testosterone:
 Growth of male genital organs, pubic hair, and
sebaceous glands.
 Testosterone and estrogen  responsible for growth
spurt, directly or indirectly by increasing GH
production.
 Both hormones stimulate epiphyseal growth and
maturation, though estrogen is ultimately responsible
for epiphyseal fusion.
 Enlargement of testes (≥ 4 ml in volume or ≥ 2,5 cm length)
 First Manifestation of puberty in boys.
 Followed by penile growth with thickening and pigmentation
of the scrotum.
 Pubic hair appears around 1 year after pubertal onset and
body odour develops.
 Axillary hair and facial hair develop towards mid-puberty,
after 14 years of age.
≥ 4 ml
Siklus Menstruasi

 Menstruasi: Terjadi akibat interaksi hormon yang

dihasilkan oleh hipotalamus, hipofisis dan ovarium.

 Data Third National Health and Nutrition Examination

Survey (NHANES) umur rata-rata menarche remaja
Amerika adalah 12,43 tahun. Walaupun hampir 90%
remaja mencapai menarche pada stadium Tanner 4.
 Lamanya siklus menstruasi: jumlah hari mulai hari
pertama keluarnya darah sampai menstruasi pada siklus
berikutnya.

 Rata-rata lama siklus 21-35 hari, rata-rata keluarnya

darah 3-7 hari dan kehilangan darah 30-40 ml per hari.

 Siklus menstruasi dibedakan menjadi 2 fase: fase folikular

atau proliferatif (fase estrogen) dan fase luteal atau
sekresi (fase progesterone)
Kadar hormon & perubahan endometrium selama siklus menstruasi
Any Questions ?????