Professional Documents
Culture Documents
Delayed Puberty - A Disorder in Timing
Delayed Puberty - A Disorder in Timing
Delayed Puberty - A Disorder in Timing
Disorder in Timing
Physical Examination
• Examination of Growth
• Height
• Weight
• Head circumference
• Upper to lower segment ratios
• Pubertal Assessment (Tanner staging)
• Axillary hair
• Pubic hair & staging
• Breast development & staging
• Genital development & staging
• Neurological assessment
Breasts (female)
• Tanner I
• no glandular tissue; areola follows the skin contours of the chest (prepubertal)
[typically age 10 and younger]
• Tanner II
• breast bud forms, with small area of surrounding glandular tissue; areola begins to
widen [10-11.5]
• Tanner III
• breast begins to become more elevated, and extends beyond the borders of the
areola, which continues to widen but remains in contour with surrounding breast
[11.5-13]
• Tanner IV
• increased breast size and elevation; areola and papilla form a secondary mound
projecting from the contour of the surrounding breast [13-15]
• Tanner V
• breast reaches final adult size; areola returns to contour of the surrounding breast,
with a projecting central papilla. [15+]
Normal Pubertal Physiology
- HPG axis (hypothalamic-
pituitary-gonadal) is
essential in turning on
puberty at appropriate
times
- Pulsatile secretion of
GnRH is essential
- GnRH is produced in
hypothalamus (in arcuate
nucleus)
- GnRH travels to the
anterior pituitary to
stimulate the production
of LH & FSH
Role of Gonadotropins
• FSH
• Stimulates androstenedione by the ovary
• Involved in spermatogenesis in the testes
• Induces receptors for LH
• LH
• Uses androstenedione for substrate to produce
estradiol in theca cells
• Stimulates testosterone synthesis by Leydig cells
• FSH is usually higher than LH in prepubertal stages,
and this reverses in pubertal stages
Age of Pubertal Progression
• Females
• The larche
• Generally considered the onset of puberty
• Occurs in most girls at 9.5-10.4
• Menarche
• Mean age of onset = 12 yrs
• Adrenarche
• Usual onset at approx age 9.4-10.6 yrs
• Linear Growth
• Generally occurs before Tanner Stage 2 breast development
• Generally adds 20-25cm of height in females
• GH increases during puberty as well (provides 50% of growth spurt)
• Males
• Gonadarche
• Testicular enlargement generally heralds the onset of puberty (testes >
4ml). This usually starts around 10.8-11.1 yrs.
• Initial increases in testicular size are due to increase in Sertoli (supporting
cells)
• Average time to complete genital development = 3yrs
• Thelarche
• 2/3 of males will have gynecomastia develop during puberty
(midpubertal)
• Gynecomastia results from direct testicular secretion of estrogen as well
as peripheral conversion of prohormones to estrogen
• Pubarche
• Linear growth
• Peak growth generally occurs after Tanner Stage 5
• Generally adds 25-30cm in height for males
Pubertal Milestones
Females Males
Tanner stage 2 breasts Testicular growth
Tanner stage 2 pubic hair Tanner 2 genital development
Peak linear growth Tanner stage 2 pubic hair
Greatest weight gain Tanner stage 3 genital
Tanner stage 3 breast Tanner stage 3 pubic hair
Axillary hair growth Peak linear growth
Acne Onset of pubertal gynecomastia
Menarche Axillary hair
Tanner stage 4 breast Voice pitch changes
Tanner stage 4 pubic hair Acne
Pubertal Delay
• LH gene defects and FSH gene defects can result in high levels of
FSH & LH with low sex steroids
• Secondary sex characteristics are driven by LH effects, can have FSH
receptor defect & normal secondary sex characteristics
Eugonadotropic pubertal delay