Puberty in girls is the period that links childhood to adulthood. It is the phase of gradual development of secondary sexual characteristics. This stage includes profound biological, morphological, and psychological changes leading to full sexual maturity.
Normal Puberty
Morphological Changes
- Breast Budding (Thelarche)
- Pubic & Axillary Hair
Growth (Adrenarche)
- Growth in Height
- Menstruation (Menarche)
Hormonal
Changes
- Thyroid Gland - Leptin production
- Menarche - Hypothalamic-Pituitary-Gonadal axis
activation
- Adrenal Glands - Steroid hormone production
- Gonadarche - Initiation of ovarian function
Genital
Changes
- Shape - Elongation and increased bulk
- Follicular Enlargement - Proliferation of stromal cells
- Vagina - Increased estrogen levels, glycogen
deposits → Acidic pH due to Lactobacilli
- Breasts - Increased size, fat deposition, and
duct system development
- Tanner Staging - Classification of pubertal development into five stages
Abnormal Puberty
Precocious
Puberty
Defined
as the appearance of secondary sexual characteristics before the age of 8 years or
menarche before 10 years.
1.
Gonadotropin-Dependent
(True/Complete Precocious Puberty)
o Constitutional (Most common)
o Juvenile Primary Hypothyroidism
o CNS lesions (Tumors, Trauma, Infections -
Tuberculosis, Encephalitis)
o Neurofibromatosis, Craniopharyngioma
2. Gonadotropin-Independent
(Peripheral Precocious Puberty)
o Granulosa Cell Tumors
o Theca Cell Tumors
o Leydig Cell Tumors
o Choriocarcinoma
o Arrhenoblastoma
o McCune-Albright Syndrome
o Adrenal Hyperplasia or Tumors
o Hepatoblastoma
o Exogenous Estrogen or Androgen Exposure
Variants of
Precocious Puberty
- Premature Thelarche - Isolated breast development before 8 years
- Premature Pubarche - Early pubic or axillary hair growth
before 8 years
- Premature Menarche - Isolated vaginal bleeding without
other secondary sexual characteristics
Delayed
Puberty
- Absence of breast development &
pubic hair by 13-14 years
- Absence of menarche by 16 years
1.
Causes
o Hypogonadotropic
Hypogonadism (Low gonadotropins,
underactive gonads)
§ Gonadal Dysgenesis (Turner Syndrome - 45XO,
Pure Gonadal Dysgenesis - 46XX, 46XY)
§ Ovarian Failure (46XX)
§ Gonadotropin Deficiency (Isolated
Gonadotropin Deficiency)
§ Constitutional Delay
§ Chronic Illness, Malnutrition
§ Primary Hypothyroidism
o Anatomical
Causes
§ Müllerian Agenesis
§ Imperforate Hymen
§ Transverse Vaginal Septum
Treatment
- Gonadotropin Therapy - If due to pituitary or hypothalamic
dysfunction
- Estrogen Therapy - For hypogonadism
- Corrective Surgery - For anatomical defects.
Endocrinology in Puberty
1.
Hormonal Changes in Puberty
o
Thyroid Gland: Secretion of leptin.
o
Menarche: Involves the hypothalamo-pituitary-gonadal axis
activation.
o
Adrenal Glands: Responsible for steroid production (adrenarche).
o
Gonadarche: Initiation of ovarian function.
2.
First Menstruation (Menarche)
o
The first menstrual cycle is called menarche.
o
Age of onset: 10-16 years
(Average 13 years).
o
Estrogen levels increase, leading to endometrial proliferation.
o
The first menstrual cycle is usually anovulatory.
3.
Changes in Genital Organs
o
Shape: Elongated and bulkier.
o
Follicular Enlargement: Stimulation
of stromal cells.
o
Vagina:
§ Increased estrogen → More glycogen → Increased Lactobacilli activity → Acidic pH (pH 4-5).
§ Becomes more active and sensitive.
o
Breasts:
§ Enlargement of mons pubis & labia majora.
§ Duct system proliferation and fat
deposition.
§ More alveolar development.
4. Tanner Staging (Classification of Pubertal Development)
Common
Disorders in Puberty
1. Precocious
Puberty
o
The term precocious puberty
is used for girls who exhibit any secondary sexual characteristics before
the age of 8 or menstruation
before the age of 10.
Types:
o
Gonadotropin-Dependent (Complete, Central,
Isosexual or True Precocious Puberty)
§ Constitutional (Most Common)
§ Juvenile Primary Hypothyroidism
§ CNS Lesions (Tumors, Trauma, Infections)
§ Tuberculosis
§ Encephalitis
§ Neurofibromatosis
§ Craniopharyngioma
o
Gonadotropin-Independent (Peripheral
Precocious Puberty)
§ Granulosa Cell Tumor
§ Theca Cell Tumor
§ Leydig Cell Tumor
§ Choriocarcinoma
§ Arrhenoblastoma
§ McCune-Albright Syndrome
§ Adrenal Hyperplasia or Tumors
§ Hepatoblastoma
§ Exogenous Estrogen or Androgen Intake
2. Variants of
Precocious Puberty
o
Premature Thelarche: Isolated
breast development before the age of 8
years, commonly seen in 2-4
years old girls.
o
Premature Pubarche: Isolated axillary and pubic hair growth before 8 years.
o
Premature Menarche: Isolated cyclic vaginal bleeding without the
appearance of other secondary sexual characteristics.
3. Delayed Puberty
o
Absence of breast development and pubic hair
by 13-14 years.
o
Absence of menarche by 16 years.
Causes:
o
Hypogonadotropic Hypogonadism (Low
gonadotropins, underactive gonads)
§ Gonadal Dysgenesis (Turner Syndrome - 45XO, Pure Gonadal Dysgenesis - 46XX, 46XY)
§ Ovarian Failure (46XX)
§ Gonadotropin Deficiency (Isolated Gonadotropin Deficiency)
§ Constitutional Delay
§ Chronic Illness, Malnutrition
§ Primary Hypothyroidism
o
Anatomical Causes
§ Müllerian Agenesis
§ Imperforate Hymen
§ Transverse Vaginal Septum
4.
Treatment
o
Gonadotropin Therapy - If due to
pituitary or hypothalamic dysfunction.
o
Estrogen Therapy - For hypogonadism.
o
Corrective Surgery - For
anatomical defects.