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Normal Puberty Hengameh Normal Puberty Hengameh

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Normal Puberty Hengameh - PPT Presentation

Abdi MD Endocrinologist Endocrine Research Center Research Institute for Endocrine Sciences Shahid Beheshti University of Medical Sciences 30 July 2015 Introduction Puberty is not a de novo event but rather a phase in ID: 779464

stage puberty development hair puberty stage hair development boys pubic girls pubertal menarche onset breast growth median serum testes

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Slide1

Normal Puberty

Hengameh Abdi, MD, EndocrinologistEndocrine Research CenterResearch Institute for Endocrine SciencesShahid Beheshti University of Medical Sciences30 July 2015

Slide2

Introduction:

Puberty is not a de novo event but rather a phase in the continuum of development of gonadal function and the ontogeny of the hypothalamic-pituitary-gonadal system from the fetus to full sexual maturation and fertility. During puberty, secondary sexual characteristics appear, and

the adolescent

growth spurt

occurs, resulting in the striking sex dimorphism of mature individuals; fertility is achieved, and profound psychological effects ensue.

2

Slide3

Agenda:

Control of the onset of human puberty Hormonal changes during puberty Secondary sexual characteristics Adrenarche Other changes of puberty Puberty in Iran

3

Slide4

The neuroendocrine control of puberty is

mediated by the hypothalamic GnRH-secreting neurosecretory neurons in the medial basal hypothalamus, which act as an endogenous pulse generator (oscillator).

(KISS1R)

4

Slide5

Dual mechanism for the inhibition of puberty (Juvenile pause)

5

Styne

DM,

Grumbach

MM.

P

uberty. In:

Melmed

S, ed. Williams Textbook of Endocrinology. Elsevier Saunders 2011. 1088

Slide6

Change in the pattern of pulsatile FSH and LH secretion

6

Styne

DM,

Grumbach

MM.

P

uberty. In:

Melmed

S, ed. Williams Textbook of Endocrinology. Elsevier Saunders 2011. 1088

Slide7

Timing and onset of puberty:

Genetic neural control: Increased pulsatile release of GnRH caused by a balance in the inhibitory and excitatory factors Genetic factors are

estimated to

account for

50% to 80% of the variation in the onset of normal puberty.EthnicityEnvironmental factors:

Socioeconomic

factors

(such as family stress or the presence of an adult

nonbiologically

-related

male)

Nutrition

and

Physical activity

General health

Geography

Environmental endocrine

disruptors

(environmental contaminants that may affect endocrine processes)

7

Slide8

Timing and onset of puberty:(cont.)

Body fat and Leptin Leptin appears to be one of several factors that influence the maturation of the gonadotropin-releasing hormone (GnRH) pulse generator. Serum leptin concentrations increase immediately before puberty in both genders.8

Slide9

Mean plasma estradiol, FSH and LH in

prepubertal and pubertal females by pubertal stage of maturationGrumbach MM. Onset of puberty. In: Berenberg SR, ed. Puberty, Biologic and Social Components. Leiden, The Netherlands: H.E

.

Stenfert

Kroese, 1975:1-21.9

Slide10

Mean plasma testosterone, FSH and LH in

prepubertal and pubertal males by pubertal stage of maturationGrumbach MM. Onset of puberty. In

:

Berenberg

SR, ed. Puberty, Biologic and Social Components. Leiden, The Netherlands: H.E. Stenfert Kroese, 1975:1-21.10

Slide11

Laboratory information:

GnRH/GnRH agonist test The basal values of serum LH and FSH measured in modern supersensitive assays:Serum LH >0.2 IU/L on ICMA or >0.6 IU/L on IFMA are specific but not sensitive for the onset of puberty.

Urine LH

and FSH measured in ultrasensitive assays:A 5-fold rise in urinary FSH in boys and girls, with

a

50-fold

rise in urinary LH in boys and a

100-fold rise

in girls during puberty.

11

Slide12

Laboratory information:(cont.)

Onset of puberty in boys is indicated by:Testes >2.5 cm in length (volume >3 ml)Serum testosterone concentration >50 ng/dLPubertal LH response to GnRH bolus

Pubertal pattern of LH

pulsatility

Serum testosterone >20 ng/dL predicts enlargement of testes to greater than 4 mL by 12 months

in 77% of cases and in 15 months in 100% of

case.

Prepubertal

boys have serum testosterone <10 ng/

dL

.

Prepubertal

girls have serum estradiol <5-10

pg

/

mL.

12

Slide13

What to expect in girls during puberty?

13

Slide14

Pubertal maturation in girls:

Increase in height velocity (rather than breast development or thelarche) is usually the first sign of puberty in girls, although breast budding is what most lay or medical observers first notice

.

A

substantial minority have pubic hair as the initial manifestation (pubarche).Menarche occurs, on average, 2.6 years after the onset of puberty (Menarche usually occurs in the 6-month

period

preceding or

following the fusion of the second and first distal

phalanges and

the appearance of the sesamoid

bone)

The

95

th

percentile

for menarche is 14.5

years.

14

Slide15

Stages of breast development according to

Marshall and Tanner Stage 1: preadolescent; elevation of papilla only.Stage 2: breast bud stage; elevation of breast and papilla as a small mound, with enlargement of the areolar diameter.

Stage

3:

further enlargement of the breast and areola, with no separation of their contours. Stage 4: projection of the areola and papilla to form a secondary mound above the level of the breast.

Stage 5:

mature

stage; projection of the papilla only, resulting from recession of

the areola

to the general

contour.

15

Slide16

Stages of

female pubic hair development according to Marshall and Tanner Stage 1: preadolescent; the vellus over the pubes is not further developed than that over the anterior abdominal wall; there is no pubic hair.Stage 2: sparse growth of long, slightly pigmented, downy hair that is straight or only slightly curled, appearing chiefly along the labia. Stage

3:

hair is considerably darker, coarser,

and curlier. The hair spreads sparsely over the junction of the pubic region. Stage 4: hair is adult in type, but the area covered by it is still considerably

smaller than

in most adults. There is no spread to the medial surface of the thighs.

Stage 5:

hair is adult in quantity and type, distributed as an inverse

triangle of

the classic feminine pattern. The spread is to the medial surface of

the thighs

but not up the

linea

alba or elsewhere above the base of the

inverse triangle

.

16

Slide17

The sequence of events at puberty in females

The stage of breast development usually progresses along with the stage of pubic hair development in normal girls, but because different endocrine organs control these two processes, discordance can occur.17

Slide18

The sequence of events at puberty in females

Root AW. J Pediatr. 1973; 83(1)18Because girls reach PHV about 1.3 years before menarche, there is limited growth potential after

menarche; most

girls grow only about 2.5 cm taller after

menarche, although there is a variation from 1 to 7 cm.

Slide19

What to expect in

boys during puberty?19

Slide20

Pubertal maturation in boys:

Growth of the testes is usually the first sign of puberty in the male. Pubertal testicular enlargement is indicated when the longitudinal measurement of a testis is greater than 2.5 cm (excluding the epididymis) or the volume is greater than 4 mL.

Almost all boys have an increase in testicular volume (≥3 mL) prior to the appearance of penile growth and pubic

hair.

20

Slide21

Stages of male genital development according to Marshall and Tanner

Stage 1: preadolescent. Testes, scrotum, and penis are about the same size and proportion as in early childhood. Stage 2: the scrotum and testes have enlarged; the scrotal skin shows a change in texture and some reddening.

Stage 3:

growth

of the penis has occurred, at first mainly in length but with some increase in breadth; there is further growth of the testes and scrotum. Stage 4: the penis is further enlarged in length and breadth, along with

development of

the glans. The testes and scrotum are further enlarged. The scrotal

skin has

further darkened.

Stage

5:

genitalia are adult in size and shape. No

further enlargement

takes place after stage 5 is reached.

21

Slide22

Stages of male pubic hair development according to Marshall and Tanner

Stage 1: preadolescent; the vellus over the pubic region is not further developed than that over the abdominal wall; there is no pubic hair.Stage 2: sparse growth of long, slightly pigmented, downy hair that is straight or

slightly curled

, appearing chiefly at the base of the penis.

Stage 3: hair is considerably darker, coarser, and curlier and spreads sparsely over the junction of the pubes.

Stage

4:

hair is adult in type, but the area it covers is still

considerably smaller

than in most adults. There is no spread to the medial surface of

the thighs

.

Stage

5:

hair is adult in quantity and type, distributed as an

inverse triangle

. The spread is to the medial surface of the thighs but not up

the

linea

alba or elsewhere above the base of

the inverse

triangle

.

22

Slide23

The sequence of events at puberty in males

The growth and maturation of the penis usually correlates closely with pubic hair development, because both features are under androgen control.23

Slide24

The sequence of events at puberty in

malesRoot AW. J Pediatr. 1973; 83(1)24

Slide25

Peak Height Velocity: G (8.3 cm/

yr), B (9.5 cm/yr)Mean age (pubertal stage): G: 11.5 yr (2-3), B: 13.5 yr (3-4)

Grumbach

MM. J

Pediatr Endocrinol

Metab

. 2000; 13[

suppl

6]: 1439-1455

25

Slide26

Adrenarche:

Adrenarche describes the maturational increase in adrenal androgen production, which begins at about six years of age in both girls and boys. Adrenarche seems to be unrelated to the pubertal maturation of the hypothalamic-pituitary-gonadal axis.Premature adrenarche refers to the rise in serum concentrations of adrenal androgens that causes the appearance of the pubic

hair:

Boys: <9 yr African American girls: <6 yr

White American girls:

<7

yr

26

Slide27

Adrenarche:

(cont.)Adrenarchal androgens contribute to development of sebaceous glands and pubic hair (pubarche), and possibly to bone mineralization.27

Slide28

Other changes of puberty:

Voice in boys: breaking of the voice occurs at approximately 13 years, and the adult voice is achieved by about 15 years. Facial hair in boys: P3 P5G5

Spermarche

is the age at first ejaculation (heralded by nocturnal sperm emissions and appearance of sperm in the urine): mean age of 13.5Axillary hair: B: 14 yr African American G: 12

yr

(White G: later

)

Acne

:

Acne vulgaris can be the first notable sign of puberty in a girl, preceding pubic hair and breast development; In boys, progresses with advancement through puberty. 100% of boys have

comedones

by genital stage 5.

28

Slide29

Other changes of puberty:(cont.)

Vagina: Structural changes; secretion of clear or whitish discharge increases in the months before menarche. Ovaries: The ultrasound appearance of the

prepubertal

ovary changes with pulsatile gonadotropin secretion, and a multicystic appearance occurs with more than six follicles of at least 4 mm in diameter; During prepuberty

, the ovarian volume is 0.2 to 1.6 mL on

ultrasound scans

, and after the onset of puberty, the

volume increases

to 2.8 to 15

mL

.

Uterus:

The

length of the uterus increases from 2 to 3

cm to

5 to 8 cm; and the volume increases from 0.4 to 1.6

mL to

3 to 15

mL.

29

Slide30

Puberty in Iran

Slide31

Pubertal development in Iranian girls: Comparison with other countries

Country/TimeProvinceAge at B2Age at P2Age at Menarche

Iran,

2001-2004

Tehran, (n=4020)Mean (95% CI)10.15 (10-10.28)Mean (95% CI)10.48 (10.34-10.62)Mean (95% CI)

14.54 (14.47-14.63)

Iran,

2003-2004

Razzaghy-Azar

et al.

Tehran, (n=1420)

Median (10-90)

9.74 (8.23-11.94)

2.5

th

percentile: 7.42

97.5

th

percentile: 13.11

Median (10-90)

10.49 (8.86-12.17)

2.5

th

percentile: 7.03

97.5

th

percentile: 13.10

Median (10-90)

12.68 (11.27-15.96)

(n=399)

Iran,

2005-2006

Isfahan

(n=3192)

Median (10-90)

10.14 (8.33-11.95)

Median (10-90)

10.78 (9-12.48)

Median (10-90)

12.65 (11.18-14.11)

USA,

1997

Mean (SD)

9.96 ± 1.82

Mean (SD)

10.51 ± 1.67

Mean (SD)

12.88 ± 1.20

Denmark, 1991-1993

Mean

10.88

Mean

11.29

Mean

13.42

Netherlands,

1965-1997

Mean

10.5

Mean

10.8

Mean

13.15

UK, 1969

Mean

11.1

Mean

11.7

Mean

12.9

Slide32

Probability of different stages of

breast development in 6–18-year-old Iranian girlsRazzaghy-Azar M. Annals of Human Biology. 2006; 33(5/6): 628–63332

Slide33

Probability of different stages of

pubic hair development in 6–18-year-old Iranian girlsRazzaghy-Azar M. Annals of Human Biology. 2006;

33(5/6): 628–633

33

Slide34

Probability of

the occurrence of menarche in 6–18-year-old Iranian girlsRazzaghy-Azar M. Annals of Human Biology. 2006; 33(5/6): 628–63334

Slide35

Pubertal development in Iranian boys: Comparison with other studies

Country/TimeProvinceP2G2Iran, 2003-2004

Tehran, (n=792)

Median (10-90)

10.34 (6.84-13.10)Median (10-90)9.01 (?-11.84)

USA,

1995

Ohio

(n=78)

Mean (SD)

11.2 ± 0.8

Mean (SD)

11.2

± 0.7

USA,

2001

(n=2114)

African-Americans 11.2

Whites 12.0

African-Americans 9.5

Whites 10.1

35

Slide36

Probability of different stages

of pubic hair and genital developmentin 6–15-year-old Iranian boys

Razzaghy

-Azar M. Journal of Iran University of Medical Sciences. 2006

36

Slide37

Timing of puberty in Iranian girls according to their living areas

The lowest age of menarche: 1) Tehran: 11.99 ± 1.35 yr 2) Fars: 12.40 ± 1.27 yrThe lowest age of thelarche:

1)

Ghazvin-Zanjan: 8.97 ± 1.45 yrHighest age of pubarche:

1)

Kordestan-Lorestan-Ilam

region: 10.70

±

1.23

yr

Motlagh

ME. J Res Med Sci. 2011; 16(3): 276-281

37

Slide38

Thanks for your patience!