➢ PUBERTY :-
DEFINITION :
The physiological, biological and morphological changes in the human body is known as puberty .
It’s seen in both gender , male & female .
1) In male :- following Symptoms are seen …
1) Chest hair growth
2) Pubic hair growth
3) Axillary hair growth
4) Voice changes
5) Testes & penis get bigger
Sexual and other physical maturation that happens during puberty result from hormonal changes.
In boys, it's hard to know exactly when puberty is coming. There are changes that happen, but they occur slowly over a period of time rather than as a single event.
There are certain stages of development that boys go through when developing secondary sex characteristics.
Here is a brief overview of the changes that happen:
• In boys, the first puberty change is the enlargement of the scrotum and testes. At this point, the penis does not enlarge.
• As the testes and scrotum continue to grow, the penis grows.
• The first growth of pubic hair produces long, soft hair that is only in a small area around the genitals.
• This hair then becomes darker and coarser as it continues to spread.
• The pubic hair eventually looks like adult hair, but in a smaller area. It may spread to the thighs and sometimes up the stomach.
• Body size will increase. Sometimes the feet, arms, legs, and hands may grow faster than the rest of the body. This may cause a teen to feel clumsy.
• Some boys may get some swelling in the breast area. This is a result of the hormonal changes that are happening. This is common among teenage boys and is often a short-term or temporary condition. Talk with your son's healthcare provider if this is a concern.
• Voice changes may happen, as the voice gets deeper. Sometimes the voice may "crack" during this time. This is a temporary condition and will improve over time.
• Hair will start to grow in the genital area. Boys will also have hair growth on their face, under their arms, and on their legs.
• As the puberty hormones increase, teens may have an increase in oily skin and sweating. This is a normal part of growing. It's important to wash daily, including the face. Acne may develop.
• As the penis enlarges, the teen boy may begin to have erections. This is when the penis becomes hard and erect because it is filled with blood. This is due to hormonal changes and may happen when the boy fantasizes about sexual things. Or it may happen for no reason at all. This is normal.
• During puberty, a boy's body also begins making sperm. Semen, which is made up of sperm and other body fluids, may be released during an erection. This is called ejaculation. Sometimes this may happen while the teen is sleeping. This is called a wet dream (nocturnal emission). This is a normal part of puberty. Once sperm is made and ejaculation happens, teen boys who have sex can get someone pregnant.
2) In female :-
Following Symptoms are seen…
1) Breast growth
2) Public hair growth
3) Axillary hair growth
4) Voice changes
5) Peak growth in height
6) Menstruation
• Morphological changes :- there are 6 important physical changes during puberty in female.
Most of the changes occur gradually but only the menarche or menstruation may be dated. all these are usually complete between age of 10 to 16 year .
Controlling factors for onset of puberty are genetic , nutritional factor , body weight , psychological state , social & cultural background .
• Endocrinology in puberty :- The level of gonadal steroids & gonadotropin are low untill the age of 6-8 years. these is mainly due to the negative feedback effect of estrogen to the hypothelic pituitary system .
1) Hypothalamopituitary gonadal axis :- The gonadotropin releasing hormone pulses from hypothalamus results in pulsatile gonadotropin secretion.
GnRH – FSH , LH -estradiol
2) Thyroid gland :- play an active role in the hypothalamopituitary gonadal axis .
3) Adrenal gland :- increase their activities of sex steroid synthesis . Increased sebum formation , pubic & axillary hair & change in voice are primarily due to adrenal androgen production.
4) Gonadarche :- increase amplitude & frequency of GnRH it’s increase secretion of FSH & LH it’s increase ovarian follicular development & then increase estrogen .
5) Leptin :- a peptide , secreted in the adipose tissue is also involved in puberty in pubertal changes & menarche . Leptin is important for feedback involving GnRH & LH pulsatility .
6) Kisspeptin :- it’s a hypothalamic hormone . It stimulates the release of GnRH . kisspeptin is thought to initiate puberty .
• MENARCHE :-
DEFINITION :- The onset of first menstruation in life is called MENARCHE . It may occur anywhere between 10 to 16 years but the peak time is 13th year .
The 1st period is usually anovular.
The ovulation may be irregular for a variable period following MENARCHE & may take about 2 years for regular ovulation to occurs. the menses may be irregular to start with.
• GROWTH :- growth of height in an adolescent girls is mainly due to estrogen hormone.
• CHANGES IN GENITAL ORGANS :-
1) Ovaries :- change in shape , the elongated sahos becomes bulky & oval .
2) The uterine body & the cervix ratio at birth is about 1:2 the ratio became 1:1 when MENARCHE occurs .
3) Vagina :- The vaginal changes are more pronounced .a few layer of thin epithelium in a child become stratified epithelium of many layers
4) The vulva is more reactive to steroids hormones , the mons pubis & the labia minora increase in size .
5) Breast changes are pronounced .under the influence of estrogen .the breast becomes prominent & round .
➢ COMMON DISORDERS OF PUBERTY
• Precocious puberty
• Delayed puberty
• Menstrual abnormalities
1) PRECOCIOUS PUBERTY :-
Definition :-
The term precocious puberty is reserved for girls who exhibit any secondary sex characters before the age of 8 year or menstruate before age of 10 year .
Types or cause :-
Diagnosis :-
meticulous history taking & physical examinations are essential .
Basic investigation :-
1) Serum HCG ,LH FSH & PRL .
2) Thyroid profile
3) USG ,CT OR MRI of abdomen & pelvis
4) Serum estradiol , testosterone , 17-OH progesterone
5) EEG of abdomen
6) GnRH stimulation test
TREATMENT :-
Treatment depends upon the cause & speed of progress of disease .
- The estrogen therapy should stop
- Cortisone therapy for adrenal hyperplasia and surgery to remove the adrenal or ovarian tumor .
DRUG USE & DOSE :-
Depot forms once a month can be used , dose is adjusted to maintain the serum estradiol below 10 pg/ml
Leuprolide acetate can be given 7.5 mg 4 weekly although 3 month regimen are available .
Medroxyprogesterone acetate – 30 mg daily orally or 100-200 mg . IM weekly to suppress gonadal steroids . It can suppress menstruation & breast development .
2) DELAYED PUBERTY :-
Definition :-
Puberty is said to be delayed when the breast tissue & pubic hair have not appeared by 13-14 years or menarche appears as late as 16 years
CAUSE :-
DIAGNOSIS :-
A. Examination of secondary sexual characters
B. Serum FSH , PRL TSH ,T4
C. Abnormal sellar CT /MRI
TREATMENT :-
Assurance improvement of general health & treatment of any illness may be of help in nonendocrinal cause .
Unopposed estrogen 0.3 mg daily given for 1st 6 months ,then combined estrogen & progestin , sequential regimen is started.
3) MENSTRUAL ABNORMALITIES :-
The period may be heavy , irregular or scanty initially .
CAUSE :-
A. Dysfunctional uterine bleeding
B. Endocrine dysfunction
C. Hematological
D. Pelvic tumors
E. Pregnancy complications
INVESTIGATION :-
A. Hematological examination
B. Clotting time
C. Platelet count
D. Thyroid profile
MANAGEMENT :-
Blood transfusion may be needed
Medroxyprogesterone acetate or norethisterone 5 mg thrice daily is given till bleeding stops. Usually bleeding controlled within 3-7 day & medicine continue for 21 days .
In emergency conjugate equine estrogen 20-40 mg IV is given every 6-8 hours , once bleeding controlled combined oral pills are started .
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