2. What is puberty?
• biological changes and sexual maturation that
occur during the transition from childhood to
adulthood
• Average age of onset:
–10 (range 8-13) years in Girls
–12 (range 10-15) years in Boys
3. Important items in the puberty evaluation
History :
- Growth record
- Family history of growth disorders and ages
of maturation
- Review of systems, and
- Nutritional history.
Neinstein L.S. Adolescent Health Care:
A Practical Guide, 2002
Neinstein LS and Kaufman FR:
Abnormal Growth and Development, 2002.
4. Physical examination
Should include a complete examination but particularly
focus on:
- Nutritional status
- Body measurements
- Sexual maturity rating
- Thyroid exam
- Cardiac exam (for congenital heart disease)
- Chest exam (for chronic pulmonary disease)
- Abdominal exam (hepatosplenomegaly as sign of
chronic system disease)
- External vaginal examination (evaluate for presence of
uterus and ovaries)
- Neurologic exam (for intracranial pathology)
5. Basic Laboratory tests
- Complete blood count (anemia)
- Urinalysis (chronic renal disease)
- Sedimentation rate (screen for chronic systemic
disease)
- Chemistry panel including glucose, creatinine,
calcium
phosphorus, albumin, protein and liver enzymes
- A bone age is an essential part of the evaluation
for delayed puberty.
- TSH: A screen for thyroid dysfunction
6. • For specific diagnostic assessments & therapeutic
management needs appropriate other health
professionals (Endocrinologist, Gynaecologist)
• Health care provider must be prepared to help
the adolescent with long term follow-up &
psychological support including
- Identification of the problem,
- Growth and sexual maturation,
- Sexual identity and
- Reproductive potential.
8. PRECOCIOUS PUBERTY
Precocious onset of puberty is defined as occurring
younger than 2 SD before the average age
Girls <8 years old :
Develops breast & pubic hair before 8 years old
Boys <9 years old :
Has an increase in testicle size & penis length
before 9 years of age
9. Causa of Precocious Puberty
1. Gonadotrophin-dependent (true / central)
- Intra-cranial lesions
(tumours, hydrocephalus, CNS malformations,
irradiation, trauma)
- Gonadotrophin secreting tumours – v. rare
2. Gonadotrophin-independent (FSH & LH suppressed)
Exogenous Sex Hormone
10. Delayed puberty
Delayed onset of puberty is defined as occurring older
than 2 SD after the average age
Girls > 13.4 years old
Boys > 14 years old
Adolescents that are beyond these limits should be
considered for evaluation for hypothalamic, pituitary,
gonadal dysfunction, or undiagnosed chronic illness.
11. Male Guidelines for Delayed Puberty
• Genital (G) stage 1 persists beyond age 13.7 years, or
• Pubic hair (PH) stage 1 persists beyond 15.1 years of age
• More than 5 years have elapsed from initiation to
completion of genital growth.
• The following sexual maturity ratings (SMRs) persist past
the listed guidelines:
- G2 > 2.2 years
- G3 > 1.6 years
- G4 > 1.9 years
- PH2 > 1.0 year Neinstein L.S. Adolescent Health Care:
A Practical Guide, 2002
- PH3 > 0.5 year
Neinstein LS and Kaufman FR:
- PH4 > 1.5 years Abnormal Growth and Development, 2002.
12. Female Guidelines for delayed puberty
• Breast (B) stage 1 persists beyond age 13.4, or
• Pubic hair stage 1 persists beyond 14.1 years, or
• There is failure to menstruate beyond 16 years of age.
• More than 5 years have elapsed between initiation of
breast growth and menarche.
• The following sexual maturity ratings persist past the
listed guidelines:
– B2 > 1.0 year
– B3 > 2.2 years
– B4 > 6.8 years
– PH2 > 1.3 years Neinstein L.S. Adolescent Health Care:
A Practical Guide, 2002
– PH3 > 0.9 years Neinstein LS and Kaufman FR:
– PH4 > 2.4 years Abnormal Growth and Development, 2002.
13. Causa of Delayed Puberty
General
• Constitutional delay of growth and puberty
• Malabsorption
– Coeliac / imflammatory bowel disease
• Underweight
– Dieting, anorexia nervosa, over-exercise
• Chronic illness
– Asthma, malignancy, beta thallasaemia major
14. Causa of Delayed Puberty (con’t)
• Gonadal failure
- Chromosomal Abnormalities
– Post-malignancy chemo / radiotherapy / surgery
– Polyglandular autoimmune syndromes
• Gonadal deficiency
– Congenital hypogonadotrophic hypogonadism
– Hypothalamic/pituitary lesions (tumours, post-
radiotherapy)
– Rare gene mutations inactivating FSH/LH or their
receptors
16. Turner’s Syndrome
• About one case in 3,000 live female births
• Short stature
• CVS
•Coarctation of aorta
•Spont. aortic dilatation
•hypertension
• Lymphoedema
• Recurrent otitis media
• Dysplastic nails
• Crohn’s/U.C., cancer colon
• R.A.
• Thyroid disease
• D.M.
17. Klinefelter's syndrome
• One case in 700 live male births
• Tall stature
• Eunuchoid body :
- Long legs
- Relatively short arms,
- Height:arm-span ratio >1.0
• Testes are small but firm, and
• Gynecomastia is often present.
18. Constitutional delay of puberty
• 90% of delayed puberty is constitutional delay of puberty
• The following items should be considered :
- No chronic disease contribute to growth failure
- Nutritional status is normal
- Growth rate at least 3.7 cm/year
- Physical examination normal including genital anatomy
- Normal CBC, sedimentation rate, urinalysis result and TSH
- Normal serum LH & FSH (may not be needed in all cases)
- The bone age is delayed 1.5 to 4.0 years
- Supportive evidence includes a family history of constitutional
delay & a height between 3 rd and 25th percentiles for
chronologic age