Puberty

Precocious Puberty

below is table of development & normal years

HPA axis

Breasts (8y)

Axillary Hair (9y)

Growth Spurt(10)

Menarche (11)

✏1. Precocious puberty isn't a problem unless

  • growth spurt ends/ menarche occurs at a lower height than normal.
    • tx will intervene to prevent menarche

  1. Or if deficiencies of bone
    • (bone age > chronological age)

Tits

  • strangely no emoji for this

Pits

Mits 🥊

  • long bones, like in fingers of hand

Lips 👄

  • where she bleeds from

Hypothalamus

GnRH (pulsatile)

Ant. Pit

FSH/LH

Adrenal

Makes androgens : CAH or DHEAS

Ovaries

E/P

Endometrium

Bleeds

Path: something is overstimulating HPA axis

Pt: 2º sex characteristics
≤ 8yo 👧🏻

Dx: Bone age via wrist XR

✅bone age 2y > chron. age: Precocious puberty

Where is the stimulation on HP axis coming from? CNS (pit) or not?
GNrH stim test (aka Leuprolide stim test)

✅Stimulates LH: Central condition, axis is stimulated

Look at brain: MRI

  • esp for child (no rad)

✅Tumor found.
Tx: resect

❎No tumor: Constitutional

Tx to allow chron age to match bone age:
Continuous Leuprolide

turns off axis allowing body to catch up

❎Continuous Leuprolide (GnRH) shuts down HPA here.

❎No effect: Peripheral Lesion.

Ovaries, adrenal gland, etc

Abn US: adrenal glands

Transvag. US: ovaries

DHEAS/testosterone levels

17-OH hydroxyprogesterone in urine: CAH

✅Tx: Steroids (mineralocorticoids, glucocorticoids replete)

✅Tx: Resect

✅Tx: Reassurance

Delayed Puberty

Pt:

  1. no 2º sex char by 13yo
    OR
  2. no bleeding by 15yo

Dx: Bone age:

  1. wrist XR
    &
  2. biochemical profile: FSH/LH

✅Hypergonadotropic hypogonadism: elev. FSH/LH


HPA is turned on. Nothing receiving the signal

(Pretest FM):
Path: Gonadal Dysgenesis (50% of primary amenorrhea cases)

  • Turner Syndrome 45 XO

❎Hypogonadotropic hypogonadism: not elevated FSH/LH


HPA not on

f/u: Karyotype

Cause for why HPA not on?
⚠Don't do below tests if there is a strong family Hx. (mom didn't start puberty until 16)

Prolactin level: Prolactinoma

(Pretest FM): Hyperprolactinemia (rare)

TSH/free T4: Thyroid disease

(Pretest FM): Hypothyroidism (rare)

  • incr TSH

🤰🏻Pregnancy test if concerned about bleeding

(Pretest FM): most common cause of 2º amenorrhea

  • suspect if pt denies sexual activity & normal periods prior

CBC, LFT, ESR: chronic diseases

MRI: Pituitary lesion r/o.

(Pretest FM): Path: Trauma 💥

❎❎❎Everything negative? Constitutional delay

Any of above tests ✅? Tx for specific disease

Wait

  • 🚫no growth hormone
  • FHx strong indicator for constitutional delay.
  • forget Tanner stages

Cyst (peripheral lesion)

  • Germ cell tumor
    • Granulosa theca (↑E)
    • Sertoli-Leydig (↑T)

Brain Tumor: ↑FSH/LH sec (rare)

CAH (or Peripheral lesion)
Tumor secreting androgens