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Puberty and the Menstrual Cycle
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Adrenarche Regeneration of zona reticularis Production of androgens (DHEAS,
DHEA, androstenedione) Gonadarche
Pulsatile release of GnRH from hypothalamus →
Anterior pituitary releases LH + FSH →
Ovaries produce estrogen
Adrenarche and Gonadarche
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Thelarche: ↑ estrogen → breast development (10 yo)
Pubarche: ↑ androgens → pubic and axillary hair development (11 yo)
Menarche: ↑ estrogen → first menses (12 yo) Typically 2.5 years after thelarche Concerning if does not occur by age 15 or 3 years after thelarche
Growth spurt: ↑estrogen → ↑ GH and somatomedin c
Thelarche, Pubarche and Menarche
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Onset of secondary sexual characteristics <8 yo
Central (gonadotropin-dependent) precocious puberty Premature activation of HPG axis Appropriate sexual characteristics (but early) ↑ linear growth, ↑ bone age, ↑ FSH, LH and estradiol 80-90% idiopathic in girls; some due to CNS lesions
Precocious Puberty
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Peripheral (gonadotropin-independent) precocious puberty
Excess secretion of sex hormones from peripheral source Eg adrenal glands, ovaries, exogenous source, germ cell tumor
Possible normal sexual characteristics or virilization Causes include:
Ovarian cysts or tumors (granulosa theca cell) McCune-Albright Syndrome Primary hypothyroidism Congenital adrenal hyperplasia Adrenal tumor
Peripheral Precocious Puberty
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Precocious Puberty Management
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Premature thelarche Isolated breast development
Premature adrenarche Isolated male-hormone mediated sexual characteristics
Possibly just variant of normal puberty Continue to monitor
Isolated precocious puberty
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Breasts I: prepubertal breasts II: palpable breast buds III: enlarged breasts / areola IV: areola forms mound on breasts V: adult breasts and areola recesses to
contour of breast
Pubic hair I: no pubic hair II: minimal hair mostly on labia majora III: hair becomes coarser and darker,
continues to spread IV: hair is adult like, has spread but spares
thighs V: hair extends to medial surface of thighs
Tanner Scale
Illustration by Michał Komorniczak; This file has been released into the Creative Commons 3.0. Attribution-ShareAlike (CC BY-SA 3.0) http://creativecommons.org/licenses/by-sa/3.0/deed.en
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Average cycle: 28 ± 7 days Average menses: 4 days, 40 mL, 3-6 ppd
Menorrhagia: >7 days or >80 mL Metrorrhagia: frequent irregular intervals Menometrorrhagia: prolonged + irregular Oligomenorrhea: >35 days Polymenorrhea: <21days
Menstrual Cycle
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