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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