Puberty Puberty Disorders Puberty Puberty The time at

Puberty & Puberty Disorders

Puberty • Puberty : The time at which the reproductive organs start to function (Spermatogenesis & Androgen secretion), (9 - 14 Y)

Puberty • Puberty : The time at which the reproductive organs start to function (Spermatogenesis & Androgen secretion), (9 - 14 Y) • Adolescence : The period from puberty to complete maturation

Puberty • Puberty : The time at which the reproductive organs start to function (Spermatogenesis & Androgen secretion), (9 - 14 Y) • 3 Main Events : 1) Adrenarche (Increase adrenal androgens), 1 -2 years before increase gonadotrophins & testis androgens 2) Genarche (Increase testis growth), 1 -2 years before pubarche 3) Pubarche (Pubic hair growth)

Puberty • Theories of Onset : Ø Hypothalamic ( Gn. RH) Ø Extra-hypothalamic (Brain) Ø Gonadal ( testis sensitivity to gonadotrophins)

Puberty • Clinical Changes (Tanner Staging) : 1) Genital Development 2) Pubic Hair Development

Puberty 1) Genital Development : § § § Stage Stage 1 (Pre-pubertal = childhood ˂ 2. 5 cm) 2 Gradual Testis enlargement, 3 Penile growth & Scrotal 4 darkening, texture change 5 (Adult Genitalia ˃ 4. 5 cm i. e. no further growth)

Puberty 2) Pubic Hair Development : § § § Stage Stage thighs) 1 (Pre-pubertal = vellus hair) 2 (Sparse hair at base of penis) 3 (Dark & coarse hair at mons pubis) 4 (Hair is like adult but not at thigh) 5 (Adult Hair i. e. extends to medial § Stage 6 (Most men will have further spread towards the umbilicus)

Tanner Staging of Pubic Hair Development

Puberty • Other Pubertal Changes : § Voice change § Linear Growth § Physical Growth (Skeletal mass doubles between 12 – 16 years) § Masculine Hair Distribution (Moustache, beard & chest) § Sexual Desire § A. V. & Apocrine Sweating

Puberty • Testis Histology Changes : Ø Resting Phase (Birth – 4 years) (Small ST & no cell differentiation) Ø Growth Phase (5 – 9 years) (Increase ST diameter, elongation & no cell differentiation) Ø Maturation Phase (9 – 15 years) (Increase ST diameter, elongation, tortuousity & germ cell differentiation)

Puberty Disorders • Delayed Puberty (After 14 Y) • Precocious Puberty (Before 9 Y)

Delayed Puberty • Constitutional (85%) • Hypogonadotrophic Hypogonadism (Hypothalamus & Pituitary Disorders) • Hypergonadotrophic Hypogonadism (Testis Failure) • Chronic Systemic illness (Cardiac, Renal, Hepatic Disease, Chemotherapy & Malnutrition)

Delayed Puberty • Treatment of Delayed Puberty : – Aims (Psycho-social, 2 ry sex characters & avoid decrease bone density) – Treatment of the Cause – Treatment of Constitutional DP (200 mg testosterone enanthate / month for 3 months). It cold be repeated

Delayed Puberty • Treatment of Pathological Failed Puberty : – 100 – 250 mg mg TE TE / / 6 4 4 2 weeks (1 st year) weeks (2 nd year) weeks (3 rd year) - 3 weeks (thereafter)

Precocious Puberty Iso-sexual (Early Virilization) Contra-sexual (Early Feminization)

Precocious Puberty Iso-sexual (Early Virilization) • Hypergonadotrophic (Central or True) • Gonadotrophin Independent (Peripheral or Pseudo)

Precocious Puberty • Hypergonadotrophic (True) : ( Gn. RH Function) Gonadotrophins Testis – Hypothalamic Hamartoma – Long standing hydrocephalus, Head trauma, Meningitis & Encephalitis – Idiopathic (Familial)

Precocious Puberty • Gonadotrophin Independent (Pseudo) : – Adrenal Androgens (Congenital adrenal hyperplasia)

(1) 21 hydroxylase (2) 11 hydroxylase Cholesterol Pregnanolone 17 -OH P. Dehydroepiandrosterone Progesterone 17 -OH P. Androstenedione Estrone Testosterone Estradiol (1) Aldosterone (1) 11 -DOC (2) Cortisol Dihydrotestosterone (DHT)

Precocious Puberty • Gonadotrophin Independent (Pseudo) : – Adrenal Androgens (Congenital adrenal hyperplasia) – – Androgen Secreting Adrenal tumor Familial Testotoxicosis Leydig Cell Tumor Accidental Exposure to Androgens

Precocious Puberty Iso-sexual (Early Virilization) Contra-sexual (Early Feminization) • Hypergonadotrophic • Adrenal or Testicular (Central or True) estrogen secreting • Gonadotrophin tumor Independent (Peripheral or Pseudo)

Precocious Puberty • Treatment of PP : – True PP Gn. RH High dose Long acting – Pseudo PP § Cong. Adr. Hyperpl. Steroids § Androgen Antagonists (Flutamide & Cyproterone) – Tumor Excision

Puberty Disorders Delayed P. Precocious P. Age 14 Years 9 Years Gender (Boys : Girls) 10 : 1 1 : 10 Most Common Cause Constitutional (85 %) Pathological (Central) 90 %

Gynecomastia

Gynecomastia • Definition : Increase size of the glandular tissue of male breast (uni- / bilateral & painless / painful) • D. D. : ü Gynecomastia ü Lipomastia ü Cancer

Gynecomastia

Gynecomastia • Tanner Staging : (1) No Gynecomastia (2) Breast budding palpable within the areola (3, 4) Gradual increase in glandular tissue (5) Full development of female breast

Tanner Staging of Female Breast & Gynecomastia

Adolescent Gynecomastia

Bilateral Gynecomastia

Idiopathic Gynecomastia

Unilateral Gynecomastia

Gynecomastia (due to Leydig cell tumor)

Horizontal Skin Fold in Gynecomastia ( ˃ 2 cm)

Gynecomastia • Etiology : (Androgen / estrogen imbalance or increase PRL);

Gynecomastia • Etiology : (Androgen / estrogen imbalance or increase PRL); ü “ Physiological “ ü “ Pathological “

Gynecomastia Physiological § § § Neonatal Pubertal Senescent

Gynecomastia Physiological § § § § Neonatal Pubertal Senescent Pathological Decrease androgens Increase PRL Neoplastic (Endocrine secretory tumor) Drugs

Gynecomastia • Treatment : ü Medical (Aromatase inhibitors, Tamoxifen & Danazole) ü Surgical

Capsule Summary • Normal Timing of Puberty • Tanner Staging of Genital Development, Pubic Hair Development & Breast Development • Physiological Gynecomastia • Causes of Abnormal Puberty Development • Treatment of Delayed Puberty

Puberty • Tanner Staging : The time at which reproductive organs start to function (Spermatogenesis & Androgen secretion) (9 - 14 Y) Genarche (Increase testis growth) 2) Adrenarche (increase adrenal androgens) 3) Puberche (Pubic hair growth) 1) • Adolescence : The period from puberty to complete maturation.

a b c Tanner Staging of Female Breast & Gynecomastia d e