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6-8 yrs to 13-15 yrs
regeneration of zone reticularis: increased DHEA, DHEAS, androstenedione



begins around 8 years
pulsatile GnRh leads to LH and FSH production
initially just in sleep, eventually leads to estrogen production in ovary
stimulates: thelarche, pubarche, growth spurt, menarche



estrogen stimulates; first stage around 10
first sign of puberty
breast development



estrogen stimulates; around 11 (lags thelarche by 6 mo)
development of pubic and axillary hair



12-13 yrs (2.5 years after development of breast buds)
estrogen stimulates
onset of menstruation
for first 2 years: most cycles anovulatory


peak growth velocity

due to increased GH and IGF (stimulated by E)
starts around 9 or 10 and peaks around 12 (9cm/yr)
reached before tanner stage 3 in breast development and stage 2 of pubic hair development


female tanner stages

I: preadolescent; elevation of papillae only
II: sparse, pigmented downy hair along labia; elevation of breast and areolar enlargement
III: darker, courser and curlier hair, further enlargement of breast and areola
IV: hair distribution is adult in type (but not full quantity); projection of areolae and papillae to from secondary mount
V: hair in adult distribution and quantity ; projection of papillae only as areolae recess to beast contour


age considered precocious puberty in
1. white girls
2. AA girls
3. risks
4: Dx

breast or pubic hair development
1. 7 years
2. 6 years
3. female, AA, obese, exposure to sex hormones, McCune Albright syndrome, congenital adrenal hyperplasia
4. breast/pubic hair, growth spurt, skeletal maturity greater than age; estradiol greater than 5 pg/mL


causes of gonadotropin dependent precocious puberty

CNS: tumor, lesion, primary hypothyroidism



most frequent type of CNS tumors to cause precocious puberty
contain GnRH neurons (ectopic hypothalamic tissue)


causes of gonadotropin independent precocious puberty

1. ovarian cysts or tumors
2. exogenous E
3. androgen secreting tumor, CAH
4. McCune-Albright


McCune Albright syndrome

precocious puberty
cafe-au-alit skin
fibrous dysplasia
present with premature vaginal bleeding (before breast development)


incomplete precocious puberty

variant of normal puberty (early development of sexual characteristics)
check bone age: normal, no further testing
monitor closely


types of incomplete precocious puberty
1. premature thelarche
2. premature adrenache/pubarche

1. isolated growth development; normal growth rate, girls younger than 3 usually
2. pubic hair without signs of puberty in children younger that 7-8 years; risk of PCOS


precocious puberty
1. Hx
2. PE

1. age, rate of puberty, growth velocity, CNS path (headache, visual impairment, seizure), sex steroid exposure, family Hx
2. growth curve, neurological exam, thyroid, skin, pubic hair breast, genitalia, palpation for pelvic/abdominal mass


precocious puberty: labs

1. bone age: skeletal 2 years greater than age
2. LH, FSH levels in pubertal ranges
3. estradiol greater than 5
5. GnRH stimulation


additional testing for precocious puberty
1. Gn dependent
2. Gn independent

1. thyroid testing, brain MRI
2. additional blood tests, pelvic US, bone scan


Tx of precocious puberty
1. Gn dependent
2. Gn independent

1. GnRH antagonist therapy: leuprolide
2. Tx underlying condition


delayed puberty

1. absence of sexual maturation by 13 years
2. no evidence of monarch by 15-16 years
3. when menses have not begun 5 years after thelarche


causes of delayed puberty
1. hypogonadotropic hypogonadism
2. hypergonadotropic hypergonadism
3. Eugonadism

1. pituitary tumor, GnRH insufficiency, hyper-prolactinemia, constitutional delay, chronic disease, CNS disorder, trauma
2. ovarian failure, gonadal dysgenesis, iatrogenic (CA, Sx)
3. mullerian agenesis, outlet obstruction (imperforate hymen, transvaginal septum), androgen insensitivity


Kallman syndrome

hypogonadotropic hypogonadism, anosmia


delayed puberty
1. PE
2. labs
3. Tx

1. tanner staging, vaginal patency, estrogen effect, pelvic masses, signs of Turners
2. pelvic USG, FSH, TSH, PRL, karyotype, MRI of brain
3. address cause, induce puberty with estrogen, monitor


stages of coming out
1. identity confusion
2. identity comparison
3. identity tolerance
4. identity acceptance
5. identity pride
6. identity synthesis

can be out of order and skip steps
1. begins to acknowledge, but find unacceptable (make excuses for behavior)
2. accept but don't describe self as gay (accept behavior but not identity or vice versa)
3. accept likelihood, try on identity
4. move from tolerance to acceptance, anger at society rather than self; choose to be around people that accept them
5. marches, pride and anger, us against them
6. begin to understand that not all heterosexuals are homophobic, relax, re-integrate into society


important to remember as a doctor when patient is in identity pride stage

1. safe sex
2. don't Dx with personality disorder, sex addiction, etc.


What triggers awareness of homosexuality and what age?
1. male

1. by 13 years; romantic feeling
2. by 19 years; sexual feelings


problems with hormone therapy for transgender
1. testosterone
2. estrogen
3. anti-androgens

1. liver damage
2. clotting, increase in BP and blood glucose
3. lower BP, disturb electrolytes, dehydration



to talk about sex and sexuality
P: permission
LI: limited information
SS: specific suggestions
IT: intensive therapy



permission 1st
D: description of problem
O: onset
U: understanding cause
P: past attempts at solution or treatment
E: expectations for treatment


recruitment of egg
1. first recruitment
2. second recruitment

selection and growth of dominant follicle
1. paracrine control: AMH
2. endocrine (FSH): AMH, inhibin B and estrogen


how can you determine if a women is ovulating?

day 21 of cycle:
progesterone is over 5