2. Whatis puberty?
• biological changes and sexual maturation
that occur during the transition from
childhood to adulthood
• Average age of onset:
–10 (range 8-13) years in Girls
–12 (range 10-15) years in Boys
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History :
- Growth record
- Family history of growth disorders and
ages of maturation
- Review of systems, and
- Nutritional history.
Neinstein L.S. Adolescent Health Care:
A Practical Guide, 2002
Neinstein LS and Kaufman
FR: Abnormal Growth and
Development, 2002.
4. Physical examination
Should include a complete examination but particularly
focus on:
- Nutritional status
- Body measurements
- Sexual maturity rating
- Thyroid exam
- Cardiac exam (for congenital heart disease)
- Chest exam (for chronic pulmonary disease)
- Abdominal exam (hepatosplenomegaly as sign of
chronic system disease)
- External vaginal examination (evaluate for presence of
uterus and ovaries)
- Neurologic exam (for intracranial pathology)
5. Basic Laboratory
tests
- Complete blood count (anemia)
- Urinalysis (chronic renal disease)
- Sedimentation rate (screen for chronic
systemic disease)
- Chemistry panel including glucose,
creatinine, calcium
phosphorus, albumin, protein and liver
enzymes
- A bone age is an essential part of the
evaluation for delayed puberty.
- TSH: A screen for thyroid dysfunction
6. • For specific diagnostic assessments &
therapeutic management needs appropriate
other health professionals (Endocrinologist,
Gynaecologist)
• Health care provider must be prepared to
help the adolescent with long term follow-
up & psychological support including
- Identification of the problem,
- Growth and sexual maturation,
- Sexual identity and
- Reproductive potential.
7.
8. PRECOCIOUS PUBERTY
Precocious onset of puberty is defined as
occurring younger than 2 SD before the
average age
Girls <8 years old :
Develops breast & pubic hair before 8
years old
Boys <9 years old:
Has an increase in testicle size & penis
length before 9 years of age
10. Delayed puberty
Delayed onset of puberty is defined as occurring
older than 2 SD after the average age
Girls > 13.4 years old
Boys > 14 years old
Adolescents that are beyond these limits should
be considered for evaluation for hypothalamic,
pituitary, gonadal dysfunction, or undiagnosed
chronic illness.
11. MaleGuidelines for Delayed Puberty
• Genital (G) stage 1 persists beyond age 13.7 years,
or
• Pubic hair (PH) stage 1 persists beyond 15.1 years
of age
• More than 5 years have elapsedfrom initiation to
completion of genital growth.
• The following sexual maturity ratings (SMRs) persist
past the listed guidelines:
- G2 > 2.2 years
- G3 > 1.6 years
- G4 > 1.9 years
- PH2 > 1.0
year
- PH3 > 0.5
year
Neinstein L.S. Adolescent Health Care:
A Practical Guide,
2002 Neinstein LS and
Kaufman FR:
Abnormal Growth and Development,
2002.
12. FemaleGuidelines for delayed puberty
• Breast (B) stage 1 persists beyond age 13.4, or
• Pubic hair stage 1 persists beyond 14.1 years, or
• There is failure to menstruate beyond 16 years of
age.
• More than 5 years have elapsed between
initiation of breast growth and menarche.
• The following sexual maturity ratings persist past
the listed guidelines:
– B2 > 1.0 year
– B3 > 2.2 years
– B4 > 6.8 years
– PH2 > 1.3
years
– PH3 > 0.9
years
Neinstein L.S. Adolescent Health Care:
A Practical Guide,
2002 Neinstein LS and
Kaufman FR:
Abnormal Growth and Development,
2002.
13. CausaofDelayed Puberty
General
• Constitutional delay of growth and
puberty
• Malabsorption
– Coeliac / imflammatory bowel disease
• Underweight
– Dieting, anorexia nervosa, over-exercise
• Chronic illness
– Asthma, malignancy, beta thallasaemia
major
16. Turner’s Syndrome
• About one case in 3,000 live female
births
• Short stature
• CVS
• Coarctation of aorta
• Spont. aortic dilatation
• hypertension
• Lymphoedema
• Recurrent otitis media
• Dysplastic nails
• Crohn’s/U.C., cancer colon
• R.A.
• Thyroid disease
• D.M.
17. Klinefelter's syndrome
• One case in 700 live male
births
• Tall stature
• Eunuchoid body :
- Long legs
- Relatively short arms,
- Height:arm-span ratio
>1.0
• Testes are small but firm, and
• Gynecomastia is often
present.
18. Constitutionaldelay of puberty
• 90% of delayed puberty is constitutional delay of
puberty
• The following items should be considered :
- No chronic disease contribute to growth failure
- Nutritional status is normal
- Growth rate at least 3.7 cm/year
- Physical examination normal including genital anatomy
- Normal CBC, sedimentation rate, urinalysis result and TSH
- Normal serum LH & FSH (may not be needed in all cases)
- The bone age is delayed 1.5 to 4.0 years
- Supportive evidence includes a family history of
constitutional delay & a height between 3 rd and 25th
percentiles for chronologic age
