1. Dr Olcay Evliyaoğlu Pediatric Endocrinology Department
Pubertal disorders
Dr Olcay Evliyaoğlu
Pediatric Endocrinology Department

2. Puberty
Sexual differentiation begins on 4-5th week of gestational age.

3. ADOLESENCE
Physical, sexual, physcological development. Transition to adulthood from childhood
Not an adult nor child
Time of transition
Establishment of individualism.

4. PUBERTY Secondary sex characteristics are developed Includes
Physical growth
Sexual development
Psychological development

5. Growth spurt, disturbution of muscle and fat
bone maturation and fusion of epiphysical centers
Adult height
At the end of this period spermatogenesis in boys, ovulation in girls occur

6. What makes HHG axis work
STRESS -
MATURATİON +
CENTRAL NERVOUS SYSTEM +
NUTRİTİON
LEPTIN
GLUTAMAT
GABA
ENDROFIN + + - - +
HYPOTHALAMUS -
GnRH - - - - + +
PİTUİTARY
PRL - - - LH -
FSH - - + +
OVARY
TEKA
GRANULOZA
ESTROGEN INHIBIN
ANDROGEN

7. Gonadarche Hypothalamus GnRH pulse frequency and amplitude increase
Pituitary
LH pulse frequency and amplitude increase
At early stages at nights
With progression of puberty pulses occur during day

8. Gonadarche LH Teca cells androstenedion FSH Granulosa cells
Estradiol (E2)

9. Gonadarche LH
Leydig cells
testosteron

10. Adrenarche Increase in the secretion of adrenal androgens
Appearance of pubic hair (pubarche)
Axillary hair

11. Adrenarche
CRH
Hypothalamus
Pituitary
ACTH
Adrenal cortex
Adrenal androgens

12. Genetic and environmental conditions effect timing of puberty· 
Environmental factors:
Socioeconomic factors
Nutrition
General health
Geographical place lived

13. Nutrition and puberty Menarche is earlier in obese girls
Malnutrition , chronic diseases, and excessive physical activity delay puberty and menarche

14. LEPTİN Codes Ob gene Synthesized in adipose tissue.
Leptin signals stimulate central nervous system
Leptin levels are decreased in excessive physical activity, anorexia nevrosa and amenorea.

15. hypothalamus
LHRH secreting neurons
Leptin LHRH
pituitary gonadotrophs
Leptin
mRNA
Adipose cells
LH, FSH

16. Timing of puberty is related to bone age rather than chronological age
BA< CY delay in puberty
BA = CA puberty on expected age
BA>CA early puberty (puberty precocous)

17. · In girls the first sign of puberty is telarche, generally observed on ages, menarche is observed 2-3 years after telarche.
In girls growth spurt occurs 2 years earlier than boys. Growth spurt in girls is at the time of telarche,
In boys growth spurt occur at the time when testes volumes are 10 ml.
Telarche Pubarche Menarche

18. Pubertal development in girls breast development (tanner staging)
1. Prepubertal
2. Palpation of breat bud
3. Palpation of breat tissue with out
any changes in contures
4. Development of breast tissue
5. Adult type breast

19. Pubic hair 1.No hair 2. Appearance of short hair on labium majora
3. Black and thic hair on mons pubis
4. Adult type hair but not spread to inguinal area
5. Adult type with the shape of inverted triangle

20. Tanner staging Girls pubic hair Stage 1: no pubic hair
Stage 2: lightly pigmented localized on labiums
Stage 3: coarser, darker , more curved, increased in amount spread to pubis
Stage 4: curved and increased still less than an adult.
Stage 5: adult women triangle spread to thighs

21. Tanner staging Breast development Stage 1: prepubertal
Stage 2: breast budding
Stage 3: enlargement of breast tissue and areola
Stage 4: Areola and papilla forms secondary mound .
Stage 5: Mature

22. Tanner stage 4
2-3years after telarche
Menarche

23. Tanner stage 4
2-3years after telarche
Menarche

24. FSH secretion
Dominant follicule
Follicular phase
estrogen
LH secretion
Ovulation
corpus luteum
Progesterone
Endometrium prepared
Luteal phase
If no implantation uterine bleeding

25. Follicular /proliferative phase Luteal /secretuary phase
Pituitary hormones
Ovarian hormones
ovulation
corpus albicans
follicule
corpus luteum
ovary
İstihdam
dominant
Seçim
istihdam
Endometrium
Follicular /proliferative phase
Luteal /secretuary phase 25

26. + + - Luteal phase LH estrogen estrogen Ovulation corpus luteum
Progesterone
endometrium is prepared for implantation

27. If no implantation occurs Corpus luteum regression
Progesterone levels decline
Endometrium can not hold itself-desquamation
Luteal phase
14+2 days
Spiral arteriols in the functional and basal layers of endometriumun contracts and
approx in 7 gün days bleeding stops

28. · In boys initial finding of puberty is enlargement of testes
·       In boys initial finding of puberty is enlargement of testes. This is followed by scrotum pigementation and thinning of scrotal skin. Penis enlarges. Pubic hair develops. Growth spurt occurs at years and usually continues until 18 years.

29. Pubertal development in boys Tanner staging
Prepubertal testes diameter < 2.5 cm= 4 ml
Testes volumes
1-3 ml  P1
4-9 ml  P2
10-14 ml P3
15-20 ml P4
> 20 ml  P5

30. Tanner staging Pubic hair stage 1: no pubic hair
Stage 2: little pubic hair
Stage 3: pubic hair on pubis
Stage 4: adult type hair but no invasion on tighs
Stage 5 : adult type hair spread to thighs