ENDOCRINOLOGY DIVISIONDEPARTMENT OF CHILD HEALTHMEDICAL SCHOOLUNIVERSITY OF SUMATERA UTARAPUBERTY

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What is Puberty?Puberty, from the Latin word: Pubertas age of maturity refers to the stage of transition from the sexually immature child to the potentially fertile adolescent, during which secondary sexual characteristics appear and the ability to procreate is established. Close interaction between the hypothalamic-pituitary-gonadal axis (HPG axis) & adrenal cortex.

HPG axis Sexual characteristics (breast, increase in testicular and penile size, menarche.Adrenal androgen Sexual hair (pubarche), acne, axillary odourUnderstanding of regulation and progress of puberty is crucial for evaluation and management of pubertal disorders

HYPOTHALAMIC-PITUITARY-GONADAL (HPG) AXISCentral signals (GABA, NPY, Glutamate)Peripheral signals (Leptin, Ghrelin)Kisspeptin GnRH Pituitary FSH Inhibin LH LH EstradiolTestosterone Testis

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HORMONAL CHANGES IN PUBERTYIncreased GnRH secretion the first identifiable event of puberty.At the onset of puberty LH pulse secretion are evident only during the night, approximately 1-3 years before any external signs of puberty are manifest. Mid puberty LH pulse secretion appears during the day. Adulthood The day/night pattern disappears Increase LH levels as much as 25x during puberty as compared to FSH (2,5 fold) LH level Better indicators of pubertal status compared to FSH levels.

Serum Gonadotropin and sex steroid levels in relation to Sexual Maturity Rating (SMR)

BOYSSMR Stage12345LH (IU/L)0,1 0,30,4 2,3 0,5 1,80,3 1,61,5 6,3FSH (IU/L)0,1 0,90,1 2,8 0,3 3,00,4 5,00,6 5,0Testosterone (ng/dL)

Hormonal changes..Hormones:-Gonadotroin-Sex Steroid-Growth hormonePhysical:-Reproductive system-Secondary sex characteristics-Growth spurtFinal HeightMaturation reproductive systemFertility

Influencing factorsGenetics : 50 80% of variation in pubertal timingEnvironmental factors e.g. nutritional statusLeptin Regulates appetite and metabolism through hypothalamus. Permissive role in reegulation of timing of puberty.Adrenarche : development of pubic and axillary hair, body odour, and acne

What is the age of onset of puberty ? Females: 8 13 years Males: 9 14 years

Physical Changes of Puberty *GIRLS*EstrogenStimulates growth of the uterus- Corpus/Cervix ratio Pepubertal < 1 Pubertal = 1- Endometrium proliferationStimulates endometrial growthStimulates cervical mucus secretionLabia Majora : Pigmentation, vascularisation, erotisationEnlargement of clitorisVagina: - Mucosal thickening -Changes in Epithelial cell ratio (superficial, intermediate, parabasal) - glicogen deposit pH , fungal infection

Breast buds (Thelarche) First Manifestation, followed by the development of pubic hair six months later and then axilla hair Sexual Maturating Scale (Tanners staging).

Pubertal growth spurt early in puberty and grow rapidly in breast stage 2-3, averaging 8,5 cm/yr.

Menstrual cycles usually commence around 2-2,5 yeears after thelarche, usually in Tanner stage 3-4 og breast development.

Testosterone:Growth of male genital organs, pubic hair, and sebaceous glands.Testosterone and estrogen responsible for growth spurt, directly or indirectly by increasing GH production.Both hormones stimulate epiphyseal growth and maturation, though estrogen is ultimately responsible for epiphyseal fusion.Physical Changes of Puberty *BOYS*

Enlargement of testes ( 4 ml in volume or 2,5 cm length) First Manifestation of puberty in boys.Followed by penile growth with thickening and pigmentation of the scrotum.Pubic hair appears around 1 year after pubertal onset and body odour develops.Axillary hair and facial hair develop towards mid-puberty, after 14 years of age.

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Siklus Menstruasi

Menstruasi: Terjadi akibat interaksi hormon yang dihasilkan oleh hipotalamus, hipofisis dan ovarium.

Data Third National Health and Nutrition Examination Survey (NHANES) umur rata-rata menarche remaja Amerika adalah 12,43 tahun. Walaupun hampir 90% remaja mencapai menarche pada stadium Tanner 4.

Lamanya siklus menstruasi: jumlah hari mulai hari pertama keluarnya darah sampai menstruasi pada siklus berikutnya.

Rata-rata lama siklus 21-35 hari, rata-rata keluarnya darah 3-7 hari dan kehilangan darah 30-40 ml per hari.

Siklus menstruasi dibedakan menjadi 2 fase: fase folikular atau proliferatif (fase estrogen) dan fase luteal atau sekresi (fase progesterone)

Kadar hormon & perubahan endometrium selama siklus menstruasi

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