Puberty :

-it is the rendering of the Latin word (pubertas) meaning (Grown up).it is the stage of physical maturation in which an individual becomes physiologically capable of sexual reproduction and is defind by WHO as the age between 10 and 19 years.

*usually it takes 3-4 years for the completion of the secondary sexual characteristics.

Factors affecting the onset of puberty:

1-gentic , a major influence.

2-Nutritional state.

3-General health.

4-Geographic location.

5-Exposure to light.

6-psychological state

Pubertal events:

*Thelarche 8- 13 years

*Adrenarche 9- 13years

*Axillary hair 10- 14years

*peak height 10- 14years

*Menarche 11- 15years

*Mature sexual hair and breasts 14- 15years

Pubertal changes before the age of 8years are regarded as precocious puberty

Classification

1--Gonadotrop independent p.p. (True p.p.) (central) due to premature & early activation of the hypothalamic – pituitary – gonadal axis:-

a—idiopathic or constitutional

b—CNS lesions:

a-Hypothalamic tumor

b- infection

c-head injury

d-congenital defects

2--Gonadotropin – Independent p.p.

*Adrenal tumors , McCune-Albr.ght syndrome

*Endocrinopathies – congenital adrenal

Hyperplasia , primary hypothyroidism

*Accidental exposure to steroids

*Aromatase excess syndrome

3—Intermediate type p.p.

*Gonadotropin – secreating tumors – teratomas hepatoblastoma , dysgerminoma , ovarian granulosa cell tumor , thecoma

Diagnosis history:-events of growth, behavioral changes , drug usage, history of intracranial lesion ,symptoms of hypothyroidism physical examination:- general,neurological,endocriological

Visual fields assessment .

height measurements investigation:- T3 T4 TSH , FSH , LH , E2 ,Testosterone , u/s ,MRI

If normal investigation ,then assess the bone age a-normal i.e.:- chronological age then asses E2 &DHEAS TO exclude ectopic source / ovarian / adrenal pathology

b-low i.e.:- bone age less than chronological age .then do T3 T4 TSH c- higher: then we asses E2 ,LH response to GnRH mangment : aim:- 1-to identify the correctable causes 2-to arrest pubertal development 3-to suppress linear growth and further acceleration of skeletal maturation 4- to prevent sexual abuse and pregnancy 5-reassurance the parents - surgery for tumors / chemo /radiotherapy -replacement therapy in case cah in hepothyrodism -in Mc Cune –AL bright syndrome treatment by testolactone 40 mg/kg/day to suppress conversion of testosterone to estrogen

- with gonadotrophines dependent giving medroxyprogesterone acetate 100-700m im every 2-4weeks ,cyproterone acetate (has anti;-androgenic gonadotropic ).or to give LHRH analogues 0.2-0.3 mg/kg maximum 7.5 mg in every 4 weeks