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Cases in Adolescent Pubertal Development

Cases in Adolescent Pubertal Development. William P. Adelman MD Associate Professor of Pediatrics Uniformed Services University. ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION. Residency Requirements for Pediatrics Adolescent Medicine

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Cases in Adolescent Pubertal Development

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  1. Cases in Adolescent Pubertal Development William P. Adelman MD Associate Professor of Pediatrics Uniformed Services University

  2. ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION Residency Requirements for Pediatrics Adolescent Medicine The program must provide all residents with experience in adolescent medicine that will enable them to recognize normal and abnormal growth and development in adolescent patients. The experience must include, as a minimum, a 1-month block rotation to ensure a focused experience in the area of adolescent medicine. This experience must be supervised by faculty qualified to teach adolescent medicine. The program must also provide the resident with an integrated experience that incorporates adolescent issues into ambulatory and inpatient experiences throughout the 3 years (e.g., inpatient unit, community settings, continuity clinic, and subspecialty rotations).

  3. ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION Residency Requirements for Pediatrics Adolescent Medicine It must include instruction and experience in at least the following: i) normal pubertal growth and development and the associated physiologic and anatomic changes; ii) health promotion, disease prevention, and anticipatory guidance of adolescents; iii) common adolescent health problems, including chronic illness, sports-related issues, motor vehicle safety, and the effects of violence in conflict resolution; iv) interviewing the adolescent patient with attention to confidentiality, consent, and cultural background; v) psychosocial issues, such as peer and family relations, depression, eating disorders, substance abuse, suicide, and school performance; and vi) male and female reproductive health, including sexuality, pregnancy, contraception, and STDs.

  4. Goals and Objectives • Understand Normal Changes of Puberty • Understand Sexual Maturity Rating (Tanner Staging) • Recognize elements of history and physical exam that differentiate normal from abnormal puberty

  5. Case #1 Suzy Smith • Susan Smith is 11 years old and is here for a well child check up. On physical exam she has some breast budding and a little bit of pubic hair over the mons. Her mother has lots of questions for your regarding her development, and Susan wants to know when she will get her period.

  6. Case #1 Suzy Smith (cont.) • Which of the following would be accurate to tell Susan and her mother? • Her peak height velocity will occur in one year • She has not yet started puberty • She is Sexual Maturity Rating (SMR) [Tanner Stage] 2 • Menarche will occur in 2 years • She is at greatest risk for worsening of scoliosis over the next 24 months • Her percent body fat will decrease over the next few years as her bones increase in density • She should consume 1300 mg of calcium daily

  7. The Process of Puberty • The Sequence of events is constant from one person to the next • The Timing of events is NOT • ie Tempo of puberty

  8. Physical Changes of Puberty • Endocrine Changes • Sexual Development • Changes in Body Composition • Growth Spurt: Height and Weight

  9. Puberty: Endocrine Changes • Endocrine determinants of growth change from Growth hormone and Thyroid hormone in children to Androgens, Estrogens, and Progestins in Adolescence • Unique changes occur in complex hypothalamic-pituitary unit

  10. PUBERTY AND THE ENDOCRINE SYSTEM hypothalamus BOYS GIRLS FSHRF LHRF anterior pituitary gland FSH LH LH FSH ovarian follicle growth ovulation spermatogenesis leydig cell maturation Estrogen corpus luteum Testosterone Progesterone

  11. Puberty: Sexual DevelopmentSexual Maturity Rating (SMR) • Stages of sexual development as measured by secondary sexual characteristics • breast • pubic hair • male testes size • Scaled from 1 to 5 by Tanner in 1962 • No stage 0 • Some add level 6 for extreme adult

  12. Puberty: Body Composition • Girls: Lean Body mass 80% to 75% as adipose increases • Boys: LBM 80% to 90% with muscle mass • Muscle mass • Skeletal mass • Internal organs • Erythrocyte (Red Blood Cell) Mass

  13. Puberty: Internal organ development • Skeleton • Heart • Lungs • Brain • Erythrocytes (red blood cells)

  14. Puberty: Growth Spurt • Height growth accounts for 20-25% of adult • Height spurt lasts 24-30 mos; seasonal • Weight growth peaks during height growth • Accounts for 40-50% of ideal body weight

  15. Puberty versus Age • Characteristics that correlate better with physical maturity than chronological age: • height, weight, blood pressure • growth velocity • reproductive capacity • cognitive capabilities • caloric needs • Blood count and other lab tests

  16. Case #1 Suzy Smith • Susan Smith is 11 years old and is here for a well child check up. On physical exam she has some breast budding and a little bit of pubic hair over the mons. Her mother has lots of questions for your regarding her development, and Susan wants to know when she will get her period.

  17. Case #1 Suzy Smith (cont.) • Which of the following would be accurate to tell Susan and her mother? • Her peak height velocity will occur in one year • She has not yet started puberty • She is Sexual Maturity Rating (SMR) [Tanner Stage] 2 • Menarche will occur in 2 years • She is at greatest risk for worsening of scoliosis over the next 24 months • Her percent body fat will decrease over the next few years as her bones increase in density • She should consume 1300 mg of calcium daily

  18. Case #1 Suzy Smith • Which of the following would be accurate to tell Susan and her mother? • Her peak height velocity will occur in one year TRUE • She has not yet started puberty FALSE • She is Sexual Maturity Rating (SMR) [Tanner Stage] 2 TRUE • Menarche will occur in 2 years TRUE • She is at greatest risk for worsening of scoliosis over the next 24 months TRUE • Her percent body fat will decrease over the next few years as her bones increase in density FALSE • She should consume 1300 mg of calcium daily TRUE

  19. Case #2: Susan Smith • Susan Smith is now 14 years old and presents with a CC: “I have not yet had my period.” • Is this normal?

  20. Delayed Puberty • No menses by 16 years in girls • No signs of secondary sexual characteristics by age 14 in boys or girls • Longer than five years to complete puberty

  21. Menarche by age • Mean in US is 12.8 for white and 12.5 for black girls (range 9-16) • Mean in Tanner study (UK) 13.46 (range 9-16)

  22. Menarche by SMR • SMR Breast Pubic Hair • Stage I 0% 1% • Stage II 1% 4% • Stage III 26% 19% • Stage IV 62% 63% • Stage V 11% 14% WA Marshall and Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child 1969;44:291

  23. Case #2: Susan Smith: History • Her mother tells you that she herself and Susan’s sister did not get their periods until they were almost 16. ROS is otherwise negative except several episodes of lower abdominal pain that last 2-3 days then resolved. In confidence, Susan admits to some increased stress in her life, and she denies sexual activity.

  24. Case #2: Susan Smith: Physical Exam • Vital signs are normal and she is in NAD • Height is 30th percentile and weight is 5th percentile. (BMI =19) • She is SMR 5 for breasts and pubic hair • Abdominal exam is unremarkable

  25. Case #2: Important Clues • SMR 2 at 11 now SMR 5 at 14 (normal sequence); No delay in progression • Would have expected Menses by now for HER (3 years from thelarche with normal progression of secondary sexual characteristics) • Recurrent abdominal pain • Family history: AGE not important compared to SMR

  26. Case #2 Susan Smith: Plan • Which is the best course of action: • Reassurance. She will get her period by 16 like her mom and sister and see her back in 6 mos. • Obtain an FSH/LH to make sure her ovaries work • Obtain a urine HCG • Refer to an eating disorders specialist as her menses are due to anorexia nervosa • Perform an external genital exam

  27. Case #2 Susan Smith: Plan • Which is the best course of action: • Reassurance. She will get her period by 16 like her mom and sister and see her back in 6 mos. (AGE not important compared to SMR) • Obtain an FSH/LH to make sure her ovaries work (SMR 5 BREASTS) • Obtain a urine HCG (Could she be pregnant?) • Refer to an eating disorders specialist as her menses are due to anorexia nervosa (BMI is 50th percentile for age) • Perform an external genital exam (imperforate hymen; hydrometocolpos; etc.)

  28. External Genital Exam • Imperforate hymen • Bulging under pressure of hematocolpos

  29. Case #3: Breast Swelling • A 13.5 year old male presents with a CC: “Breast Swelling.”

  30. Case #3: Breast Swelling History • He has noticed growth of breast tissue under right nipple for about six months. It is tender. He has a strong family history of breast cancer on his mother’s side.

  31. Case #3: Breast Swelling Physical Exam • On exam, you note a 3X2 cm firm mass directly under the left nipple. There is nothing on the right side. There is no axillary adenopathy. His pubic hair is SMR III.

  32. Case #3: Plan—What to do? • Send serum for HCG, AFP, and other tumor markers. • Obtain a urine HCG • Perform a complete testicular exam to r/o masses • Reassure that this is normal pubertal gynecomastia • Obtain a urine drug screen • Refer for biopsy of the lesion since it is asymmetric

  33. GYNECOMASTIA • Glandular enlargement of the male breast • Estrogens strongly stimulate mammary growth • Androgens weakly inhibit mammary growth • Gynecomastia = male breast exposed to decreased ratio of androgen to estrogen

  34. GYNECOMASTIA

  35. TYPES OF GYNECOMASTIA • PUBERTAL • Physiologic • Healthy adolescent boys • PATHOLOGIC • Indicates an underlying disease or exposure

  36. Frequency of gynecomastia by age group (JAMA 178:449, 1961) % age in years

  37. Pubertal Gynecomastia: Etiology • Testis secretes small amount estradiol in bloodstream each day • All estrone and 85% estradiol in mature male from aromatization • In puberty, estrogens rise 24hr/day; • Testosterone only at night early, then all day

  38. ESTROGEN AND ANDROGEN BIOSYNTHESIS IN THE MALE cholesterol 20/20 Desmolase d5 pregenenolone 3 OH steroid dehydrogenase progesterone 17a hydroxylase 17a progesterone 17/20 desmolase aromatase Estrone Estradiol Androstenedione Testosterone 17 ketosteroid reductase aromatase PERIPHERAL TISSUE TESTIS OR ADRENAL GLAND

  39. Pubertal Gynecomastia: Clinical Findings • Glandular tissue < 4cm diameter • Resembles early female breast budding • Sexual development PREcedes finding • pubic hair, pigmented scrotal skin, testicular enlargement (3cm or 8ml) typically present 6 mos prior to breast enlargement • Enlarged Breasts in healthy male; no drugs

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