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Puberty

By AdminPosted On 05-Oct-2016

1. Puberty Events

Which of the following pubertal events is NOT mediated by gonadal estrogen production?

a) Menstruation.
b) Pubic hair growth.
c) Breast development.
d) Skeletal growth
e) Vaginal cornification

Correct Answer: b) Pubic hair growth. Pubic hair is considered to be the heavier, longer and coarser hair that develops during puberty as an effect of rising levels of androgens. Pubic hair is therefore part of the androgenic hair and is a secondary sex characteristic.

2. First sign of puberty

a) Budding of breasts.
b) Pubic hair
c) Menstruation
d) Growth changes
e) Changes in voice

Correct Answer: a and d both. Ref: Novak's Gynecology. Generally the first sign of puberty is accelerated growth, breast budding is usually the first recognized pubertal change, followed by appearance of pubic hair, peak growth velocity and menarche. Option 'a' is more clinical as peak growth velocity occurs after pubarche (first appearance of pubic hair).

3. Normal development sequence of puberty

a) Thelarche, adrenarche, growth, menarche.
b) Menarche, adrenarche, thelarche, growth.
c) Growth. thelarche, adrenarche, menarche
d) Adrenarche, thelarche, growth, menarche
e) Thelarche, menarche, adrenarche, growth.

Correct Answer: a and c both. Ref: Novak's Gynecology. Generally the first sign of puberty is accelerated growth, breast budding is usually the first recognized pubertal change, followed by appearance of pubic hair, peak growth velocity and menarche. Option 'a' is more clinical as peak growth velocity occurs after pubarche (first appearance of pubic hair).

4. Vaginal Discharge at 12 yrs

12-year-old girl has odourless whitish vaginal discharge since 2 months ago. She has no itching, burning, or pain. She started breast development at 9 years and her pubertal development has been normal. She has not attained menarche and not sexually active. She has no medical problems and physical examination is normal. Microscopic examination of the discharge shows no evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis?

a) Bacterial vaginosis
b) Candida vulvovaginitis
c) Physiologic leukorrhea
d) Syphilis
e) Trichomoniasis

Correct Answer: c) Physiologic leukorrhea
Physiologic leukorrhea can be seen during the months preceding menarche. Rising estrogen levels lead to a whitish discharge not associated with any symptoms of irritation. This patient has a whitish discharge, no other symptoms, and she has had normal pubertal development up to this point. The discharge itself has no characteristics of infection. Therefore, physiologic leukorrhea is the most likely diagnosis.
Bacterial vaginosis – malodorous/ clue cells
Candida vulvovaginitis - thick and white/ irritative
Syphilis - painless ulcer/ sexually active
Trichomoniasis - microscopic examination

5. Delayed Puberty

A teenager presents to a gynaecology clinic with primary amenorrhoea and delayed puberty. Further investigations reveal a karyotype as 45 XO. What condition is the teenager likely to have?a) Congenital adrenal hyperplasiab) Androgen insensitivity syndromee) Down syndromed) Kallmann syndromee) Mayer-Rockitansky-Kuster-Hauser syndromef) Turner syndromeg) XY-pure gonadal dysgenesisCorrect Answer: f) Turner Syndrome.Turner syndrome is the most common cause of gonadal dysgenesis. In the most severe form it is associated with the following features: short stature, webbing of the neck, cubitus valgus, widely spaced nipples and cardiac and renal abnormalities. Spontaneous menstruation may occur due to mosaicism, but premature ovarian failure is more common. Low-dose estrogen therapy is beneficial to promote puberty changes. Long-term hormone replacement is essential to prevent osteoporosis.Congenital adrenal hyperplasia has a normal female karyotype and the aetiology is due to an enzyme deficiency. Down syndrome is associated with trisomyAndrogen insensitivity syndrome p a normal male karyotype. The aetiology is due to the influence of anti- müllerian hormone, preventing the development of internal müllerian structures and failure of wolffian structures due to insensitivity to testosterone.Mayer - Rokitansky - Küster -Hauser syndrome has 46 XX karyotype. There is a developmental defect due to lack of fusion of the müllerian ducts. The patient will have a uterine remnant and a blind vagina.

6. Adolescent with Pubertal Changes

A 14-year-old child presents to the adolescent gynaecology clinic. She has a history of virilisation after undergoing pubertal changes. The karyotype reveals 46XY. An ultrasound scan does not show the presence of a uterus and ovaries. Which enzyme deficiency may be associated with these clinical features?

a) 5-alpha-reductase deficiency
b) Complete androgen insensitivity syndrome
c) Kallmann syndrome
d) Polycystic ovary syndrome
e) Turner syndrome

Correct Answer: a) 5-alpha-reductase deficiency. Turner syndrome is 45 XO. Polycystic ovarian syndrome has a normal female karyotype. The child described above is genetically male. However, testosterone is not converted to dihydrotestosterone in target tissues. Five-alpha-reductase deficiency prevents conversion of androgen to estrogen. The child may have been born with ambiguous genitalia and raised as a female. At puberty, elevated levels of androgen lead to masculinisation including virilisation. Complete androgen insensitivity is not the answer because increased androgens are converted to estrogen and do not show any virilisation. It involves phenotypic females and an unresponsiveness to androgens.Kalman's syndrome is a form of hypogonadotropic hypogonadism and anosmia.

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Dr. Niraj Mahajan

MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.

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