Puberty: Normal Sequence

Published on 31/05/2015 by admin

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Chapter 1 Puberty: Normal Sequence

THE CHALLENGE

Adolescence with the onset of puberty is a time of great emotional and physical change. By understanding the normal sequence of events and being sensitive to the presence of abnormalities, the caregiver may be able to make the most of opportunities to improve health and well-being.

Scope of the Problem

The variety of decisions, concerns, and changes confronting an adolescent are formidable, not the least of which are health issues raised by rapid growth, sexual maturation, and emerging sexuality. Puberty involves physical, emotional, and sexual changes that mark the transition from childhood to adulthood. Despite the potential need for medical education and care, teenagers have the lowest rate of physician office visits of any group. Embarrassment, inability to pay, lack of familiarity with health care delivery options, and legal obstructions to access all contribute to this lack of care.

Objectives of Management

Understanding the normal sequence of events involved in sexual maturation is important for counseling young women who may be concerned about “being normal.” It is also pivotal to the important task of identifying those in whom the progression is not normal so that timely evaluation and intervention may be achieved.

TACTICS

Relevant Pathophysiology

Hormonally, puberty involves a change from negative gonadal feedback to the establishment of circadian and ultradian gonadal rhythms and the positive feedback controls that result in monthly cycles and fertility. It appears that three elements must be present for puberty to progress normally: adequate body mass, adequate sleep, and exposure to light. These factors appear to facilitate or allow the complex hypothalamic, pituitary, and ovarian changes that must occur. As the hypothalamus matures there is a decrease in its sensitivity to estrogen, resulting in an increase in the production and release of gonadotropin-releasing hormone. Consequently, follicle-stimulating hormone levels begin to increase at about the 8th to the 10th year of life, accompanied by an increase in estrogen levels. As the sensitivity of the hypothalamus to negative feedback further decreases, follicle-stimulating hormone and luteinizing hormone levels continue to rise. Eventually these hormones reach a sufficient level that the follicles can respond, initiating cyclic ovulation and menstruation.

Strategies

The changes of puberty generally follow a predictable pattern. A growth spurt and the rounding of body curves generally herald puberty. Breast tissue begins to develop; nipples darken; and fat is laid down in the shoulders, hips, and buttocks and in front of the pubic bone (the mons). Body hair begins to appear because of the influence of androgens made in small amounts by the ovary and adrenal glands. Height increases because of accelerated growth in the long bones of the body, capped off by the closure of the growth centers near the end of puberty. Generally this growth spurt begins approximately 2 years before the start of menstruation itself, with growth slowing about the same time menstruation begins.

Patient Education

American College of Obstetricians and Gynecologists: Growing up (Especially for Teens). ACOG Patient Education Pamphlet AP041.

American College of Obstetricians and Gynecologists: Menstruation. ACOG Patient Education Pamphlet AP049.

IMPLEMENTATION

Special Considerations

The average age of first menstruation (menarche) is 11.6 years, with ages 8 to 16 years being the normal range. These age ranges have been gradually declining over the past few years. Puberty occurs as much as 2 years earlier for girls of African-American descent. Menarche generally occurs after the growth spurt and beginning of breast development, while changes in the pubic hair and labia are still under way. Although there is some variation in the normal progression of events, thelarche is the indication of pubertal change for most, followed by adrenarche, then peak growth velocity, and ending with the onset of menstruation. This sequence generally takes 4½ years to run its course, with a range of 1½ to 6 years.

Lee PA. Normal ages of pubertal events among American males and females. J Adolesc Health Care. 1980;1:26.

McDowell MA, Brody DJ, Hughes JP. Has age at menarche changed? Results from the National Health and Nutrition Examination Survey (NHANES) 1999–2004. J Adolesc Health. 2007;40:227. Epub 2007 Jan 24

Zacharias L, Rand WM, Wurtman RJ. A prospective study of sexual development and growth in American girls: The statistics of menarche. Obstet Gynecol Surv. 1976;31:325.

American College of Obstetricians and Gynecologists. Breast concerns in the adolescent. ACOG Committee Opinion 350. Washington, DC: ACOG, 2006.

Reindollar RH, McDonough PG. Pubertal aberrancy: Etiology and clinical approach. J Reprod Med. 1984;29:391.

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