DISORDERS

OF PUBERTY

NORMAL PUBERTY

PRECOCIOUS PUBERTY

DELAYED PUBERTY

GYNECOMASTYA

Puberty
Onset of puberty --> Factors :

Race
Social
Psychosocial
Nutritional
chronic disease
Exercise

Puberty

Puberty is complex process, which involve the

activation of hypothalamic function and
maturation of the pituitary-gonadal axis
1. Resetting of the gonadostat
2. Neuroendocrine manifestation of puberty, is the

result of an increase in LHRH ( the central nervous

system) acetylcholine, catecholamine,
aminobutiric acid , opioid peptides, prostaglandins,
serotonin
3. Peripheral factors that influence GnRH activity :
steroid, peptide hormone, body mass, nutritional
factors, natural/synthetic environmental substances

Puberty

Three kinds of physical changes occur

during this period of life:

1) the adolescent growth spurt,

2) the development of primary sex
characteristics (The changes that mark
the beginning of puberty for girls and
boys),
3) the appearance of secondary sex
characteristics (Other external changes
that make adolescents look like mature
men and women ). .

Physical changes of
puberty

The change of puberty may be very

gradual
Described by method developed by Tanner
to describe the maturation of secondary
sexual characteristics ( stage 1 is
prepubertal, stage 5 is adult)
The marker of puberty ( the first sign )
for girl : breast development
(Development of breast bud)
for boys : genital growth (Enlarge of the
testes)

Stadium
Pubertas
Tanner

Male pubertal stage

Pubertal disorder

Praecox Puberty ( is defined by

appearance of secondary sexual
characteristic before 8 years of age
in girl or 9 years in boy )

Delayed puberty ( is defined as lack

of telarche / breast budding at 13
years of age or immature breast
development and failure to start
periods/ menarche at age 15 year in
girl or if testicular enlargement (>4
ml) or pubic hair is not present by
14 years of age in boy )

Primary amenorrhea is defined as failure

to attain menarche by age 16 in the
presence of normal breast development

Hypothalamus-hypophysis-gonadal axis
LHRH/GnRH

LH/FSH

HYPOTHALAMUS

HYPOPHYSIS

GONAD
testoterone/estrogen

Causes of Praecox Puberty

Variant normal
1. premature adrenache
2. premature telarche
3. Non progressive early puberty
Praecox puberty
1. Central Praecox Puberty
2. peripheral Praecox Puberty

Management

Medical history
early breast development ( girl),
exposure sex steroid, age of puberty of
family, growth rate, drug
Physical Examination
Laboratory Studies
LH, FSH, Eostradiol/ testoterone,Bone
age, USG, stimulating hormone, CT
scan

TREATMENT

Treatment should be considered if it is judged

appropriate to halt untimely pubertal
maturation, including menstruation, and
reverse the consequences of the accelerated
growth rate and skeletal maturation
Concern about psychological and social stress
GnRHa
Monitoring treatment
Peripheral : if there is a specific underlying
cause the therapy indicated for that
condition

Praecox Puberty

Delay puberty
Hipogonadism ( temporary)

A.

constitutional delayed of puberty

Chronic disease
Under nutrition
Exercise
Anorexia nervosa
Hormonal disorder

.
.
.
.
.
.

Hypothyroid
isolated GH deficiency
Cushings, corticosteroid therapy

Management of and
treatment option

Hormone replacement therapy

Puberty induction and maintenance
Induction of fertility

Klasifikasi ginekomastia

A. Ginekomstia fisiologis

3.

Ginekomstia pada neonatus

Ginekomstia pubertas
Ginekomstia usia lanjut

B. Ginekomastia patologis

1.
2.

1.
2.
3.

Defisiensi testoteron (kelainan kongenital/sindrom,

gagal testis sekunder)
Peningkatan produksi estrogen ( tumor, peningkatan
zat untuk aromatisasi jar. ekstraglandular)
Obat-obatan

Ginekomastia
Lipomastia

A. Ginekomstia fisiologis
Ginekomastia pada neonatus

faktor estrogen maternal atau placenta (atau ke2nya)

Sementara ( beberapa kasus menetap)

Ginekomstia pubertas

Usia 10-17 tahun

Transien (sekitar 2 tahun)

Selalu diawali tanda perkembangan sex laki-laki

Bila serupa M4 atau M5 makroginekomastia (tidak

bisa regresi spontan) harus segera terapi
Ginekomstia usia lanjut

B. Ginekomastia patologis

Oleh efek obat-obatan atau penyakit yg

mendasari (tumor, liver, hipertiroid,
sindrom hipergonadotropik
hipogonadism)
Bila timbul sebelum usia 10 tahun hatihati terhadap tumor hipofise, adrenal
atau testis
Tumor mammae massa di mammae
Predisposisi ca?