Answer:

Dr. J.M. Tanner proposed a five-stage system to grade breast and pubic hair development in girls and genital and pubic hair development in boys.

TANNER STAGES OF PUBERTAL DEVELOPMENT IN GIRLS

Breast Development	Pubic Hair Development
Elevation of papilla only	No pubic hair
Breast budding	Scattered labial hair
Enlargement of breasts without areola separation	Hair spreading to mons pubis
	Slight lateral spread
Secondary mound formed by areola	Hair on medial thighs
Mature breast with single contourof breast and areola

Reference:

• Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls. Arch Dis Child 44:291, 1969. Medline Similar articles
• Mishell DR, Stenchever MA, Droegenmueller W, Herbst AL (eds): Comprehensive Gynecology, 3rd ed. St. Louis, Mosby, 1997.

Answer:

No.  It appears that the HPG axis is intact as early as 20 weeks of life. Pituitary gonadotrophs have been found to produce LH and FSH at this gestational age, and in boys testicular testosterone is essential for normal internal and external genital development. In female fetuses, functional ovarian cysts are occasionally seen. These findings indicate a functional HPG axis in fetal life. LH and FSH levels peak at 20 weeks of gestation and then are suppressed by maternal estrogen. Immediately postpartum, LH and FSH levels flare for 1-2 years and then are suppressed until puberty either by exquisite sensitivity to very low levels of estrogen or by a central inhibiting factor.

Reference:

• Reindollar RH, Byrd JR, McDonough PG: Delayed sexual development: A study of 252 patients. Am J Obstet Gynecol 140:371, 1981. Medline Similar articles
• Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls. Arch Dis Child 44:291, 1969. Medline Similar articles
• Mishell DR, Stenchever MA, Droegenmueller W, Herbst AL (eds): Comprehensive Gynecology, 3rd ed. St. Louis, Mosby, 1997.

Answer:

Estrogen increases bone growth, especially in the axial skeleton. Growth hormone has more effect on the long bones. As a result of this, hypogonadal patients often have a short trunk as compared to their arm span and lower extremity length (eunichoid habitus). Growth hormone-deficient subjects often have the opposite appearance. Estrogen also promotes fusion of the epiphyseal plates. Patients with precocious puberty have an early growth advantage, but ultimately have short stature due to premature epiphyseal closure if left untreated.

Reference:

1. Clark PA, Rogol AD: Growth hormones and sex steroid interactions at puberty. Endocrinol Metab Clin North Am 25:665-681, 1996. Medline Similar articles
2. Frisch R, Revelle R: Height and weight at menarche and a hypothesis of menarche. Arch Dis Child 46:695-701, 1971. Medline Similar articles

Answer:

The first sign of puberty is an increase in luteinizing hormone (LH) pulsatility at night. This pulsatility is followed by LH and follicle-stimulating hormone (FSH) pulses throughout the day, leading to increasing estrogen levels from the growing ovarian follicle, and finally positive feedback of estradiol to initiate an LH surge capable of inducing ovulation. Elevated progesterone levels in the luteal phase follow ovulation. Ovulation is often inconsistent for 1-2 years after menarche, leading to irregular menstrual periods. After this time, most teenagers should have established normal cycles, and a failure to do so may indicate a reproductive disorder. Estrogen also stimulates growth hormone, which in turn stimulates insulin-like growth factor I leading to increased somatic growth. The adrenal gland starts to produce increased quantities of the androgens DHEA, DHEAS, and androstenedione at 6-8 years of age, but this is not thought to be part of the pubertal process.

Reference:

1. Mishell DR, Stenchever MA, Droegenmueller W, Herbst AL (eds): Comprehensive Gynecology, 3rd ed. St. Louis, Mosby, 1997.
2. Clark PA, Rogol AD: Growth hormones and sex steroid interactions at puberty. Endocrinol Metab Clin North Am 25:665-681, 1996. Medline Similar articles

Answer:

The first sign of puberty is often said to be breast budding (thelarche) around age 10. In fact, an increase in linear growth velocity can be appreciated 1-2 years prior to breast budding, heralding the onset of puberty. Thelarche is followed by pubic hair development (pubarche) at age 11, attainment of peak growth velocity (9 cm/year) at age 12, and menses (menarche) at age 13. The average age of menarche for U.S. girls has trended downward over the last century, presumably due to better nutrition and less stringent working conditions for minors. On average it takes 2.5 years from the onset of breast budding to the first period.

AVERAGE TIMING OF PUBERTAL EVENTS IN U.S. GIRLS
Pubertal Event                               Mean Age ± SD
Breast budding                               10.8 ± 1.1 years
Pubic hair                                         11.0 ± 1.2 years
Maximum growth rate                12.1 ± 0.88 years
Menarche                                         12.9 ± 1.2 years

Reference:

• Frisch R, Revelle R: Height and weight at menarche and a hypothesis of menarche. Arch Dis Child 46:695-701, 1971. Medline Similar articles
• Harlan WR, Harlan EA, Gillo GP: Secondary sex characteristics of girls 12 to 17 years of age: The U.S. Health Examination Survey. J Pediatr 96:1074, 1980. Medline Similar articles
• Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls. Arch Dis Child 44:291, 1969. Medline Similar articles
• Mishell DR, Stenchever MA, Droegenmueller W, Herbst AL (eds): Comprehensive Gynecology, 3rd ed. St. Louis, Mosby, 1997

Answer:

Puberty is the developmental process by which fully competent adult reproductive capacity is established. It is characterized by marked neuroendocrine and physiologic changes in the reproductive system, culminating in mature secondary sexual characteristics and, in girls, the ability to ovulate and menstruate. Significant increases in somatic growth as well as dramatic psychosocial changes also characterize puberty. Of note, changes in growth and psychosocial development do not always parallel the reproductive changes, and this can lead to misunderstanding regarding an individual’s “maturity.”

Reference: Morris W (ed): American Heritage Dictionary of the English Language.  Boston, Houghton Mifflin, 1978.

Answer:

Not all require treatment. They are usually only treated if they are symptomatic. There are three levels of treatment: incision and drainage, marsupialization, and excision. Most Bartholin’s duct cysts respond to incision and drainage. The incision is made medially toward the vagina and hymenal ring. After making a 5-mm stab incision, a Ward catheter is placed to keep the cyst wall open and allow for continued drainage. The optimal goal is for the catheter to stay in place for weeks to allow epithelialization of the opening. However, the catheter frequently falls out prior to removal. 

For women with recurrent Bartholin’s duct cysts, the cyst or duct wall can be opened widely and the edges sutured back to leave an open structure. This procedure is called marsupialization. 

If problems with the duct cyst persist despite marsupialization, the gland and dilated duct can be excised in toto. This involves significant dissection and requires regional or general anesthesia. 

Reference:

1. Stenchever MA, Droegemueller W, Herbst AL, Mishell DR (eds): Comprehensive Gynecology, 4th ed. St. Louis, Mosby, 2001.
2. Lee YH, Rankin JS, Alpert S, et al. Microbiological investigation of Bartholin’s gland abscesses and cysts. Am J Obstet Gynecol 129:150-153, 1977. Medline Similar articles