PUBERTY AND THE

MENSTRUAL CYCLE.
DR BARASA A N
PUBERTY.
• Definition-is the period when endocrine and gametogenic functions
of the gonards first develop to a point where reproduction is possible.
• Starts with activation of the ovary by gonadotropins.
• The period of final maturation is called adolescence.
• Xterized by regular periodic changes of the female reproductive
system each in preparation for a pregnancy.
• The cyclic changes are divided into :
1. Ovarian cycle
2. Uterine cycle
• Associated cyclic changes in the cervix, vagina, breasts.
• Cycle control regulated by the hypothalamo-pituitary-ovarian axis.
Onset of puberty.
• Age at onset variable from place to place and with socio-economic
status.
• Been declining with time.
• Usually between 8-13 years in girls and 9-14 years in boys.
• Preceded by increased secretion of adrenal hormones (adrenarche)
usually around 8-10 years in girls and 10-12 years on boys.
Stages of puberty in girls.
Stage 1- Thelarche:
• Development of breasts.
• Under the influence of estrogen and progesterone.
• Estrogen responsible for growth of ducts while progesterone for
growth of alveoli and lobules.
Tanners stages of breast
development.
1-preadolescent stage. Elevation of breast papillae only.
2-breast bud stage(11 years).Elevation of breast and papillae as small
mounts with enlargement of the areola.
3- enlargement and elevation of breast and areola with no separation
of the contour(confluent).
4-areolar and papilla project from breast to form a secondary mount. 5-
mature breast. projection of papilla only with recession of areolar into
the general contour of the breast.
Tanner’s stage of breast dvpt.
Stage 2- puberche.
• Dvpt of pubic and axillary hair.
Under the influence of adrenal androgens(DHEA).
• Stages of puberche:
1. pre-adolescent , no pubic hair
2-sparse, long, less pigmented, straight or less curly along labia.
3- darker, courser, more curled, sparsely over pubis.
4- resembles adult type but covers a small area.
5. Adult type in quantity and distribution.
Stage 3- menarche.
• The 1st menstrual period.
• Initially irregular, becomes regular after 1st year.
Control of the onset of puberty.
• Age at onset influenced by the general health(wgt), genetic factors,
nutrition and exercise.
• Under neural mechanism- hypothalamo- pituitary- gonadal axis.
• Hypothalamus- pulsatile release on gonadotropic release
hormone(GnRH).
• Pituitary- stimulated to release gonadotropins- FSH(follicle stimulating
hormone), and LH(lutenizing hormone).
• Ovary- production of sex steroids estrogen and progesterone.
• Neural mechanism influenced by body weight.
• H-P-O axis stimulated by Leptin, a satiety hormone produced by fat cells.
Abnormalities of puberty:
Precocious puberty:
• Pubertal dvpt before age 8 in girls and 9 in boys.
• Categorized into gonadotropin dependent, gonadotropin
independent( peripheral) and constitutional precocious puberty.
• Precocious pseudo puberty-early dvpt of secondary sexual xteristics
without gametogenesis. Caused by premature exposure to sex
steroids(estrogen).
Causes of precocious puberty
1. Gonadotropic dependent-hypothalamic tumors, infections,
developmental abnormalities/ genetic mutations.
2. Gonadotropic independent-ovarian/ adrenal tumors,
hypothyroidism, mcCune Albright syndrome(increased sensitivity of
LH receptors to gonadotropins. Associated with café-au- lait skin
pigmentation and fibrous dysplasia of bone).
NB- rapid weight gain in infants born with low birth weight may
increased cause insulin sensitivity and associated hormonal changes eg
early puberche.
Causes of precocious pseudo
puberty.
1. Adrenal- congenital virilizing adrenal hyperplasia.
-Androgen secreting tumors(boys).
- Estrogen secreting tumors(girls).
2.Gonadol-interstitial cell tumors of the testes in boys.
-granulosa cell tumors of the ovary.
3. miscelanous.
2. Delayed or absent puberty.
• Absence of puberty by age 12 in girls or lack of menarche within 3 years of
onset of secondary sexual xteristics.
• Causes:
1. constitutional.
2. functional hypothalamic hypogonadism.
3. hypothalamic hypogonadism- kallman’s syndrome, CNS tumors, GnRH
deficiency.
4. hypergonadotropic hypogonadism- turner’s syndrome, previous
chemotherapy/ irradiation to the ovaries.
5. pan hypopituitarism-associated with dwarfism and other endocrine
abnormalities.
REPRODUCTIVE FUNCTION AFTER
ONSET OF PUBERTY.
• THE MENSTRUAL CYCLE.
 feedback control
• Hypothalamus releases GnRH which stimulates the anterior pituitary to
produce gonadotropins. FSH stimulates the granulosa cells of the ovarian
follicle to secretes estrogen at the start of the cycle. Low levels of estrogen
exert a negative feedback on the pituitary to reduce FSH production
necessary for selection of a dominant follicle. The low levels also exert a
negative feedback on LH.
• As estrogen levels increase, it exerts a positive effect on hypothalamus and
pituitary causing the LH surge responsible for ovulation.
• Low progesterone exerts a positive feedback on pituitary LH and FSH be4
ovulation.
• High progesterone inhibits LH and FSH.
THE MENSTRUAL CYCLE.
• Regular cyclic changes in preparation for fertilization and pregnancy.
• The most conspicuous feature is cyclic vaginal bleeding due
endometrial shedding/sloughing.
• Cycle length- variable, ranges btn 21-35 days, average= 28 days.
• Categorized into:
1. Ovarian cycle
2. Endometrial cycle
3. Others- cervical cycle, vaginal cycle, breast changes.
Ovarian cycle:
Normal ovarian physiology:
• During fetal dvpt, each ovary contains 7 million germ cells. These
undergo involution/atresia.
• By the time of birth each ovary contains about 2 million primordial follicle
each containing an immature ovum. About 50% of these are atretic.
• The remaining ova undergoes 1st meiotic division but arrest in prophase
until adulthood.
• Continuous atresia leaves about 300,000-400,000 by puberty. Only about
400-500 will ovulate if a lifetime. only one is stimulated to mature each
month.
• Just be4 ovulation the 1st meiotic division is completed to give a
secondary oocyte and one polar body which disintegrates.
• The secondary oocyte begins the second meiotic division but stops at
metaphase. The second meiotic division is completed only when the
sperm penetrates to release the second polar body which regresses.
The ovarian cycle.
Follicular phase.
• At the beginning of each cycle, several primordial follicles enlarge and
form a cavity(antrum)filled with follicular fluid.
• The antral follicle secretes circulating estrogen (theca interna cells) as
well as estrogen secreted into the antrum( granulosa cells).
• The fastest growing follicle becomes the dorminant follicle(from day
6) while the others undergo atresia( atretic follicles).
• Around day 14, the distended follicle raptures releasing the ovum=
ovulation.
• The ovum is picked by the fimbrial end of the tube and transported
through the tube where fertilization takes place.
• In absence of fertilizatn, the ovum degenerates or is rarely passed out
through the vagina.
Luteal phase:
• After ovulation, the follicle fills up with fluid forming a corpus
haemorrhagicum. Minor bleeding into the peritoneal cavity may cause
irritation/ pain (mittelshmerz).
• The granulosa and theca cells proliferate and the blood gets replaced by
yellow lipid rich fluid forming a corpus luteum (C.L)
• Luteal cells secretes both estrogen and progesterone.
• If pregnancy occurs, the C.L persists, if no pregnancy, it begins to degenerate
about 4/7 be4 menses causing a drop in estrogen and progesterone which
withdraws the endometrial support.
• The C.L is eventually replaced by fibrous tissue forming a corpus albicans.
• Luteal phase usually constant- about 14 days.
• Menstruation takes place exactly 14 days after ovulation.
• The difference between the lengths of the menstrual cycles usually
due to difference in the follicular phase duration.
Uterine cycle

1. Proliferative phase:
• Under the influence of estrogen from developing ovarian follicle,
endometrium regenerates increasing in thickness.
• Associated lengthening of uterine/ endometrial glands which remain
straight with no secretions.
2. Secretory phase.
• Endometrium becomes highly vascularized and slightly edematous
under influence of estrogen and progesterone from the C.L
• Endometrial glands become coiled and tortuous.
• Secretion of fluid within the glands.
• Formation of the decidual from the superficial 2/3rd,
• Late in luteal phase endometrium secretes prolactin(function unknown).
3. Menstrual phase:
• Due to regression of the C.L withdrawing hormonal support- vascular
spasms- ischemia- thinning of the endometrium- extreme coiling of spiral
arteries- hemorrhage- shedding of the functional layer leaving the basal layer.
• Spasms of the spiral arteries reduces blood loss. Controlled by local
prostaglandins(PGF2 alpha).
Normal menstruation.
• 75% arterial, only 25% venous.
• Components- tissue debris, prostaglandins, fibrinolysin.
• Fibrinolysis- lyses clots hence normal menstrual blood doesn’t clot. If
flow is heavy- clots.
• Duration 3-5 days(as short as 1/7 and as long as 8 days).
• Average amount 30mls(5-8omls).
• Factors affecting amount- endometrial thickness, medications,
coagulation disorders.
Anovulatory cycles.
• Common at menarche(1st 12-18 cycles) and towards menopause.
• Prolonged exposure to estrogen in absence of opposing effect of
progesterone(no C.L).
• Excess endometrial proliferation, thickening and subsequent
breakdown.
• Flow ranges from scanty to profuse. Usually irregular.
The cervix
• No desquamation/ shedding.
• Mainly changes in the cervical mucus.
• Proliferative phase-mucus thinner and more alkaline(to support
sperm survival).
• Luteal phase-mucus thick, tenacious and cellular.
• Ovulatory phase- Thin, clear and elastic (spinbarkeit) up to 8-12 cm.
forms a fern pattern on drying.
Vaginal cycle
• Estrogen(proliferative phase)- vaginal epithelia becomes cornified.
• Progesterone-thick mucus. Epithelia proliferates and gets infiltrated
with leucocytes.
Breast changes.
• Estrogen-proliferation of mammary ducts.
• Progesterone- proliferation of lobules and alveoli. Before menses-
breast swelling, pain and tenderness.
Other systems.
• Small increase in basal body temperature during luteal phase-
thermogenic effect of progesterone.

• Read- changes associated with sexual intercourse.

Relevance/ application of the
menstrual cycle.
1. Indicators of ovulation- increase in basal body
temperature(retrospective indicator).
- increase in urinary LH- corresponds to blood LH surge. Preceeds
ovulation by 9 hours.
2. Contraception- calendar or safe days.
THE END
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