Chapter 3: Puberty

GENERAL INTRODUCTORY COMMENTS

Puberty is the transitional process leading to reproductive maturity. Proper diagnosis and management of pubertal disorders requires understanding of (1) basic endocrinology of the hypothalamic-pituitary-gonadal axis; (2) developmental changes that occur at different points throughout childhood; and (3) the wide variability in timing of physical changes of puberty seen in normal children.

BASIC ENDOCRINOLOGYOF PUBERTY

The three anatomic sites most pertinent to pubertal development are the hypothalamus, the anterior pituitary gland, and the gonads (ovaries or testes), known collectively as the hypothalamic-pituitary-gonadal (HPG) axis (Figure 3-1). Also shown in this figure are the critical hormones and feedback loops of the HPG axis.

Kisspeptins are peptides secreted by neurons in the arcuate and anteroventral periventricular nucleus of the hypothalamus.¹ These peptides bind to a G-protein–coupled receptor called GPR54 on hypothalamic neurons that secrete gonadotropin-releasing hormone (GnRH). The resulting pulses of GnRH in turn induce pulsatile secretion of the gonadotropins, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). LH and FSH working in concert lead to germ cell (spermatozoa or ova) maturation and also stimulation of sex steroid (androgen or estrogen) secretion by the gonads, along with gonadal peptides such as inhibins. The sex steroids exert a negative feedback effect at both hypothalamic and pituitary levels, reducing the secretion of kisspeptin, GnRH, and LH, whereas inhibins control FSH secretion via a separate negative feedback loop at the pituitary level. Later in life, once menstrual cycles begin, women also develop a positive feedback cycle whereby estrogens stimulate gonadotropin release during phases of the cycle critical for ovulation.

Inhibins are dimeric gonadal peptides that inhibit FSH secretion by the pituitary gland. The two major forms of inhibin are inhibin A and inhibin B. Inhibin A is a product of ovarian follicles and is only measurable in females. Inhibin B is the product of granulosa cells in girls and of Sertoli cells in boys, and may be useful, along with anti-müllerian hormone (AMH), for evaluation of testicular abnormalities, including cryptorchidism.

Activins are dimeric gonadal proteins that stimulate FSH secretion, although there appears to be less clinically relevant information gleaned from measuring activins than there is from measuring inhibins.

These basic hormonal pathways are modulated by many different central nervous system (CNS) inputs, including stimulatory effects of glutaminergic neural systems, inhibitory effects of γ-aminobutyric acid (GABA)-ergic systems, and direct interactions between glial cells and hypothalamic neurons. The CNS in turn integrates the effects of many external factors such as nutrient availability, exercise, stress, social/psychological factors, and indirect effects of chronic disease.

DEVELOPMENTAL CHANGES RELEVANT TO PUBERTY

Fetal Period

Four critical developmental steps during fetal life establish the required anatomy ...