A. Describe physical changes occurring in the early, middle, and late phases of puberty in both sexes and correlate these with hormonal changes, using appropriate standards of comparison

• Tanner staging, growth charts
• Principal endocrine changes in adolescence
• gender determined differences
• other sex steroid effects (eg. bone mineralization)
• average ages, upper and lower limits of normal

Readings

Interactive lecture

Individual/group work

Lecture highlights physical manifestations in different phases of puberty, indicating such differences between girls and boys as follows, early phase: obvious breast budding and acceleration of growth (girls) versus imperceptible increase in testicular volume (boys). Middle phase: menarche at a precise age (girls) versus mature spermatogenesis at a non-precise age and growth acceleration (boys). Late phase: body fat increase and change in distribution (girls) versus voice deepening, facial hair and increased muscle mass (boys).

Plot growth and puberty data of an adolescent on growth charts; interpret hormonal data of an adolescent

Participants decide if the following examples are within physiological limits of young people of racial/ethnic groups within their own countries/practices:

• a girl with pubic hair development begun at 7.5 yrs
• a girl with breast development started at 8.5 yrs
• a girl with menarche at 9.5 yrs
• a girl with primary amenorrhea at 15.5 yrs
• a boy with prepubertal penis at 14 yrs

Refs 1 - 3

Module A1

Groups develop recommendations on interviewing adolescents for school doctors responsible for routine health visits. Answers are compared and evaluated during plenary with discussion about the issues of communication, confidentiality/consent and contexts (cultural, religious, etc.)

1. Should pubertal development be assessed and why? What are suitable conditions to do so?
2. What are the key questions to be used when taking a history from an adolescent boy or girl to evaluate pubertal development and the adolescent’s perception of it?
3. What are ways of respectfully assessing pubertal development through a physical examination?

Case study and
role play

Case study:
A boy of 15 complains about his short stature (3rd centile) citing negative remarks from the coach of his football team. Your findings: target height (sex-corrected mid-parental height) at 10th centile; born full term small at 2.4 kg; puberty stage P4 G4; previous growth regular between the 3rd and 10th centiles.  When and how do you comment on these findings?

Some considerations for use with case study (with attention paid in role play to the use of proper timing during interview, and proper wording to address these issues):

• Height has a familial/genetic component that does not result from a choice by the parents nor by their children.
• Small size at birth may also account for relatively short height later in life.
• Normal growth along a normal centile indicates that growth and sex hormone are in order.
• Being short does not prevent one from being a good athlete.
• Treatment manipulation of growth is not efficient and not necessarily safe in such a case.

Case study :
A 13.5 year-old boy consults for mild obesity (BMI +2.3 SD). Your findings: breasts (B3 appearance) with prominent fat and little true gynecomastia; testes are 5 ml but penis is still prepubertal (G2) and partly hidden in pubic fat.  How do you comment on these findings?

Some considerations for case study

• Fat tissue in excess may result in a breast-like appearance.
• True glandular breast tissue does develop slightly but transiently during puberty in a majority of normal boys.
• Breast tissue does not indicate wrong sex orientation or wrong (female) hormones in blood. The tissue may result from local transformation into estrogens of the increased male hormones produced by the testes.
• A hidden penis appears smaller than it is.
• Increased testicular volume indicates that puberty just started and the signs of hormonal effects (pubic hair, penile growth) are to be expected soon.
• Being age 13.5 at such a stage corresponds to the lower limit of a normal range of 4 years between the fastest and slowest maturers.

A. List common conditions with growth and / or pubertal problems, and recognize their associated growth patterns and etiologies.

• Familial short stature
• Precocious puberty
• Intrauterine growth retardation
• Constitutional delay of puberty
• Panhypopituitarism (craniopharyngioma)
• Turner syndrome

(non-limiting list)

The lecturer lists the common etiologies of short stature or delayed puberty in adolescent boys and girls, noting the prominent features. Participants identify and juxtapose the constitutional versus non-constitutional etiologies (e.g. familial pubertal delay vs Kallmann syndrome, idiopathic central precocious puberty vs sexual precocity in children from international adoption, idiopathic GH deficiency vs craniopharyngioma).

Participants interpret growth charts suggestive of the common conditions, and explain their conclusions.

Case study:
A girl of 14 consults because of her short stature. She had recurrent otitis in childhood, and occasional school problems. The exam indicates P3 B1. She has a mild dysmorphic appearance (short neck).

Ref 7-10

Growth charts

Define the appropriate examination procedures, including other medical opinions, that you would request for an adolescent in whom you suspect

• Turner syndrome
• GH deficiency
• Kallmann syndrome
• Anorexia nervosa

Which specialists would possibly be involved?

C. Identify subjective reasons for diagnostic and therapeutic intervention in non-specific disorders of growth or puberty

Focus group

Individual reflection, small group discussion

Case study:
An adolescent boy with borderline (3rd centile) short stature who just entered puberty at the age of 14 is referred by his general practitioner. Examination reveals no specific etiological condition. Although the boy and his parents are not particularly worried, you have some concerns.

Discuss:
What could be reasons for considering and proposing minimal diagnostic assessment?
What could be reasons for considering referral for therapeutic intervention?

Group work with
role play

For Objectives D and E, group formulates questions (sample questions provided below) and uses them to role play case study.

Case study:
A 14 year old girl is seen at consultation for absence of breast development (B1). The findings : pubic hair P4 ; girl is involved in gymnastics 10 hours/week ; mother’s menarcheal age 15 years. You take her history, paying attention to uncovering situational factors that impact the patient’s feelings and condition. What areas need to be considered in an assessment of  situational factors? For what purpose? Using which questions?

Sample questions :

• Does it bother you that your breasts have not developed yet? Are your parents worried about it?
• How do you feel when compared to your schoolmates? Or to your classmates in gymnastic training?
• Do you feel happy or pressured by your gymnastic training?
• How about your height and your growth?  Did it slow down recently?
• How do you feel about the way your body looks right now? How do you feel when compared to your classmates? What does your coach think about your size?
• Have you done anything to try to gain or lose weight? Dieting? Restricting what you eat? Intentionally vomiting?

Group work with
role play

Case study :
A boy of 15 complains about breast development (B3) that occurred a year ago and did not change for the last 6 months. Take history and pay attention to identifying consequences of his problem. Which questions or statements could be helpful to assess and respond to an adolescent’s emotionally loaded complaint?

Sample questions for assessment:

• Your breast development started about a year ago. Were there changes in your life at that time, or during the past year?
• Does the breast development bother you? Worry you? When does it bother you the most?
• How do you feel about it in relation to your friends or classmates?
• What do you think about the rest of the way your body is developing and changing?
• How is life at home?  Do you feel cool or nervous, aggressive?
• Taking any medicine on a regular basis?
• Smoking tobacco? Using any drug or substance?

Sample statements for response:

• I can understand your concern.
• This is a very common, almost normal problem that is bothering you, perhaps because it is a little more obvious than usual.
• It should resolve spontaneously, but it can take months or even years.
• If you are bothered in the gymnastic class, we can talk about whether you’d want a certificate of exemption.
• Minor corrective surgery could be indicated, depending on how you feel now and in some months from now.

Ref 11

F. Demonstrate how you would involve the adolescent and the family in the management of the situation

Focus group

Role play

Case study :
A boy aged 14.5 presents with delayed puberty (G2P2, test. vol. 5 ml). He has school problems (repeated a grade) and exhibits social withdrawal. He wants treatment if possible, but his parents are reluctant.  They were also late bloomers and could manage their lives without therapy.
Question: What kind of information should be provided to facilitate the adolescent and family’s input in the decision-making process regarding therapy? Participants formulate responses and practice in role play.

Guideline statements:

• DP is not a disease; it is an extreme variant of normal development and a self-limiting condition.
• DP does not harm physically and will ultimately result in normal adult development and function (height, sexuality, fertility).
• DP may harm psychologically.
• In such conditions, a treatment may be useful because there are still several months or years of delay before the growth spurt.
• Testosterone therapy is transient, lasting for 6-12 months with the aim of attaining a blood level of testosterone consistent with age.
• The treatment will accelerate growth and pubertal development (penile growth, pubic hair) but will not change the final height and development outcome.
• Both options (treatment or no therapy) are medically acceptable and safe.·Give priority to the adolescent’s opinion, while listening to and answering the parent’s concerns and questions.
• Whatever the patient’s decision is may change with time and development.  The decision might be revised during follow up.