Infertility, Endocrinology, and Menstrual Dysfunction
A mother brings her 14-year-old daughter to the office for consultation. The mother is concerned that her daughter is shorter than her friends, and should have started her period by now. On physical examination, the girl is 4 ft 10 in tall. She shows evidence of breast development at Tanner stage 2. She has no axillary or pubic hair. You reassure the mother that her daughter seems to be developing normally. Educating the mother and daughter, your best advice is to tell them which of the following?
a. The daughter will start her period when her breasts reach Tanner stage 5.
b. The daughter will start her period, then have her growth spurt.
c. The daughter's period should start within 1 to 2 years since she has just started developing breast buds.
d. The daughter will have her growth spurt, then pubic hair will develop, heralding the onset of menstruation.
e. The daughter's period should start by the age of 18 years, but if she has not had her period by then, she should come back for further evaluation.
The answer is c. Significant emotional concerns develop when puberty is delayed. By definition, if breast development has not begun by the age of 13 years, delayed puberty should be suspected. Menarche usually follows about 1 to 2 years after the beginning of breast development; if menarche is delayed beyond the age of 16 years, delayed puberty should be investigated. Appropriate laboratory tests include circulating pituitary and steroid hormone levels, karyotypic analysis, and CNS imaging when indicated. An FSH value greater than 40 mIU/mL defines hypergonadotropic hypogonadism as a cause of delayed pubertal maturation. Hypergonadotropic hypogonadism is seen in girls with gonadal dysgenesis, such as with Turner syndrome.
A mother brings her 12-year-old daughter to your office for consultation. She is concerned because most of the other girls in her daughter's class have already started their period. She thinks her daughter hasn't shown any evidence of going into puberty yet. Knowing the usual first sign of the onset of puberty, you should ask the mother which of the following questions?
a. Has your daughter had any acne?
b. Has your daughter started to develop breasts?
c. Does your daughter have any axillary or pubic hair?
d. Has your daughter started her growth spurt?
e. Has your daughter had any vaginal spotting?
The answer is b. In the United ...