30.     Puberty.  

Puberty is the process of sexual maturation and spans years.

Breast development usually starts about the age of nine, followed by the appearance of pubic and axillary hair at 10, then menstruation at 12 - 13.

There is debate about the age at which failure to menstruate is abnormal.

But the normal range runs to at least 16 and some would even accept 18, so long as secondary sexual development is normal.

Patients will usually present before this age.

If secondary sexual development is normal, I usually arrange a scan for reassurance of the child and her mother.

It covers the rare imperforate hymen producing cryptomenorrhoea (see MCQ 3, question 26).

But its main value is to reassure the family that the uterus and ovaries are in place.

A good history will also raise the possibility of an imperforate hymen.

These girls usually have cyclical pain and pre-menstrual symptoms without bleeding.

One of the fascinating things about embryology is the every embryo develops female external genitalia unless exposed to testosterone.

This explains the rare Testicular Feminisation Syndrome, now more accurately known as Androgen Insensitivity Syndrome (see MCQ1, question 34.

The chromosomes are male and the gonads are testes.

But tissue insensitivity to testosterone results in the ‘default’ mechanism of development of female external genitalia.

Remember that with this syndrome the gonads should be removed because of the significant risk of malignant change.

The cervix also undergoes significant change with puberty (see also MCQ 2, question 24).

Beforehand, the ectocervix is covered with columnar skin.

With puberty this transforms into squamous skin.

This is the “transformation zone” and the area in which cancer of the cervix most commonly arises.

In places the squamous skin covers tiny islets of columnar skin that remain viable and continues to produce mucus.

This generates the Nabothian follicles that are often seen on the cervix.