Puberty

PUBERTY

Q. 1

Orchidopexy for cryptorchidism is done at the age of:

 A 1 to 2 years
 B 5 to 6 years
 C Puberty
 D

Neonatal period

Q. 1

Orchidopexy for cryptorchidism is done at the age of:

 A 1 to 2 years
 B 5 to 6 years
 C Puberty
 D

Neonatal period

Ans. C

Explanation:

FAST [Ref: Schwartz 9/e p155; Sabiston 18/e, p 502; Washington Manual of Surgery,5/ep373; Trauma by David V Feliciano 6/e p622; Last Minute Emergency Medicine by Mary Jo Wagner 2007/e]

Schwartz writes- “Blunt abdominal trauma initially is evaluated by FAST examination in most major trauma centers, and this has largely supplanted DPL, FAST is not 100% sensitive, however, so diagnostic peritoneal aspiration is still advocated in hemodynamically unstable patients without a defined source of blood loss to rule out abdominal hemorrhage. Patients with fluid on FAST examination, considered a positive FAST’, who do not have immediate indications. for laparotomy and are hemodynamically stable undergo CT scanning to quantify their injuries.”

Sabiston v,rites – Hemodynamically stable patients sustaining blunt trauma are adequately evaluated by abdominal ultrasound or CT. unless other severe injuries take priority and the patient needs to go to the operating room before the objective abdominal evaluation. In such instances, DPL or. focussed abdominal sonography for trauma (FAST) is usually performed in the operating room to rule out intra-abdominal bleeding requiring immediate surgical exploration.

  • The main decision in an abdominal injury is to decide whether an exploratory laparotomy is necessary or not. Physical examination though may help sometimes, has significant limitations and may be unreliable.
  • The diagnostic approach to penetrating (Gunshot and Stab wounds) and blunt abdominal trauma differs substantially.

Gunshot abdominal wounds: Chances of internal injury is very high in gunshot wounds thus little preoperative evaluation is required and laparotomy is mandatory.

  • Stab wounds to abdomen:
  • In contrast to GSWs, SWs are less likely to injure intra-abdominal organs.
  • Patients with isolated penetrating abdominal wound if hypotensive, or in shock or showing peritoneal signs go for exploratory laparotomy.
  • Management of stable patients is debatable and controversial. Various methods are used to determine whether laparotomy is necessary or not.
  • Anterior stab wound- In ant. stab wounds local wound exploration can be performed to determine if there is any penetration of the peritoneal cavity. If the tract terminates without entering the peritoneum, the injury can be managed as a deep laceration and laparotomy is not needed. Otherwise, penetration of the peritoneum is assumed, and significant injury must be excluded by further diagnostic evaluations. Options include diagnostic peritoneal lavage, laparoscopy, CT, FAST, and admission with observation.
  • Flank and back wounds- There is more debate over the management of stab wounds to the flank and back. These injuries are special because of the risks associated with retroperitoneal organ injury-colon, kidneys and ureter. Triple contrast CT (i.e. oral, IV, and rectal contrast) is advised to detect colon and retroperitoneal injuries and the need for laparotomy. Other methods like DPL, laparoscopy arc also advised.

[According to EAST Guidelines, 2007, http://www.east.org Current recommendations for nonoperative management of penetrating trauma include the use of Triple contrast CT and serial examination.]

  • Blunt abdominal injury:
  • Hemodynamically stable patients sustaining blunt trauma are adequately evaluated by abdominal ultrasound or CT (CT in selected cases to refine the diagnosis) unless other severe injuries take priority and the patient needs to go to the operating room before the objective abdominal evaluation. In such instances, DPL or focussed abdominal sonography for trauma (FAST) is usually performed in the operating room to rule out infra-abdominal bleeding requiring immediate exploratory laparotomy. US has largely replaced DPL.
  • Management of hemodynamically unstable pt: a hemodynamically unstable pt is evaluated by FAST and if infra-abdominal fluid detected, undergoes laparotomy. [See the algorithm below]

[Note that management of blunt trauma abdomen is fast changing towards conservative management, rather than laparotomy]



Q. 2

What is the ratio of length of cervix and body of the uterus before puberty?

 A

2:1

 B

1:2

 C

1:3

 D

1:4

Q. 2

What is the ratio of length of cervix and body of the uterus before puberty?

 A

2:1

 B

1:2

 C

1:3

 D

1:4

Ans. A

Explanation:

  • Before puberty the ratio of length of cervix to corpus is 2:1
  • At puberty the ratio of length of cervix to corpus is 1:2
  • During reproductive years the ratio may be 1:3 or 1:4

Ref: Shaw’s Textbook of Gynecology, Edition 21, Page 7


Q. 3

According to Tanner stages of development, which is the first sign of puberty in females?

 A

Pubarche

 B

Thelarche

 C

Menarche

 D

Increase in height

Q. 3

According to Tanner stages of development, which is the first sign of puberty in females?

 A

Pubarche

 B

Thelarche

 C

Menarche

 D

Increase in height

Ans. B

Explanation:

GnRH stimulates secretion of LH and FSH which causes the ovary to produce estrogens. Subsequently changes of puberty occur including breast development (thelarche), development of pubic and axillary hair (pubarche), the growth spurt (peak height velocity), and onset of menstruation (menarche).

 

 

Thelarche (breast development) is the first sign of puberty (Tanner stage B2). It usually begins between 8 and 10 years of age and is associated with increased estrogen production.

 

 

 

Pubarche (development of pubic and axillary hair) is the second stage in maturation and typically occurs between 11 and 12 years of age. Axillary hair usually appears after the growth of pubic hair is complete.

 

 

 

Menarche (onset of menstruation) usually occurs 2-3 years after thelarche at an average age of 11-13 years. Initial cycles are often anovulatory and irregular.

 

 

 

Ref: Blueprints Obstetrics & Gynecology By Tamara L. Callahan, Aaron B Caughey, Aaron B Caughey, M.D., 2008, Page 212 ; Obstetrics and Gynaecology at a Glance By Errol R. Norwitz, John O. Schorge, 2010, Page 49 ; Nelson Textbook of Paediatrics 17th edition page 1882

 


Q. 4

The first sign of puberty in girls is:

 A

Breast budding

 B

Growth spurt (Peak height velocity)

 C

Menarche

 D

Pubic and axillary hair growth

Q. 4

The first sign of puberty in girls is:

 A

Breast budding

 B

Growth spurt (Peak height velocity)

 C

Menarche

 D

Pubic and axillary hair growth

Ans. A

Explanation:

In girls, Thelarche (development of breast tissue) is the first sign of development of puberty.

The embryological development of breasts starts in the sixth embryonic week.

The thelarche usually starts at a mean age between 8-9 years.

Ref: Principles and Practice of Endocrinology and Metabolism By Kenneth L. Becker, Pages 885-90; Fundamentals of Pediatric Surgery By Peter Mattei, Pages 829-303; Recent Advances in Adolescent Health By Roza Olyai, Pages 15-16


Q. 5

What is the approximate weight of thymus gland at puberty?

 A

15 gms

 B

35 gms

 C

25 gms

 D

55gms

Q. 5

What is the approximate weight of thymus gland at puberty?

 A

15 gms

 B

35 gms

 C

25 gms

 D

55gms

Ans. B

Explanation:

The thymus is largest and more active during the neonatal and pre-adolescent periods. By the early teens, the thymus begins to atrophy and thymic stroma is replaced by adipose tissue. Nevertheless, residual T lymphopoiesis continues throughout adult life. The thyroid reaches maximum weight ( 20-37 grams) by the time of puberty.
 

  Age   Mass
  Birth   about 15 gms
  Puberty   About 35 gms
  Twenty- five years   25 gms
  Sixty years   < 15 gms
  Seventy years   as low as 5 gms

Q. 6

Males and females show difference in the age of onset of puberty. The difference in the age of onset of puberty amongst males may be explained by:

 A

Increased Activin – A levels

 B

Decreased Follistatin levels

 C

Increased Inhibin levels

 D

Easily releasable FSH pool

Q. 6

Males and females show difference in the age of onset of puberty. The difference in the age of onset of puberty amongst males may be explained by:

 A

Increased Activin – A levels

 B

Decreased Follistatin levels

 C

Increased Inhibin levels

 D

Easily releasable FSH pool

Ans. C

Explanation:

The onset of puberty is delayed in males when compared to females. As Inhibin levels suppresses FSH secretions thereby an increase in its production delays the onset of puberty.

Ref: Journal of Human Reproduction Vol. 19, Page 1107; Pediatric Endocrinology: Mechanisms,Manifestations, and Management By Ora Hirsch Pescovitz, Erica A. Eugster, Chapter 22


Q. 7

Which of the following hormones is mainly responsible for skeletal maturation of long bones during puberty?

 A

Testosterone

 B

Estrogen

 C

Growth hormone

 D

Testosterone/estrogen ratio

Q. 7

Which of the following hormones is mainly responsible for skeletal maturation of long bones during puberty?

 A

Testosterone

 B

Estrogen

 C

Growth hormone

 D

Testosterone/estrogen ratio

Ans. B

Explanation:

Estrogen promotes bone maturation and closure of epiphyseal plates in long bones. It conserves bone mass by suppressing bone turnover and maintaining balanced rates of bone formation and bone resorption. Estrogen affects the generation, lifespan, and functional activity of both osteoclasts and osteoblasts. It promotes synthesis of osteoprotegerin, decreases osteoclast formation and activity, and increases osteoclast apoptosis.
 
Ref: Molina P.E. (2013). Chapter 9. Female Reproductive System. In P.E. Molina (Ed), Endocrine Physiology, 4e.

Q. 8

Which of the following neurotransmitter has an inhibitory control over the GnRH neurons before the onset of puberty?

 A

Glycine

 B

Glutamate

 C

Gamma amino butyric acid (GABA)

 D

Beta-endorphin

Q. 8

Which of the following neurotransmitter has an inhibitory control over the GnRH neurons before the onset of puberty?

 A

Glycine

 B

Glutamate

 C

Gamma amino butyric acid (GABA)

 D

Beta-endorphin

Ans. C

Explanation:

Before the onset of puberty, the GnRH neurons are under the inhibitory control of GABA. 

Gamma amino butyric acid is a dominant inhibitory neurotransmitter in the hypothalamus. Inhibition of GnRH neurons by GABA is mediated via Glutamergic neurons. A reciprocal innervations between GABAergic and Glutamergic neurons are found. During development GABA concentration and the number of GABAergic neurons increase from 13th day to second postnatal week, which is then followed by a decline in 3rd postnatal week. GABA release in the median eminence decrease concomitantly with the pubertal increase of GnRH secretion.
 
Ref: Male Hypogonadism: Basic, Clinical, and Therapeutic Principles By Stephen J. Winters, Page 69 ; Goldfrank’s Toxicologic Emergencies By Lewis R, Page 232 – 238.

Q. 9

Which one of the following is the correct order of events at puberty in a girl ?

 A

Thelarche-puberche-menarche-growth spurt

 B

Puberche-thelarche-growth spurt menarche

 C

Menarche-growth spurt-thelarche-puberche

 D

Thelarche-puberche-growth spurt-menarche

Q. 9

Which one of the following is the correct order of events at puberty in a girl ?

 A

Thelarche-puberche-menarche-growth spurt

 B

Puberche-thelarche-growth spurt menarche

 C

Menarche-growth spurt-thelarche-puberche

 D

Thelarche-puberche-growth spurt-menarche

Ans. D

Explanation:

Ans. is ‘d’ i.e., Thelarche – puberche – growth sport-menarche


Q. 10

Hormones required during puberty ‑

 A

LSH

 B

Testesterone

 C

Leptin

 D

All of the above

Q. 10

Hormones required during puberty ‑

 A

LSH

 B

Testesterone

 C

Leptin

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e., All of the above

  • Puberty is triggered by a release of gonadotropins (FSH and LH) from pituitary gland.
  • These hormones act as signals to the gonads (testes/ovaries) that trigger the production of –

i) Estrogen, progesterone and some testosterone in women.

ii) Testosterone in men.

  • In both males and females, testosterone is responsible for development of pubic hair, accelerated bone growth, body odor and acne during puberty. For boys, testosterone is responsible for the process of virilization, including the enlargement of the penis, increased libido and growth of facial and chest hair.
  • Estrogen is the major hormone responsible for female puberal development. It causes development of breast and thickening of endometrium.
  • Progesterone causes proliferation of acini in mammary glands and converts watery cervical secretion to viscid and scanty.
  • Leptin facilitates release of gonadotropin releasing hormone (GnRH), thereby helping in pubertal onset.
  • Other hormones which are involved in puberty are thyroxine and growth hormone.

Q. 11

First sign of puberty in female ‑

 A

Tanner stage I

 B

Tanner stage II

 C

Pubic hair

 D

Axillary hair

Q. 11

First sign of puberty in female ‑

 A

Tanner stage I

 B

Tanner stage II

 C

Pubic hair

 D

Axillary hair

Ans. B

Explanation:

Ans. is `b’ i.e., Tanner stage 11

Thelarche- first sign of puberty in Girl around age of 10 year in Girl

  • Definition :- Begining of secondary (Post natal) breast development at onset of puberty in girls.
  • Tanner stage 2 breast development.
  • Because of rising level of estradiol
  • Breast development during puberty in male termed as gynecomastia not thelarche.

Q. 12

Sign of puberty in boys ‑

 A

Enlargement of penis

 B

Enlargement of testes

 C

Appearance of pubic hair

 D

Appearance of axillary hair

Q. 12

Sign of puberty in boys ‑

 A

Enlargement of penis

 B

Enlargement of testes

 C

Appearance of pubic hair

 D

Appearance of axillary hair

Ans. B

Explanation:

Ans. is ‘b’ i.e., Enlargement of testes

  • In girls, the first visible sign of puberty is the appearance of breast buds (Thelarche), between 8-12 years of age.
  • In boys the first visible sign of puberty is testicular enlargement, beginning as early as 91/2 yr.


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