Normal Growth and Puberty

  • Caren J. Landes
  • Joanne C. Blair
Part of the Medical Radiology book series (MEDRAD)


The appearances of the female reproductive tract during infancy, childhood and adolescence are regulated by the hypothalamic-pituitary-ovarian axis. During neonatal life and early infancy the development of the reproductive tract is stimulated by high levels of gonadotropins and oestrogen. During childhood, production of these hormones falls to rise again in late childhood and pubertal years. This chapter describes normal development, anatomy and diagnostic imaging appearances of the female reproductive tract in the context of the changes in hormone production that regulate development. Normal growth and bone maturation including the acquisition of bone mass is also discussed.


Bone Mineral Density Fallopian Tube Precocious Puberty Endometrial Thickness Broad Ligament 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Inferior vena cava




Dehydroepiandrosterone sulphate


Voiding cystourethrogram


Diffusion weighted-imaging


Gonadotropin-Releasing Hormone


human chorionic gonadotropin


















Cubic centimetre






Spectral Adiabatic Inversion Recovery


Multifollicular ovary


Turbospin Echo










Computed Tomography


Magnetic Resonance Imaging


Magnetic Resonance


Standard deviation


Luteinising hormone


Follicle stimulating hormone


Dual-emission X-ray absorptiometry


Anti-diuretic hormone (ADH)


Fundocervical ratio


Greulich & Pyle




Skeletal maturity score




Tanner-Whitehouse 2


Tanner-Whitehouse 3


Bone mineral density


Grams per square centimetre


Region of interest


Bone mineral content


Quantitative computed tomography


Quantitative ultrasound


Speed of sound


Broadband ultrasound attenuation




  1. Adams J, Polson DW, Abdulwahid N et al (1985) Multifollicular ovaries: clinical and endocrine features and response to pulsatile gonadotrophin releasing hormone. Lancet 2:1375–1399PubMedCrossRefGoogle Scholar
  2. Ahmed ML, Warner JT (2007) TW2 and TW3 bone ages: time to change? Arch Dis Child 92:371–372PubMedCrossRefGoogle Scholar
  3. Argyropoulou MI, Xydis V, Kiortsis DN et al (2004) Pituitary gland signal in preterm infants during the first year of life: an MRI study. Neuroradiology 46:1031–1035PubMedCrossRefGoogle Scholar
  4. Badouraki M, Christoforidis A, Economou I et al (2008) Sonographic assessment of uterine and ovarian development in normal girls aged 1 to 12 years. J Clin Ultrasound 36:539–544PubMedCrossRefGoogle Scholar
  5. Baker TG (1963) A quantitative and cytological study of germ cells in human ovaries. Proc R Soc Lond B Biol Sci 158:417–433PubMedCrossRefGoogle Scholar
  6. Baroncelli GI (2008) Quantitative ultrasound methods to assess bone mineral status in children: technical characteristics, performance, and clinical application. Pediatr Res 63:220–228PubMedCrossRefGoogle Scholar
  7. Battaglia C, Regnani G, Mancini F et al (2002) Pelvic sonography and uterine artery color Doppler analysis in the diagnosis of female precocious puberty. Ultrasound Obstet Gynecol 19:386–391PubMedCrossRefGoogle Scholar
  8. Battaglia C, Mancini F, Regnani G et al (2003) Pelvic ultrasound and color Doppler findings in different isosexual precocities. Ultrasound Obstet Gynecol 22:277–283PubMedCrossRefGoogle Scholar
  9. Baxter-Jones AD, Burrows M, Bachrach LK et al (2010) International longitudinal pediatric reference standards for bone mineral content. Bone 46:208–216PubMedCrossRefGoogle Scholar
  10. Berst MJ, Dolan L, Bogdanowicz MM et al (2001) Effect of knowledge of chronologic age on the variability of pediatric bone age determined using the Greulich and Pyle standards. AJR 176:507–510PubMedGoogle Scholar
  11. Beuscher-Willems B (2006) Chapter 13 Female genital tract. In: Schmidt G (ed) Differential diagnosis in ultrasound: a teaching atlas. Thieme Medical Publishers, NY, pp 389–390Google Scholar
  12. Binkovitz LA, Henwood MJ (2007) Pediatric DXA: technique and interpretation. Pediatr Radiol 37:21–31PubMedCrossRefGoogle Scholar
  13. Bridges NA, Cooke A, Healy MJ et al (1996) Growth of the uterus. Arch Dis Child 75:330–331PubMedCrossRefGoogle Scholar
  14. Brown MA, Ascher SM (2006) Adnexa. In: Semelka RC (ed) Abdominal-pelvic MRI, 2nd edn. Wiley-Liss, Hoboken, pp 1334–1379Google Scholar
  15. Bull RK, Edwards PD, Kemp PM et al (1999) Bone age assessment: a large scale comparison of the Greulich and Pyle, and Tanner and Whitehouse (TW2) methods. Arch Dis Child 81:172–173PubMedCrossRefGoogle Scholar
  16. Buzi F, Pilotta A, Dordoni D et al (1998) Pelvic ultrasonography in normal girls and in girls with pubertal precocity. Acta Paediatr 87:1138–1145PubMedCrossRefGoogle Scholar
  17. Carpenter CT, Lester LL (1993) Skeletal age determination in young children: analysis of 3 regions of the hand/wrist film. J Pediatr Orthop 13:76–79PubMedCrossRefGoogle Scholar
  18. Clement PB (2002) Anatomy and histology of the ovary. In: Kurman RJ (ed) Blaustein’s pathology of the female genital tract. Springer, New York, pp 649–674Google Scholar
  19. Cohen HL, Tice HM, Mandel FS (1990) Ovarian volumes measured by US: bigger than we think. Radiology 177:189–192PubMedGoogle Scholar
  20. Cohen HL, Shapiro MA, Mandel FS, Shapiro ML (1993) Normal ovaries in neonates and infants: a sonographic study of 77 patients 1 day to 24 months old. AJR Am J Roentgenol 160:583–586PubMedGoogle Scholar
  21. Davis JA, Gosink BB (1986) Fluid in the female pelvis: cyclic patterns. J Ultrasound Med 5:75–79PubMedGoogle Scholar
  22. Diaz A, Laufer MR, Breech LL (2006) American Academy of Pediatrics Committee on Adolescence; American College of Obstetricians and Gynecologists Committee on Adolescent Health Care Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics 118:2245–2250PubMedCrossRefGoogle Scholar
  23. dos Santos Silva I, De Stavola BL, Mann V et al (2002) Prenatal factors, childhood growth trajectories and age at menarche. Int J Epidemiol 31:405–412PubMedCrossRefGoogle Scholar
  24. Elster AD (1993) Modern imaging of the pituitary. Radiology 187:1–14PubMedGoogle Scholar
  25. Euling SY, Selevan SG, Pescovitz OH et al (2008) Role of environmental factors in the timing of puberty. Pediatrics 121:S167–S171PubMedCrossRefGoogle Scholar
  26. Farooqi IS, Jebb SA, Langmack G et al (1999) Effects of recombinant leptin therapy in a child with congenital leptin deficiency. N Engl J Med 341:879–884PubMedCrossRefGoogle Scholar
  27. Fielding KT, Nix DA, Bachrach LK (2003) Comparison of calcaneus ultrasound and dual X-ray absorptiometry in children at risk of osteopenia. J Clin Densitom 6:7–15PubMedCrossRefGoogle Scholar
  28. Fleischer AC (1999) Sonographic assessment of endometrial disorders. Semin Ultrasound CT MR 20:259–266PubMedCrossRefGoogle Scholar
  29. Galler JR, Ramsey FC, Salt P et al (1987) Long-term effects of early kwashiorkor compared with marasmus. I. Physical growth and sexual maturation. J Pediatr Gastroenterol Nutr 6:841–846PubMedCrossRefGoogle Scholar
  30. Ginde AA, Liu MC, Camargo CA Jr (2009) Demographic differences and trends of vitamin D insufficiency in the US population, 1988–2004. Arch Intern Med 169:626–632PubMedCrossRefGoogle Scholar
  31. Greulich WW, Pyle SI (1959) Radiographic atlas of skeletal development of hand and wrist, 2nd edn. Stanford University Press, StanfordGoogle Scholar
  32. Griffin IJ, Cole TJ, Duncan KA et al (1995) Pelvic ultrasound measurements in normal girls. Acta Paediatr 84:536–543PubMedCrossRefGoogle Scholar
  33. Haber HP, Mayer EI (1994) Ultrasound evaluation of uterine and ovarian size from birth to puberty. Pediatr Radiol 24:11–13PubMedCrossRefGoogle Scholar
  34. Herman-Giddens ME, Slora EJ, Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in office settings network. Pediatrics 99:505–512PubMedCrossRefGoogle Scholar
  35. Herter LD, Golendziner E, Flores JA et al (2002) Ovarian and uterine findings in pelvic sonography. Comparison between prepubertal girls, girls with isolated thelarche, and girls with central precocious puberty. J Ultrasound Med 21:1237–1246PubMedGoogle Scholar
  36. Holm K, Laursen EM, Brocks V et al (1995) Pubertal maturation of the internal genitalia: an ultrasound evaluation of 166 healthy girls. Ultrasound Obstet Gynecol 6:175–181PubMedCrossRefGoogle Scholar
  37. Ibáñez L, Ferrer A, Marcos MV et al (2000) Early puberty: rapid progression and reduced final height in girls with low birth weight. Pediatrics 106(5):E72PubMedCrossRefGoogle Scholar
  38. Kadlubar FF, Berkowitz GS, Delongchamp RR et al (2003) The CYP3A4*1B variant is related to the onset of puberty, a known risk factor for the development of breast cancer. Cancer Epidemiol Biomarkers Prev 2:327–331Google Scholar
  39. Kangarloo H, Diament MJ, Gold RH et al (1986) Sonography of adrenal glands in neonates and children: changes in appearance with age. J Clin Ultrasound 14:43–47PubMedCrossRefGoogle Scholar
  40. Kaplowitz PB, Oberfield SE, the Drug, Therapeutics, Executive Committees of the Lawson Wilkins Pediatric Endocrine Society (1999) Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. Pediatrics 104:936–941PubMedCrossRefGoogle Scholar
  41. Kaplowitz PB, Slora EJ, Wasserman RC, Pedlow SE, Herman-Giddens ME (2001) Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics 108:347–353PubMedCrossRefGoogle Scholar
  42. Kiortsis D, Xydis V, Drougia AG et al (2004) The height of the pituitary in preterm infants during the first 2 years of life: an MRI study. Neuroradiology 46:224–226PubMedCrossRefGoogle Scholar
  43. Kitamura E, Miki Y, Kawai M et al (2008) T1 signal intensity and height of the anterior pituitary in neonates: correlation with postnatal time. AJNR Am J Neuroradiol 29:1257–1260PubMedCrossRefGoogle Scholar
  44. Kulin HE, Bwibo N, Mutie D et al (1982) The effect of chronic childhood malnutrition on pubertal growth and development. Am J Clin Nutr 36:527–536PubMedGoogle Scholar
  45. Landy H, Boepple PA, Mansfield MJ et al (1990) Sleep modulation of neuroendocrine function: developmental changes in gonadotropin-releasing hormone secretion during sexual maturation. Pediatr Res 28:213–217PubMedCrossRefGoogle Scholar
  46. Lazar L, Pollak U, Kalter-Leibovici O et al (2003) Pubertal course of persistently short children born small for gestational age (SGA) compared with idiopathic short children born appropriate for gestational age (AGA). Eur J Endocrinol 149:425–432PubMedCrossRefGoogle Scholar
  47. Lee MY, Choi HY, Sung YA et al (2001) High signal intensity of the posterior pituitary gland on T1-weighted images. Acta Radiol 42:129–134PubMedCrossRefGoogle Scholar
  48. Lee JH, Jeong YK, Park JK et al (2003) “Ovarian vascular pedicle” sign revealing organ of origin of a pelvic mass lesion on helical CT. Am J Roentgenol 181:131–137Google Scholar
  49. López C, Balogun M, Ganesan R et al (2005) MRI of vaginal conditions. Clin Radiol 60:648–662PubMedCrossRefGoogle Scholar
  50. Maghnie M, Genovese E, Arico M et al (1994) Evolving pituitary hormone deficiency is associated with pituitary vasculopathy: dynamic MR study in children with hypopituitarism, diabetes insipidus, and Langerhans cell histiocytosis. Radiology 193:493–499PubMedGoogle Scholar
  51. Mäkitie O, Doria AS, Henriques F et al (2005) Radiographic vertebral morphology: a diagnostic tool in pediatric osteoporosis. J Pediatr 146:395–401PubMedCrossRefGoogle Scholar
  52. Marshall WA, Tanner JM (1969) Variations in pattern of pubertal changes in girls. Arch Dis Child 44:291–303PubMedCrossRefGoogle Scholar
  53. McKiernan JF, Hull D (1981) Breast development in the newborn. Arch Dis Child 56:525–529PubMedCrossRefGoogle Scholar
  54. Mølgaard C, Thomsen BL, Prentice A et al (1997) Whole body bone mineral content in healthy children and adolescents. Arch Dis Child 76:9–15PubMedCrossRefGoogle Scholar
  55. Nalaboff KM, Pellerito JS, Ben-Levi E (2006) Imaging the endometrium: disease and normal variants. Radiographics 21:1409–1424Google Scholar
  56. Norjavaara E, Ankarberg C, Albertsson-Wikland K (1996) Diurnal rhythm of 17 beta-estradiol secretion throughout pubertal development in healthy girls: evaluation by a sensitive radioimmunoassay. J Clin Endocrinol Metab 81:4095–4102PubMedCrossRefGoogle Scholar
  57. Nussbaum AR, Sanders RC, Jones MD (1986) Neonatal uterine morphology, as seen in real time US. Radiology 160:641–643PubMedGoogle Scholar
  58. Okamoto Y, Tanaka YO, Nishida M et al (2003) MR imaging of the uterine cervix: imaging–pathologic correlation. Radiographics 23:425–445PubMedCrossRefGoogle Scholar
  59. Oppenheimer DA, Carroll BA, Yousem S (1983) Sonography of the normal neonatal adrenal gland. Radiology 146:157–160PubMedGoogle Scholar
  60. Orsini LF, Salardi S, Pilu G et al (1984) Pelvic organs in premenarcheal girls: real-time ultrasonography. Radiology 153:113–116PubMedGoogle Scholar
  61. Polhemus DW (1953) Ovarian maturation and cyst formation in children. Pediatrics 11:588–594PubMedGoogle Scholar
  62. Porcu E (2004) Imaging in pediatric and adolescent gynecology. In: Sultan C (ed) Pediatric and adolescent gynecology. Evidence-based clinical practice endocrine development, vol 7. Basel, Karger, pp 9–22CrossRefGoogle Scholar
  63. Powls A, Botting N, Cooke RW, Pilling D (1996) Growth impairment in very low birthweight children at 12 years: correlation with perinatal and outcome variables. Arch Dis Child Fetal Neonatal Ed 75:F152–F157PubMedCrossRefGoogle Scholar
  64. Rathaus V, Grunebaum M, Konen O et al (2003) Minimal pelvic fluid in asymptomatic children: the value of the sonographic finding. J Ultrasound Med 22:13–17PubMedGoogle Scholar
  65. Roche AF, Chumlea WC, Thissen D (1988) Assessing the skeletal maturity of the hand-wrist: FELS method. Charles C Thomas, SpringfieldGoogle Scholar
  66. Salardi S, Orsini LF, Cacciafi E et al (1985) Pelvic ultrasonography in premenarcheal girls: relation to puberty and sex hormone concentration. Arch Dis Child 60:819–822CrossRefGoogle Scholar
  67. Seigel MJ (2010) Female Pelvis. In: Pediatric sonography. Siegel MJ (Ed). 4th edn LWW pp 511–533Google Scholar
  68. Stanhope R, Adams J, Jacobs HS et al (1985) Ovarian ultrasound assessment in normal children, idiopathic precocious puberty, and during low dose pulsatile gonadotrophin releasing hormone treatment of hypogonadotrophic hypogonadism. Arch Dis Child 60:116–119PubMedCrossRefGoogle Scholar
  69. Stavrou I, Zois C, Ioannidis JP et al (2002) Association of polymorphisms of the oestrogen receptor alpha gene with the age of menarche. Hum Reprod 17:1101–1105PubMedCrossRefGoogle Scholar
  70. Stranzinger E, Strouse PJ (2008) Ultrasound of the pediatric female pelvis. Semin Ultrasound CT MRI 29:98–113CrossRefGoogle Scholar
  71. Takeuchi M, Matsuzaki K, Nishitani H (2010) Manifestations of the female reproductive organs on MR Images: changes induced by various physiologic states. Radiographics 30:e39CrossRefGoogle Scholar
  72. Tanner JM (1975) Growth and endocrinology of the adolescent. In:Gardner LI (ed) Endocrine and genetic diseases of childhood and adolescents, 2nd edn. Philadelphia, WB Saunders, p 14Google Scholar
  73. Tanner JM, Whitehouse RH, Cameron N et al (1975) Assessment of skeletal maturity and prediction of adult height (TW2 method), 2nd edn. Academic Press, LondonGoogle Scholar
  74. Tanner JM, Healy MJR, Goldstein H, Cameron N (2001) Assessment of skeletal maturity and prediction of adult height (TW3 method). WB Saunders, LondonGoogle Scholar
  75. Thodberg HH (2009) Clinical review: an automated method for determination of bone age. J Clin Endocrinol Metab 94:2239–2244PubMedCrossRefGoogle Scholar
  76. Thodberg HH, Sävendahl L (2010) Validation and reference values of automated bone age determination for four ethnicities. Acad Radiol 17:1425–1432PubMedCrossRefGoogle Scholar
  77. Timor-Tritsch I (2006) Relevant Pelvic Anatomy. In: Timor-Tritsch I, Goldstein SR (eds) Ultrasound in Gynecology, 2nd edn. Churchill Livingstone, New York, pp 69–70Google Scholar
  78. Umek WH, Morgan DM, Ashton-Miller JA et al (2004) Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol 103:447–451PubMedCrossRefGoogle Scholar
  79. Veening MA, van Weissenbruch MM, Roord JJ et al (2004) Pubertal development in children born small for gestational age. J Pediatr Endocrinol Metab 17:1497–1505PubMedCrossRefGoogle Scholar
  80. Winter JS, Faiman C, Hobson WC et al (1975) Pituitary-gonadal relations in infancy. I. Patterns of serum gonadotropin concentrations from birth to four years of age in man and chimpanzee. J Clin Endocrinol Metab 40:545–551PubMedCrossRefGoogle Scholar
  81. Winter JS, Hughes IA, Reyes FI et al (1976) Pituitary-gonadal relations in infancy: 2. Patterns of serum gonadal steroid concentrations in man from birth to two years of age. J Clin Endocrinol Metab 42:679–686PubMedCrossRefGoogle Scholar
  82. Wren TA, Liu X, Pitukcheewanont P et al (2005) Bone densitometry in pediatric populations: discrepancies in the diagnosis of osteoporosis by DXA and CT. J Pediatr 146:776–779PubMedCrossRefGoogle Scholar
  83. Xita N, Tsatsoulis A, Stavrou I et al (2005) Association of SHBG gene polymorphism with menarche. Mol Hum Reprod 11:459–462PubMedCrossRefGoogle Scholar
  84. Ziereisen F, Heinrichs C, Dufour D et al (2001) The role of Doppler evaluation of the uterine artery in girls around puberty. Pediatr Radiol 31:712–719PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg  2011

Authors and Affiliations

  1. 1.Department of RadiologyAlder Hey Children’s Hospital NHS Foundation TrustLiverpoolUK
  2. 2.Department of EndocrinologyAlder Hey Children’s Hospital NHS Foundation TrustLiverpoolUK

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