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Delayed Puberty

By

Andrew Calabria

, MD, The Children's Hospital of Philadelphia

Last full review/revision Sep 2022| Content last modified Sep 2022
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Delayed puberty is defined as absence of the start of sexual maturation at the expected time.

  • Most often, children simply develop later than their peers but ultimately develop normally.

  • Sometimes, delayed puberty is caused by chronic medical problems, hormonal disorders, radiation therapy or chemotherapy, disordered eating or excessive exercise, genetic disorders, tumors, and certain infections.

  • Typical symptoms include a lack of testicular enlargement in boys and a lack of breasts and menstrual periods in girls.

  • The diagnosis is based on the results of a physical examination, various laboratory tests, a bone age x-ray, genetic testing, and other imaging tests.

  • Treatment depends on the cause and may include hormone replacement therapy.

The start of sexual maturation (puberty) takes place when the hypothalamus gland begins to secrete a chemical signal called gonadotropin-releasing hormone. The pituitary gland Overview of the Pituitary Gland The pituitary is a pea-sized gland that is housed within a bony structure (sella turcica) at the base of the brain. The sella turcica protects the pituitary but allows very little room for expansion... read more responds to this signal by releasing hormones called gonadotropins, which stimulate the growth of the sex glands (the testes in boys and the ovaries in girls). The growing sex glands secrete the sex hormones testosterone in boys and estrogen in girls. These hormones cause the development of secondary sex characteristics, including facial hair and muscle mass in boys, breasts in girls, and pubic and underarm hair and sexual desire (libido) in both sexes.

Some adolescents do not start their sexual development at the usual age.

In boys, delayed puberty is more common and is defined as

  • No enlargement of the testes (testicles) by age 13 or 14

  • A time lapse of more than 4 years from the start to the completion of growth of the genitals

In girls, delayed puberty is defined as

Milestones in Sexual Development for Girls and Boys

During puberty, sexual development occurs in a set sequence. However, when the changes begin and how quickly they occur vary from person to person.

For girls, puberty begins around age 8 to 13 years and lasts about 4 years.

For boys, puberty begins around age 9 to 14 years and lasts about 4 to 6 years.

The chart shows a typical sequence and normal range of development for the milestones of sexual development.

Milestones in Sexual Development for Girls and Boys

Causes of Delayed Puberty

In the majority of cases, delayed puberty represents a normal variation, which may run in the family (also called constitutional delay of puberty Constitutional Delay of Puberty Hypogonadism is decreased production of testosterone, sperm, or both in males. Hypogonadism occurs when there is a problem in the testes or a problem in the pituitary gland or the hypothalamus... read more ). These adolescents have a normal growth rate and are otherwise healthy. Although the growth spurt and puberty are delayed, they eventually proceed normally.

Various disorders, such as poorly controlled diabetes mellitus Diabetes Mellitus (DM) in Children and Adolescents Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more Diabetes Mellitus (DM) in Children and Adolescents , inflammatory bowel disease Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more , kidney disease, cystic fibrosis Cystic Fibrosis (CF) Cystic fibrosis is a hereditary disease that causes certain glands to produce abnormally thick secretions, resulting in tissue and organ damage, especially in the lungs and the digestive tract... read more , and anemia Overview of Anemia Anemia is a condition in which the number of red blood cells is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts... read more , can delay or prevent sexual development. Development may be delayed or absent in adolescents receiving radiation therapy or cancer chemotherapy. Puberty may also be delayed by autoimmune disorders (such as Hashimoto thyroiditis Hashimoto Thyroiditis Hashimoto thyroiditis is chronic, autoimmune inflammation of the thyroid gland. Hashimoto thyroiditis results when antibodies in the body attacks the cells of the thyroid gland—an autoimmune... read more , Addison disease Adrenal Insufficiency In adrenal insufficiency, the adrenal glands do not produce enough adrenal hormones. Adrenal insufficiency may be caused by a disorder of the adrenal glands, a disorder of the pituitary gland... read more Adrenal Insufficiency , and some disorders that directly affect the ovaries). A tumor that damages the pituitary gland or the hypothalamus can lower the levels of gonadotropins or stop production of the hormones altogether.

Symptoms of Delayed Puberty

In girls, breast development, pubic hair growth, the first menstrual period, or a combination do not occur. In boys, genital growth, pubic hair growth, or both do not occur. Short stature Growth Hormone Deficiency in Children , poor speed of growth, or both may indicate delayed puberty in either sex.

Adolescents who have delayed puberty may be noticeably shorter than their peers, can be teased or bullied, and often need help coping with and managing social concerns. Although adolescents are typically uncomfortable about being different from their peers, boys in particular are more likely to feel psychologic stress and embarrassment resulting from delayed puberty.

Diagnosis of Delayed Puberty

  • A physical examination

  • Bone age x-ray

  • Blood tests

  • Sometimes magnetic resonance imaging

  • Genetic testing

  • Pelvic ultrasonography (for girls)

The initial evaluation of delayed puberty should consist of a complete history and physical examination to evaluate pubertal development, nutritional status, and growth.

Doctors often take x-rays of one or more bones to see the level of bone maturity (called a bone age x-ray).

Doctors take blood samples and do basic laboratory tests to look for signs of chronic disease, hormone level tests, and possibly genetic testing.

Doctors usually evaluate boys who have no signs of puberty by age 13 or 14 years and girls who have no signs of puberty by age 12 or 13 years or who have not menstruated by age 15 years. If these children otherwise appear healthy, they most likely have constitutional delay. The doctor may decide to re-examine these adolescents at 6-month intervals to ensure that puberty begins and progresses normally.

Treatment of Delayed Puberty

  • Treatment of cause

  • Hormone therapy

The treatment for delayed puberty depends on its cause. When an underlying disorder is the cause of delayed puberty, puberty usually proceeds once the disorder has been treated.

An adolescent who is naturally late in developing needs no treatment, but if the adolescent is severely stressed by delayed or absent development, some doctors may give supplemental sex hormones to begin the process sooner. This treatment is much more common among boys. Children with delayed puberty often need additional support from parents, family members, and friends to ensure they have a healthy body image and self-esteem.

If boys show no sign of puberty by age 13 or 14, they may be given a 4- to 6-month course of testosterone injections once a month. At low doses, testosterone starts puberty, causes the development of some masculine characteristics (virilization), and does not prevent adolescents from reaching their adult height potential.

In girls, low doses of estrogen may be started with pills or skin patches. This estrogen therapy may be used to induce puberty or, in some cases, such as in girls who have Turner syndrome, may be needed for long-term hormone replacement.

Genetic disorders cannot be cured, but hormone therapy may help sex characteristics develop.

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