Delayed puberty is when a person lacks or has incomplete development of specific sexual characteristics past the usual age of onset of puberty.
In the United States, girls are considered to have delayed puberty if they lack breast development by age 13 or have not started menstruating by age 15. Delayed puberty affects about 2% of adolescents.
Most commonly, puberty may be delayed for several years and still occur normally, in which case it is considered constitutional delay of growth and puberty, a common variation of healthy physical development. estradiol and progesterone for girls).
In North American girls, puberty is considered delayed when breast development has not begun by age 13, when they have not started menstruating by age 15, These children have a history of shorter stature than their age-matched peers throughout childhood, but their height is appropriate for bone age, meaning that they have delayed skeletal maturation with potential for future growth.
It is often difficult to establish if it is a true constitutional delay of growth and puberty or if there is an underlying pathology because lab tests are not always discriminatory. In the absence of any other symptoms, short stature, delayed growth in height and weight, and/or delayed puberty may be the only clinical manifestations of certain chronic diseases including coeliac disease.
Malnutrition or chronic disease
When underweight or sickly children are present with pubertal delay, it is warranted to search for illnesses that cause a temporary and reversible delay in puberty. and thalassemia, cystic fibrosis, HIV/AIDS, hypothyroidism, chronic kidney disease, and chronic gastroenteric disorders (such as coeliac disease and inflammatory bowel disease) cause a delayed activation of the hypothalamic region of the brain to send signals to start puberty.
Childhood cancer survivors can also present with delayed puberty secondary to their cancer treatments, especially males. The type of treatment, amount of exposure/dosage of drugs, and age during treatment determine the level by which the gonads are affected, with younger patients at a lower risk of negative reproductive effects. Eating disorders such as bulimia nervosa and anorexia nervosa can also impair puberty due to undernutrition.
Carbohydrate-restricted diets for weight loss have also been shown to decrease the stimulation of insulin which in turn does not stimulate kisspeptin neurons, vital in the release of puberty-starting hormones. This shows that carbohydrate restricted children and children with diabetes mellitus type 1 can have delayed puberty.
Primary failure of the ovaries or testes (hypergonadotropic hypogonadism)
alt=|thumb|Hypothalamic-pituitary-testicular axis and the hormones produced by each part of the axis. The + signs indicate that the organ is stimulated by the hormones released from the previous organ in the chain.
Primary failure of the ovaries or testes (gonads) will cause delayed puberty due to the lack of hormonal response by the final receptors of the HPG axis.
Congenital disorders
Congenital diseases include untreated cryptorchidism where the testicles fail to descend from the abdomen. defects in the production of testicular steroids, receptor mutations preventing testicular hormones from working, chromosomal abnormalities such as Noonan syndrome, or problems with the cells making up the testes. The HPG axis can be altered in two places, at the hypothalamic or at the pituitary level.
History and physical
Constitutional and physiologic delay
Children with constitutional delay are reported to be shorter than their peers, lacking a growth spurt, and having an overall smaller build. Deficiencies in GnRH, the signalling hormone produced by the hypothalamus, can cause congenital malformations including cleft lip and scoliosis. It is often sufficient to simply measure the baseline gonadotrophin levels to differentiate between the two.
Girls can be started on estrogen with the same goals as their male counterparts.
Malnutrition or chronic disease
If the delay is due to systemic disease or malnutrition, the therapeutic intervention is likely to focus direction on those conditions. In patients with coeliac disease, an early diagnosis and the establishment of a gluten-free diet prevents long-term complications and allows restoration of normal maturation. Choice of formulation (topical vs injection) is dependent on the child's and family's preference as well as on how well they tolerate side effects. such as idiopathic short stature.
More therapies are being developed to target the more discreet modulators of the HPG axis including kisspeptin and neurokinin B.
In cases of severe delayed puberty secondary to hypogonadism, evaluation by a psychologist or psychiatrist, as well as counseling and a supportive environment are an important supplemental therapy for the child. Transition from pediatric to adult care is also vital as many children are lost during transition of care. Adolescent boys with delayed puberty have a higher level of anxiety and depression relative to their peers. Children with delayed puberty also display decreased academic performance in their adolescent education, but changes in academic achievement in adulthood have not been determined. However, some studies show that these children fall short of their target height from about 4 to 11 cm. Men with delayed puberty often have low to normal bone mineral density unaffected by androgen therapy.