Delayed puberty

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Overview

Puberty can be a stressful and concerning time for adolescents and their families, as it represents a period of significant emotional and physical changes to the body. Puberty normally occurs between the ages of 8 to 13 years for females and 9 to 14 years for males. In females, the first sign of true puberty is breast development or thelarche. In males, the first sign is testicular enlargement, where testicular size increases to a volume of 4 ml or greater, or the length of 2.5 cm. When variation exists on the timing and onset of puberty, the primary pediatrician or provider must closely monitor the child's development and ensure that any pathological or reversible causes are ruled out. 

When a child exhibits early signs of puberty, it is defined as precocious puberty. This condition occurs when the first signs of puberty appear before 8 years in females and 9 years in males. However, this activity discusses delayed puberty for females and males. In females, delayed puberty is the lack of breast development by 13 years, a delay of over 4 years between thelarche and completion of puberty, or a lack of menarche by 16 years. In males, a pubertal delay is evident by a lack of testicular enlargement by 14 years or more than 5 years between testicular enlargement and completion of puberty.[1] Puberty represents the maturation of the hypothalamic-pituitary-gonadal (HPG) axis. Development of acne, axillary or pubertal hair, and body odor are a result of adrenal androgen secretion and defined as adrenarche[2] Adrenarche is independent of the HPG axis. Therefore, a child could display signs of adrenarche but still have a diagnosis of pubertal delay.[3]

Symptoms

Puberty that happens late is called delayed puberty. This means a child's physical signs of sexual maturity don't appear by age 12 in girls or age 14 in boys. This includes breast or testicle growth, pubic hair, and voice changes. These are known as secondary sexual characteristics.Girls: Lack of any breast development by age 12. More than 5 years between initial breast growth and first menstrual period. Failure to menstruate by age 15.

Boys: Lack of testicular enlargement by age 14. Lack of pubic hair by age 15.


Causes

The most common cause of delayed puberty is a functional delay in production of gonadotropin-releasing hormone (GnRH) from the hypothalamic neuronal networks that synergize to initiate the episodic or pulsatile release of the GnRH.

Chromosomal problems.

Genetic disorder.

Chronic illness.

Tumors of the pituitary gland or hypothalamus.

Underactive pituitary gland (hypopituitarism)

Underactive thyroid (hypothyroidism)

Abnormal development of the reproductive system.

Risk factors

a long-term illness, such as cystic fibrosis, diabetes or kidney disease.

malnutrition, possibly from an eating disorder or a condition such as cystic fibrosis or coeliac disease.

a problem with the ovaries, testes, thyroid gland or pituitary gland.

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Complications

Pubertal delay can have many psychosocial influences during development and can cause emotional, social, or academic stress. In CDPG, it is essential to emphasize that this is simply a normal variation in pubertal timing and that treatment will not significantly impact predicted target height.[4] If the patient has other causes besides CDPG for the pubertal delay, it is vital that the provider evaluates the patient thoroughly so that there is a definitive diagnosis sooner, and management can commence earlier. Complications for the other causes of pubertal delay, excluding CDPG, depend on the underlying condition and differs accordingly. 

Prevention

If the delayed puberty is inherited, no treatment is usually needed. In some cases, treatment may be done with hormone therapy. This helps to cause secondary sexual characteristics to occur. In other cases, surgery may be done to correct a physical problem.