Puberty represents sexual maturation in males and females. It is caused by changes in the hypothalamic-pituitary-gonadal axis (HPG axis). The HPG axis is essentially responsible for mediating development through hormonal changes and the growth of reproductive organs. It occurs between 8 years and 13 years of age in females and 9 years and 14 years of age in males and is represented by growth spurts, the development of body hair, pubic hair, body odor, and acne.

What Is Delayed Puberty?

Delayed puberty is when the initiation of sexual maturation (puberty) fails to occur at the expected time. While it is common for some children to exhibit sexual maturation later than their peers, they will eventually develop, grow and function normally both in terms of sexual development and general growth. Others may suffer from illnesses or be taking medications that contribute to delayed puberty.

Who Is Affected by Delayed Puberty?

Both males and females are affected by delayed puberty, although males are more prone to experience delayed puberty than females. People suffering from certain chronic diseases, athletes, and those under medications or therapy for cancer and other diseases may also exhibit symptoms of delayed puberty.

What Are the Causes of Delayed Puberty?

Both Sexes:

Functional hypogonadotropic hypogonadism is caused by:

Chronic Illnesses: Asthma, cystic fibrosis, sickle cell anemia.
Nutritional Deficiency: Eating disorders, malnutrition due to diseases, and malnutrition due to their economic situation.
Congenital: Panhypopituitarism- a condition where hormonal production and secretion by the pituitary gland is reduced.
Psychological Causes: Common in teenagers.

Males:

1. Constitutional Delay of Puberty and Growth (CDPG): Caused by decreased growth speed. The child will usually have at least one parent who was a late bloomer. They are shorter and less physically developed than other males their age.

2. Hypogonadotropic Hypogonadism: Permanent delay in HPG axis maturation. Affected individuals will exhibit deficiency in hormone production and release.

Causes:

Idiopathic: Unknown causes.
Congenital: Genetic mutations.
Brain tumors and lesions.
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3. Hypergonadotropic Hypogonadism: Occurs due to primary gonadal failure.

Low testosterone levels and increased hormonal production is seen.

Causes:

Acquired: Infection, radiation, surgery.
Congenital: Klinefelter syndrome (abnormal sexual chromosomal pattern, with the patient displaying features such as tall stature, small testes, behavioral problems, etc.

Females:

1. Functional Hypogonadotropic Hypogonadism: It is the most common cause of delayed puberty in females.

Causes:

Reduced body fat.
Eating disorders.
Reduced leptin concentration.
Decreased estrogen production and secretion.

2. Hypergonadotropic Hypogonadism: It is caused by primary ovarian failure.

Causes:

Acquired: Radiation therapy.
Congenital: Turner Syndrome (abnormal sexual chromosomal pattern, with the patient displaying features such as short stature, broad chest, webbed neck, and other malformations).

3. Constitutional Delay in Puberty and Growth (CDPG): Less common in females - usually occurs in those with a family history of pubertal delay (parents and siblings).

What Are the Signs and Symptoms of Delayed Puberty?

In Males:

Testicular growth is absent.
Penile growth is negligible.
Little to no body hair even by the age of 15.
High-pitched voice remains - voice breaking and subsequent deep voice are not attained even by the age of 16.
Short and thin body.
Visible stress and anxiety.
Deposits of fat around hips and pelvis.
Growth spurts are absent or delayed.

In Females:

Lack of pubic hair.
Menstruation has not begun even by the age of 16.
Breasts have not developed by age of 13.
Undeveloped uterus.
Short height.
Slow growth rate.
Delay in bone growth, that is, bone age is not consistent with the child’s actual age.
Growth spurts are absent or delayed.

How Is Delayed Puberty Evaluated and Diagnosed?

Family History: Before proceeding with lab tests, the doctor may inquire about the patient’s family history, particularly the parental history of delayed puberty.
Growth Curves: Growth curves may be plotted in relation to age, gender, weight, height, and BMI (body mass index)
Bone Age Determination: An X-ray of the left hand and wrist will illustrate the bone growth.
Blood Tests: Complete blood count (CBC), erythrocyte sedimentation rate, thyroid workup - to check for inflammatory or hormonal conditions.
Magnetic Resonance Imaging (MRI) Scan: When there is suspicion of a brain tumor as the causative factor for delayed puberty.
Ultrasound: Ultrasound of the ovaries and uterus for females and the testicles for males.
Genetic Testing: Testing for genetic and chromosomal abnormalities.
Other Tests: Testing for growth factors and serum hormones.

How Is Delayed Puberty Treated?

Treatment of delayed puberty requires identification of the cause. Further treatment may be done for the specific cause, or hormonal therapy may be begun.

A.Treating the Cause:

1. Constitutional Delay of Puberty and Growth:

The patient is observed carefully.
Low doses of testosterone for males and estrogen for females may be started.
Growth hormone therapy may be given to those patients concerned about their short stature.

2. Hypogonadism:

Steroid therapy will be necessary whether hypogonadism occurs due to HPG axis maturation delay or primary gonadal failure.

In Males:

Low-dose testosterone therapy is begun in males and is increased over time to match adult hormone levels.

In Females:

Low-dose oral estrogen is begun and increased with time until vaginal bleeding is achieved, indicating the appearance of the first period.
A combination of estrogen with progesterone may then be given in the form of transdermal patches (patches that can be applied on the skin and that release the drugs through the skin layers).
Often, oral contraceptives may be recommended for treatment.

B.Hormonal Therapy:

Hormonal therapy may contribute to the development of sexual characteristics even if it cannot reverse genetic problems.

What Are the Consequences of Delayed Puberty?

Delayed puberty may have a harmful influence on adult health, although it causes no significant long-term effects for the most part. The possible harmful effects that may be caused are as follows:

Conclusion

Delayed puberty is frequently a source of embarrassment and peer rivalry among adolescents. However, if the causes are not life-threatening or otherwise problematic, then it must be remembered that a physician's opinion plus recommended treatment should fix all the issues being experienced. Adolescence is a time to be enjoyed, allowing the body to grow and develop steadily and being patient with the process are essential keys to staying happy and developing in mind and body.