Delayed puberty

Puberty is the period whereby the body undergoes transition from that of a child’s to an adult type. Among the transformations on females are breast development, pubic hair growth and occurrence of menstruation. The body becomes curvier and there is characteristic growth spurt. Males also undergo growth spurt. Pubic and facial hair starts to grow on them while their penis and testes start to enlarge.  ^[1]
 

Delayed puberty has been traditionally delineated as the nonappearance of testicular enlargement in males or absence of breast development in females at an age that is 2 to 2.5 SD later than the typical average of the general population. The typical mean for males is 14 years old whereas 13 years old is the mean age for girls. However, due to variations of pubertal onset among racial and ethnic groups, some suggest restructured definitions. Delayed puberty may cause distress to the individual and also to the immediate family particularly the parents. Although most cases are simple deviations of normal development, undergoing a medical evaluation from a specialist may be helpful since delayed puberty may be caused by an underlying medical problem.  ^{[2] [3] [4] [5]}

Epidemiology

The condition is estimated to occur in 3% of the pediatric population. Boys are more commonly affected than girls. ^[4]

Causes

There are numerous causes of delayed puberty. It can be caused by impaired hypothalamo-pituitary axis such as when there is tumor e.g. craniopharyngioma, astrocytoma. The axis can also be damaged during irradiation treatment, head injury, surgery, congenital diseases like congenital panhypopituitarism and when there is deficiency of gonadotrophin-releasing hormone (GnRH)/luteinising hormone (LH)/follicle-stimulating hormone such as in conditions like Prader-Willi syndrome. ^[4]

When there is an intact hypothalamo-pituitary axis, the causes of a delayed puberty include steroid medications, malnutrition, chronic diseases like Chron’s disease, hypothyroidism, extreme physical exercise and sporadic or familial constitutional delay in growth and puberty. Peripheral causes include bilateral testicular damage, gonadal dysgenesis, irradiation, drugs like cyclophosphamide, polycystic ovarian syndrome, toxic damage and iron overload. ^[4]

Diagnosis

History which includes family patterns and psychosocial aspects are obtained. A thorough physical examination is done. Laboratory exams may include GnRH test and tests for prolactin and growth hormone, blood tests, Basal FSH and LH and serum estradiol/testosterone and chromosome studies. ^[4]

Treatment

If there is no organic cause, reassurance and monitoring are often sufficient. If there is underlying medical problem, treatment modalities include sex hormone therapy and growth hormone therapy ^[5]

References:

1.      http://kidshealth.org/teen/sexual_health/changing_body/delayed_puberty.html

2.      http://www.nejm.org/doi/full/10.1056/NEJMcp1109290

3.      http://tweenparenting.about.com/od/physicalemotionalgrowth/f/LateDevelopment.htm

4.      http://www.patient.co.uk/doctor/delayed-puberty

5.      http://www.healthychildren.org/English/ages-stages/gradeschool/puberty/pages/Delayed-Puberty.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token