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{{Delayed puberty}}
{{Delayed puberty}}
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==Overview==
==Overview==
The symptoms of [[puberty]] usually develop between ages 8 to 13 in girls and 9 to 14 in boys and start with [[breast]] development in girls and [[testicular]] enlargement in boys. If the [[testicular]] enlargement or [[breast]] development has not occurred at a mean age of [[puberty]] in population plus 2-2.5 [[Standard deviation|standard deviation (SD)]], it will be called delayed [[puberty]]. The mean age depends on various factors, such as [[race]], [[nutrition]], and also socioeconomic status. Recently, the age of onset of [[puberty]] is decreasing in the US and other countries. The main complications of delayed puberty are [[osteoporosis]], [[psychological]] problems, [[polycythemia]], and [[irritation]] from hormonal gels and patches. The major determinant of delayed [[puberty]] [[prognosis]] is underlying [[Comorbidity|co-morbidity]], not the [[disease]] itself. [[Constitutional delay of puberty|Constitutional delay of growth and puberty (CDGP)]] has an excellent [[prognosis]]. The [[puberty]] and final height in these patients will be normal in the future, without any [[Hormone replacement therapy|hormone replacement]] therapy.


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


=== Natural history ===
=== Natural history ===
* The symptoms of puberty usually develop between 8 and 13 in girls and between 9 and 14 in boys, and start with symptom of breast development in girls and testicular enlargement in boys.<ref name="pmid10414639">{{cite journal |vauthors=Blondell RD, Foster MB, Dave KC |title=Disorders of puberty |journal=Am Fam Physician |volume=60 |issue=1 |pages=209–18, 223–4 |year=1999 |pmid=10414639 |doi= |url=}}</ref>
* The symptoms of [[puberty]] usually develop between ages 8 to 13 in girls and ages 9 to 14 in boys and start with [[breast]] development in girls and [[testicular]] enlargement in boys.
* If the testicular enlargement or breast development has not occurred at an mean age of puberty in population plus 2-2.5 SD, it will be called delayed puberty. The mean age is depend on various factors, such as race, nutrition, and also socioeconomic status. Recently, the puberty age is decreasing in US and other countries.<ref name="pmid12415029">{{cite journal |vauthors=Sun SS, Schubert CM, Chumlea WC, Roche AF, Kulin HE, Lee PA, Himes JH, Ryan AS |title=National estimates of the timing of sexual maturation and racial differences among US children |journal=Pediatrics |volume=110 |issue=5 |pages=911–9 |year=2002 |pmid=12415029 |doi= |url=}}</ref><ref name="pmid12359790">{{cite journal |vauthors=Wu T, Mendola P, Buck GM |title=Ethnic differences in the presence of secondary sex characteristics and menarche among US girls: the Third National Health and Nutrition Examination Survey, 1988-1994 |journal=Pediatrics |volume=110 |issue=4 |pages=752–7 |year=2002 |pmid=12359790 |doi= |url=}}</ref><ref name="pmid20124146">{{cite journal |vauthors=Susman EJ, Houts RM, Steinberg L, Belsky J, Cauffman E, Dehart G, Friedman SL, Roisman GI, Halpern-Felsher BL |title=Longitudinal development of secondary sexual characteristics in girls and boys between ages 91/2 and 151/2 years |journal=Arch Pediatr Adolesc Med |volume=164 |issue=2 |pages=166–73 |year=2010 |pmid=20124146 |pmc=2863107 |doi=10.1001/archpediatrics.2009.261 |url=}}</ref><ref name="pmid19403485">{{cite journal |vauthors=Aksglaede L, Sørensen K, Petersen JH, Skakkebaek NE, Juul A |title=Recent decline in age at breast development: the Copenhagen Puberty Study |journal=Pediatrics |volume=123 |issue=5 |pages=e932–9 |year=2009 |pmid=19403485 |doi=10.1542/peds.2008-2491 |url=}}</ref><ref name="pmid19926714">{{cite journal |vauthors=Sørensen K, Aksglaede L, Petersen JH, Juul A |title=Recent changes in pubertal timing in healthy Danish boys: associations with body mass index |journal=J. Clin. Endocrinol. Metab. |volume=95 |issue=1 |pages=263–70 |year=2010 |pmid=19926714 |doi=10.1210/jc.2009-1478 |url=}}</ref>
* If the [[testicular]] enlargement or [[breast]] development has not occurred at a mean age of [[puberty]] in population plus 2-2.5 [[Standard deviation|SD]], it will be called delayed [[puberty]]. The mean age depends on various factors, such as [[race]], [[nutrition]], and also socioeconomic status. Recently, the age of onset of [[puberty]] is decreasing in the US and other countries.  
* If left untreated, all of patients with constitutional delay of puberty and growth may progress to develop normal puberty and growth.
* If left untreated, all of the patients with a [[Constitutional delay of puberty|constitutional delay of puberty and growth]] may progress to develop normal [[puberty]] and [[growth]].
* All patients with delayed [[puberty]] have to be precisely monitored until normal [[puberty]] and growth become accomplished. It may take about 2-5 years. Final height can be measured by adding or subtracting 2.5 inches to the average height of parents. On average, [[puberty]] is accompanied by gaining 25 cm of height in girls and 30 cm in boys.
'''''Delayed [[puberty]] in boys is identified as:<ref name="urlComplications of puberty - Irelands Health Service">{{cite web |url=http://www.hse.ie/eng/health/az/P/Puberty/ |title=Complications of puberty - Ireland's Health Service |format= |work= |accessdate=}}</ref>'''''
* No sign of [[testicular]] enlargement by 14 years of the age
OR
* No [[pubic hair]] by 15 years of age
OR
* No [[penis]] and [[testicles]] development to adult type 5 years after onset of [[puberty]]
'''''Delayed [[puberty]] in girls is identified as:<ref name="urlComplications of puberty - Irelands Health Service" />'''''
* No signs of [[breast]] development by 14 years of age
OR
* No [[pubic hair]] by 14 years of age
OR
* No [[breast]] development to adult type 5 years after onset of puberty
OR
* No [[menstruation]] by 16 years of age
=== Normal puberty timing ===
Approximate mean ages for onset of various pubertal changes are as follows:


All patients need to be monitored until the pubertal process is complete. Puberty is accompanied by the growth spurt and is typically complete within 2 to 5 years. Growth should be monitored on age- and sex-appropriate growth charts to ensure that the full growth potential is achieved. Puberty contributes 25 cm of height in females and 30 cm in males on average.
Developmental changes during [[puberty]] in girls occur over a period of 3-5 years, usually between 9 and 14 years of age. They include the occurrence of [[secondary sex characteristics]] beginning with [[breast]] [[development]], the adolescent [[growth spurt]], the onset of [[menarche]] (not correspond to the end of [[puberty]]), and the acquisition of [[fertility]], as well as profound [[psychological]] modifications.<ref name=":0" />
==== North American, Indo-Iranian (India, Iran) and European girls ====
*[[Thelarche]]: 10 years and 5 months of age   
*[[Pubarche]]: 11 years of age 
*[[Growth spurt]]: 10-12.5 years of age
*[[Menarche]]: 12.5 years of age
*Adult height reached: 14.5 years of age


Continued pubertal assessment is best assessed by Tanner staging. [null <nowiki>[26]</nowiki>] [null <nowiki>[27]</nowiki>] Stage 5 is adult for both sexes and indicates completion of the process. Testicular size is documented as a measurement of the longest axis or as the testicular volume using the Prader orchidometer. [null image]
==== North American, Indo-Iranian (India, Iran) and European boys ====
 
*Testicular enlargement: 11.5 years of age
It is not always possible to clarify whether a patient has a permanent defect at initial testing prior to pubertal induction, as the interpretation of the LH-releasing hormone (LHRH) stimulation test is not straightforward. [null <nowiki>[31]</nowiki>] If the diagnosis of a permanent defect is in doubt, endocrine tests should be repeated after completion of growth and puberty to ascertain the need for long-term hormone replacement. [null <nowiki>[32]</nowiki>]
*[[Pubic hair]]: 12 years of age
 
*[[Growth spurt]]: 12.5–15 years of age
Additional monitoring of patients with an underlying etiology of chromosomal syndromes, tumors, and autoimmune disorders will depend upon the individual condition.
*Completion of [[growth]]: 17.5 years of age


=== Complications ===
=== Complications ===
{| class="wikitable"
'''Osteoporosis'''
|-
* Lack of [[estrogen]] and other [[sex steroids]] can lead to decreasing [[bone]] [[mineralization]] and [[osteoporosis]].<ref name="GilsanzChalfant2011">{{cite journal|last1=Gilsanz|first1=Vicente|last2=Chalfant|first2=James|last3=Kalkwarf|first3=Heidi|last4=Zemel|first4=Babette|last5=Lappe|first5=Joan|last6=Oberfield|first6=Sharon|last7=Shepherd|first7=John|last8=Wren|first8=Tishya|last9=Winer|first9=Karen|title=Age at Onset of Puberty Predicts Bone Mass in Young Adulthood|journal=The Journal of Pediatrics|volume=158|issue=1|year=2011|pages=100–105.e2|issn=00223476|doi=10.1016/j.jpeds.2010.06.054}}</ref>
|[null psychological problems]
* The amount of [[bone mass]] gained during [[puberty]] is the key determinant factor in development of [[osteoporosis]].<ref name="GilsanzChalfant2011" />
Pubertal delay and short stature due to lack of a growth spurt can result in bullying. A delay in treatment can lead to difficulties in interpersonal relationships, and early treatment must therefore be commenced. Patients with anorchia need to be counseled for testicular prosthesis. Those with permanent hypogonadism should receive counseling regarding the lack of fertility.
* If left untreated, patients with delayed [[puberty]] attain normal sexual maturation but will experience a decreased peak [[bone mass]] .<ref name="pmid1734250">{{cite journal |vauthors=Finkelstein JS, Neer RM, Biller BM, Crawford JD, Klibanski A |title=Osteopenia in men with a history of delayed puberty |journal=N. Engl. J. Med. |volume=326 |issue=9 |pages=600–4 |year=1992 |pmid=1734250 |doi=10.1056/NEJM199202273260904 |url=}}</ref>
|low
'''Psychological problems'''<ref name="pmid3302895">{{cite journal |vauthors=Lee PD, Rosenfeld RG |title=Psychosocial correlates of short stature and delayed puberty |journal=Pediatr. Clin. North Am. |volume=34 |issue=4 |pages=851–63 |year=1987 |pmid=3302895 |doi= |url=}}</ref>
|variable
* Delayed [[puberty]] may threaten the final height and also adult phenotype.
|-
* Delayed or absent [[secondary sexual characteristics]] may affect a person's [[self-esteem]] and interpersonal relationships.
|[null skin irritation from gels and patches]
* Patients with a disease resulting in [[anorchia]] have to be counseled about [[testicular prosthesis]].
Occurs in up to one third of patients using the patch.
'''Polycythemia'''
|low
* The use of [[testosterone]] in the treatment of delayed [[puberty]] can cause [[RBCs]] overproduction which can lead to increased [[hematocrit]].
|variable
'''Irritation from gels and patches'''
|-
* Therapeutic [[hormonal]] gels and patches that are frequently used in delayed [[puberty]] can cause allergic reactions and irritation.
|[null polycythemia]
This is a particular problem with intramuscular testosterone preparations. The testosterone dose may need to be reduced.
|low
|variable
|-
|[null osteoporosis] [null (view full topic)]
The absence of sex steroids leads to inadequate bone mineralization. This may result in fractures and osteoporosis later in adult life. All patients with permanent hypogonadism require sex-steroid replacement throughout the reproductive period.
|
|}


=== Prognosis ===
=== Prognosis ===
Overall outlook relates to the underlying cause of delayed puberty rather than to the delay itself.
* The major determinant of prognosis in delayed [[puberty]] is underlying [[Comorbidity|co-morbidity]], not the [[disease]] itself.
* [[Constitutional delay of puberty|Constitutional delay of growth and puberty (CDGP)]] has an excellent [[prognosis]]. The [[puberty]] and final height in these patients will occur normally in the future even without any [[Hormone replacement therapy|hormone replacement]] therapy.
* Patients with benign [[Comorbidity|co-morbidity]] induced delayed [[puberty]], like delayed [[puberty]] due to [[lifestyle]] disorders ([[malnutrition]] or excessive [[exercise]]) or mild [[chronic diseases]], can completely gain their normal [[puberty]] characteristics after suitable treatment of underlying diseases.
* Permanent causes of delayed [[puberty]], such as idiopathic [[hypogonadotropic hypogonadism]], [[genetic diseases]], [[chromosomal]] disorders (e.g., [[Turner's syndrome]] or [[Klinefelter's syndrome]]), or [[pituitary]] surgical procedures (e.g., [[craniopharyngioma]] treatment) need lifelong [[hormone replacement therapy]].<ref name="urlDelayed puberty Prognosis - Epocrates Online">{{cite web |url=https://online.epocrates.com/diseases/112651/Delayed-puberty/Prognosis |title=Delayed puberty Prognosis - Epocrates Online |format= |work= |accessdate=}}</ref>


Patients with a temporary delay such as those with constitutional delay in puberty have an excellent prognosis and achieve normal gonadal function postpuberty without testosterone (or estrogen) replacement therapy.
==References==
{{Reflist|2}}
​
]]


Similarly, patients with a chronic illness, malnutrition, or intense exercise typically recover normal gonadal function after resolution of the illness or exercise.
{{WH}}
 
{{WS}}
Patients with a permanent cause such as organic gonadotropin deficiency, Turner syndrome, Klinefelter syndrome, or previous pituitary surgery for a craniopharyngioma require lifelong hormone therapy.


==References==
[[Category:Needs content]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Medicine]]
[[Category:Pediatrics]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
 
[[Category:Mature chapter]]
{{WH}}
[[Category:Developmental biology]]
{{WS}}
[[Category:Sexuality and age]]
[[Category:Sexual health]]
[[Category:Growth disorders]]
[[Category:Congenital disorders]]
[[Category:Up-To-Date]]

Latest revision as of 21:15, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

The symptoms of puberty usually develop between ages 8 to 13 in girls and 9 to 14 in boys and start with breast development in girls and testicular enlargement in boys. If the testicular enlargement or breast development has not occurred at a mean age of puberty in population plus 2-2.5 standard deviation (SD), it will be called delayed puberty. The mean age depends on various factors, such as race, nutrition, and also socioeconomic status. Recently, the age of onset of puberty is decreasing in the US and other countries. The main complications of delayed puberty are osteoporosis, psychological problems, polycythemia, and irritation from hormonal gels and patches. The major determinant of delayed puberty prognosis is underlying co-morbidity, not the disease itself. Constitutional delay of growth and puberty (CDGP) has an excellent prognosis. The puberty and final height in these patients will be normal in the future, without any hormone replacement therapy.

Natural History, Complications, and Prognosis

Natural history

  • The symptoms of puberty usually develop between ages 8 to 13 in girls and ages 9 to 14 in boys and start with breast development in girls and testicular enlargement in boys.
  • If the testicular enlargement or breast development has not occurred at a mean age of puberty in population plus 2-2.5 SD, it will be called delayed puberty. The mean age depends on various factors, such as race, nutrition, and also socioeconomic status. Recently, the age of onset of puberty is decreasing in the US and other countries.
  • If left untreated, all of the patients with a constitutional delay of puberty and growth may progress to develop normal puberty and growth.
  • All patients with delayed puberty have to be precisely monitored until normal puberty and growth become accomplished. It may take about 2-5 years. Final height can be measured by adding or subtracting 2.5 inches to the average height of parents. On average, puberty is accompanied by gaining 25 cm of height in girls and 30 cm in boys.

Delayed puberty in boys is identified as:[1]

  • No sign of testicular enlargement by 14 years of the age

OR

OR

Delayed puberty in girls is identified as:[1]

  • No signs of breast development by 14 years of age

OR

OR

  • No breast development to adult type 5 years after onset of puberty

OR

Normal puberty timing

Approximate mean ages for onset of various pubertal changes are as follows:

Developmental changes during puberty in girls occur over a period of 3-5 years, usually between 9 and 14 years of age. They include the occurrence of secondary sex characteristics beginning with breast development, the adolescent growth spurt, the onset of menarche (not correspond to the end of puberty), and the acquisition of fertility, as well as profound psychological modifications.[2]

North American, Indo-Iranian (India, Iran) and European girls

North American, Indo-Iranian (India, Iran) and European boys

  • Testicular enlargement: 11.5 years of age
  • Pubic hair: 12 years of age
  • Growth spurt: 12.5–15 years of age
  • Completion of growth: 17.5 years of age

Complications

Osteoporosis

Psychological problems[5]

Polycythemia

Irritation from gels and patches

  • Therapeutic hormonal gels and patches that are frequently used in delayed puberty can cause allergic reactions and irritation.

Prognosis

References

  1. ↑ 1.0 1.1 "Complications of puberty - Ireland's Health Service".
  2. ↑
  3. ↑ 3.0 3.1 Gilsanz, Vicente; Chalfant, James; Kalkwarf, Heidi; Zemel, Babette; Lappe, Joan; Oberfield, Sharon; Shepherd, John; Wren, Tishya; Winer, Karen (2011). "Age at Onset of Puberty Predicts Bone Mass in Young Adulthood". The Journal of Pediatrics. 158 (1): 100–105.e2. doi:10.1016/j.jpeds.2010.06.054. ISSN 0022-3476.
  4. ↑ Finkelstein JS, Neer RM, Biller BM, Crawford JD, Klibanski A (1992). "Osteopenia in men with a history of delayed puberty". N. Engl. J. Med. 326 (9): 600–4. doi:10.1056/NEJM199202273260904. PMID 1734250.
  5. ↑ Lee PD, Rosenfeld RG (1987). "Psychosocial correlates of short stature and delayed puberty". Pediatr. Clin. North Am. 34 (4): 851–63. PMID 3302895.
  6. ↑ "Delayed puberty Prognosis - Epocrates Online".

​ ]]

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