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| {{SK}} Dealyed puberty | | {{SK}} Delayed puberty |
| == Overview ==
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| '''Puberty''' is described as '''delayed''' when a boy or girl has passed the usual age of onset of [[puberty]] with no physical or [[hormone|hormonal]] signs that it is beginning. Puberty may be delayed for several years and still occur normally, in which case it is considered constitutional delay, a variation of healthy physical development. Delay of puberty may also occur due to [[malnutrition|undernutrition]], many forms of systemic [[disease]], or to defects of the [[reproductive system]] ([[hypogonadism]]) or the body's responsiveness to [[sex hormone]]s.
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| == Normal timing == | | ==[[Constitutional delay of puberty overview|Overview]]== |
| Approximate mean ages for onset of various pubertal changes are as follows. Ages in parentheses are the approximate 3rd and 97th percentiles for attainment. For example, less than 3% of girls have not yet achieved [[thelarche]] by 13 years of age. 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]] – which does not correspond to the end of puberty – and the acquisition of [[fertility]], as well as profound psychological modifications.
| | ==[[Constitutional delay of puberty pathophysiology |Pathophysiology]]== |
| | ==[[Constitutional delay of puberty causes|Causes]]== |
| | ==[[Constitutional delay of puberty differential diagnosis|Differentiating Constitutional delay of puberty from other Diseases]]== |
| | ==[[Constitutional delay of puberty epidemiology and demographics|Epidemiology and Demographics]]== |
| | ==[[Constitutional delay of puberty natural history, complications and prognosis|Natural history, Complications and Prognosis]]== |
| | ==Diagnosis== |
| | [[Constitutional delay of puberty history and symptoms|History and Symptoms]] | [[Constitutional delay of puberty physical examination|Physical Examination]] | [[Constitutional delay of puberty laboratory findings|Laboratory Findings]] | [[Constitutional delay of puberty x ray|X Ray]] | [[Constitutional delay of puberty MRI|MRI]] | [[Constitutional delay of puberty other diagnostic studies|Other Diagnostic Studies]] |
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| The normal variation in the age at which adolescent changes occur is so wide that puberty cannot be considered to be pathologically delayed until the menarche has failed to occur by the age of 17 or testicular development by the age of 20.
| | ==Treatment== |
| | | [[Constitutional delay of puberty medical therapy|Medical Therapy]] | [[Constitutional delay of puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Constitutional delay of puberty future or investigational therapies|Future or Investigational Therapies]] |
| For North American, Indo-Iranian (India, Iran) and European girls
| | ==Case Studies== |
| *[[Thelarche]] 10y5m (8y–13y)
| | :[[Constitutional delay of puberty case study one|Case #1]] |
| *[[Pubarche]] 11y (8.5–13.5y)
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| *Growth spurt 10–12.5y
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| *Menarche 12.5y (10.5–14.5)
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| *Adult height reached 14.5y
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| For North American, Indo-Iranian (India, Iran) and European boys
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| *Testicular enlargement 11.5y (9.5–13.5y)
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| *Pubic hair 12y (10–14y)
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| *Growth spurt 12.5–15y
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| *Completion of growth 17.5
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| The sources of the data, and a fuller description of normal timing and sequence of pubertal events, as well as the [[hormone|hormonal]] changes that drive them, are provided in the principal article on [[puberty]].
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| == Evaluation == | |
| Obviously anyone who is later than average is late in the ordinary sense. There are three indications that pubertal delay may be due to an abnormal cause. The first is simply degree of lateness: although no recommended age of evaluation cleanly separates pathologic from physiologic delay, a delay of 2-3 years or more warrants evaluation.
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| *In girls, no breast development by 13 years, or no menarche by 3 years after breast development (or by 16).
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| *In boys, no testicular enlargement by 14 years.
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| The second indicator is discordance of development. In most children, puberty proceeds as a predictable series of changes in specific order. In children with ordinary constitutional delay, all aspects of physical maturation typically remain concordant but a few years later than average. If some aspects of physical development are delayed, and others are not, there is likely something wrong. For instance, in most girls, the beginning stages of breast development precede pubic hair. If a 12 year old girl were to reach [[Tanner stage]] 3 pubic hair for a year or more without breast development, it would be unusual enough to suggest an abnormality such as defective ovaries. Similarly, if a 13 year old boy had reached stage 3 or 4 pubic hair with testes that still remained prepubertal in size, it would be unusual and suggestive of a testicular abnormality.
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| The third indicator is the presence of clues to specific disorders of the [[reproductive system]]. For example, [[malnutrition]] or [[anorexia nervosa]] severe enough to delay puberty will give other clues as well. Poor growth would suggest the possibility of [[hypopituitarism]] or [[Turner syndrome]]. Reduced sense of smell ([[hyposmia]]) suggests [[Kallmann syndrome]].
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| == Possible causes ==
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| * Variation of normal (constitutional delay)
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| * Prolonged high level of physical exertion / being an athlete
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| * Systemic disease, ''e.g.'' [[Inflammatory bowel disease]], [[chronic renal failure]]
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| * Undernutrition ''e.g.'' [[anorexia nervosa]], zinc deficiency
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| * Hypothalamic defects and diseases ''e.g.'' [[Prader-Willi syndrome]]
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| * Pituitary defects and diseases ''e.g.'' [[hypopituitarism]], [[Kallmann syndrome]]
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| * Gonadal defects and diseases ''e.g.'' [[Turner syndrome]], [[Klinefelter syndrome]]
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| * Absence or unresponsiveness of target organs ''e.g.'' [[androgen insensitivity syndrome]], [[mullerian agenesis]]
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| * Other hormone deficiencies and imbalances ''e.g.'' [[hypothyroidism]], [[Cushing's syndrome]]
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| ==Constitutional delay==
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| Children who are healthy but have a slower rate of physical development than average have constitutional delay in growth and adolescence. These children have a history of stature shorter than their age-matched peers throughout childhood, but their height is appropriate for bone age, and skeletal development is delayed more than 2.5 SD. They usually are thin and often have a family history of delayed puberty. Children with a combination of a family tendency toward short stature and constitutional delay are the most likely to seek evaluation. They quite often seek evaluation when classmates or friends undergo pubertal development and growth, thereby accentuating their delay.
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| ==Medical evaluation==
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| [[Pediatric endocrinology|Pediatric endocrinologists]] are the physicians with the most training and experience evaluating delayed puberty.
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| A complete medical history, review of systems, growth pattern, and physical examination will reveal most of the systemic diseases and conditions capable of arresting development or delaying puberty, as well as providing clues to some of the recognizable [[syndrome]]s affecting the reproductive system.
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| Since [[bone]] maturation is a good indicator of overall physical maturation, an [[x-ray]] of the hand to assess [[bone age]] usually reveals whether the child has reached a stage of physical maturation at which puberty should be occurring. Visible secondary sexual development usually begins when girls achieve a [[bone age]] of 10.5 to 11 years, and boys achieve a bone age of 11.5 to 12 years.
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| The most valuable blood tests are the [[gonadotropin]]s, because elevation confirms immediately a defect of the [[gonad]]s or deficiency of the [[sex steroid]]s. In many instances, screening tests such as a [[full blood count|complete blood count]], general chemistry screens, [[thyroid]] tests, and [[urinalysis]] may be worthwhile.
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| More expensive and complicated tests, such as a [[karyotype]] or [[magnetic resonance imaging]] of the head, are usually obtained only when specific evidence suggests they may be useful.
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| ==Management== | |
| If a child is healthy but simply late, reassurance and prediction based on the bone age can be provided. No other intervention is usually necessary. In more extreme cases of delay, or cases where the delay is more extremely distressing to the child, a low dose of testosterone or estrogen for a few months may bring the first reassuring changes of normal puberty.
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| If the delay is due to systemic disease or undernutrition, the therapeutic intervention is likely to focus mainly on those conditions.
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| If it becomes clear that there is a permanent defect of the reproductive system, treatment usually involves replacement of the appropriate hormones ([[testosterone]] for boys, [[estradiol]] and [[progesterone]] for girls).
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| ==References==
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| {{sourcesstart}}
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| * {{cite journal | author=Traggiai C, Stanhope R | title=Disorders of pubertal development | journal=Best Pract Res Clin Obstet Gynaecol | year=2003 | pages=41-56 | volume=17 | issue=1 | id=PMID 12758225}}
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| * Patrick Fenichel: [http://www.health.am/gyneco/pediatric-gynecology/#11 Delayed Puberty] Centre Hospitalo-Universitaire de Nice, Hôpital de L’Archet, Nice, France
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| * Jungmann E, Trautermann C: The status of the gonadotropin-releasing hormone test in differential diagnosis of delayed puberty in adolescents over 14 years of age. Med Klin 1994;89:529–533.
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| * Johannessonm M, Gottlieb C, Hjelte L: Delayed puberty in girls with cystic fibrosis despite good clinical status. Pediatrics 1997;1:29–34.
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| * Layman LC, Lee EJ, Peak DB, Namnoum AB, Vu KV, Van Lingen B, et al: Delayed puberty and hypogonadism caused by mutations in the follicle-stimulating hormone β-subunit gene. N Engl J Med 1997;337:607–611.
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| * Heinrichs C, Bourguignon JP: [http://www.health.am/gyneco/more/therapeutic-aspects/ Treatment of delayed puberty and hypogonadism in girls]. Horm Res 1991;36:147–152.
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| {{sourcesend}}
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| {{Reflist}}
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| == Acknowledgements == | | == Acknowledgements == |
| The content on this page was first contributed by: C. Michael Gibson, M.S., M.D. | | The content on this page was first contributed by: C. Michael Gibson, M.S., M.D. |
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| [[pt:Puberdade atrasada]] | | [[pt:Puberdade atrasada]] |
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