Girls normally enter puberty between the ages of 8-14, while the onset for boys is between the ages of 9-14. When there is a delay in puberty, it is called delayed sexual development.

For girls, delayed sexual development is defined as an absence of breast development by the age of 13, or an absence of menstruation for five years or more after initial breast development. Delayed sexual development for boys means their testicles don’t enlarge by age 14, or their sex organs don’t completely develop five years after they started to develop.

Causes

Delayed sexual development can be caused by chronic disease, abnormal chromosomes, or other factors. It can also be a variation of normal puberty, called constitutional delay. In this case, some adolescents simply take longer to develop than their peers, but eventually catch up. To understand the reason for the delay, it is necessary to look at potential causes including:

• Underlying Disease:

• • Diabetes mellitus

• • Inflammatory bowel disease

• • Kidney disease

• • Cystic fibrosis

• • Anemia

• • Hypopituitarism (infection, trauma, central nervous system lesions)

• • Chronic infections

• • Anorexia nervosa

• • Malnutrition

• • Kallman’s syndrome

• • Cancer

• • Autoimmune disease

• Chromosomal Abnormalities:

• • Turner syndrome (girls)

• • Klinefelter syndrome (boys)

• • Prader-Willi syndrome (boys and girls)

• • Noonan syndrome (boys and girls)

• Other Factors:

• • Radiation therapy

• • Cancer chemotherapy

• • Athletes undergoing vigorous training

Risk Factors

Both premature and delayed puberty can run in families. Certain long-term diseases can also increase the risk of delayed sexual development. Increased lead exposure has also been associated with delayed sexual development.

Symptoms

One common symptom for both boys and girls is shortness in height. Other symptoms include:

• Symptoms in Boys:

• • Lack of testicular enlargement by age 13 ½

• • Lack of pubic hair by age 15

• • Genital enlargement that takes more than five years from start to completion

• Symptoms in Girls:

• • Lack of breast development by age 13

• • Lack of pubic hair by age 14

• • Failure to menstruate by age 16

• • Time lag of more than five years from breast development to first period

Diagnosis

Your doctor will ask about your child’s symptoms and medical history, and perform a physical exam. He or she will also look at pubertal milestones and your child’s growth chart. An x-ray of the left wrist bone may be taken to assess if bone growth is normal for your child’s age.

Depending on these results, other tests may be ordered, including:

• Chromosome studies

• Hormonal levels: FSH, LH, estradiol in girls and testosterone in boys

• GnRH stimulation test

• MRI scan of head and pituitary gland to exclude tumors or lesions

• Additional tests (eg, T4, insulin-like growth factor or IGF-1, IGFBP-3, TSH, prolactin)

• Assess nutritional state

• Family history of pubertal delay

Treatment

The treatment of delayed sexual development depends upon the cause. For adolescents who are otherwise healthy and just developing later than their peers, often there is no treatment other than continued monitoring. For those who have a chronic underlying disease, treatment is aimed at the specific condition. Once the condition is treated, puberty typically proceeds. Treatments include:

Prevention

Most causes of delayed sexual development cannot be prevented. To help reduce the chances of your child experiencing delayed puberty, you can make sure they are kept as healthy as possible. This includes making sure they are eating well and getting all the nutrients they need to meet their needs, and also making sure any underlying illnesses are treated.

RESOURCES:

The American Academy of Family Physicians
http://www.aafp.org

American Academy of Pediatrics
http://www.aap.org

CANADIAN RESOURCES:

About Kids Health
http://www.aboutkidshealth.ca

Caring for Kids, The Canadian Paediatric Society
http://www.caringforkids.cps.ca/

References:

Blondell RD, Foster MB, Kamlesh CD. Disorders of puberty. Am Fam Physician. Available at: http://www.aafp.org/afp/990700ap/209.html. Accessed July 5, 2005.

Hero M, Wickman S, Dunkel L. Treatment with the aromatase inhibitor letrozole during adolescence increases near-final height in boys with constitutional delay of puberty. Clin Endocrinol. 2006;64:510-3.

The Merck Manual, 2nd ed. Merck website. Available at: http://www.merck.com/mmhe/print/sec23/ch271/ch271b.html. Accessed July 4, 2005.

Sedlmeyer IL, Palmort MR. Delayed puberty: analysis of a large case series from an academic center. J Clin Endocrinol Metab. 2002;87:1613-1620.