Puberty normally occurs in a series of five stages (Tanner stages) that typically begin within the ages of 8 and 13 for girls and 9 and 14 for boys. Puberty is consider delayed (delayed puberty) if it hasn't occurred by the age of 13 years in girls and 14 years in boys. Children with delayed puberty should have a full evaluation by their Pediatrician and will often need to see a Pediatric Endocrinologist.
Puberty may also considered to be delayed in girls if the whole process isn't complete in 4 years (or 4-5 years for boys) or if menarche hasn't occured by age 16.
Most children with delayed puberty are normal and just have a constitutional delay in their growth and development. Other children can have a medical condition that is causing the delay in beginning puberty because of hypogonadism, meaning the ovaries or testicles are not secreting their sex hormones (estrogen or testosterone) appropriately. Hypogonadism can be because the ovaries or testicles aren't being stimulated to secrete hormones (hypogonatotropic hypogonadism), such as seen with brain tumors, Kallmann syndrome, hypothyroidism, anorexia, and other chronic illnesses. Or hypogonadism can be secondary to a problem with the ovary or testicle itself (hypergonadotropic hypogonadism), such as seen with Klinefelter syndrome, Turner syndrome, and primary testicular or ovarian failure.
After a complete evaluation and physical exam, if your child shows signs of delayed puberty , your Pediatrician is likely to do further testing. These tests will probably include a bone age, which is the chronological age of your child's bones. This is determined by taking an x-ray, usually of his left wrist and hand. Children with a constitutional delay in beginning puberty usually have a delayed maturation of their skeleton, so while they may be 14 years old, they may have a bone age of 9 or 10 years.
The timing of when puberty begins correlates better with a child's bone age than with their real chronological age and puberty is unlikely to begin until your child has a bone age of 11 years in girls and 12 years in boys.
Genetics also influences the timing of puberty and a child is likely to be delayed in beginning puberty if other family members were also delayed.
Other testing can include, but is not limited to, determining a child's blood levels of follicle stimulating hormone (FSH), leutinizing hormone (LH), and the sex hormones (testosterone in boys or estrogen in girls). Other tests can include a complete blood count and chemistry panel, thyroid function tests, and IGF-1 (especially if also has short stature). A GnRH test with a check of LH levels may be needed if LH and FSH levels are low. Also, a karyotype (number and type of chromosomes) may be done if Turner or Klinefelter syndromes are suspected.
Children with a constitutional delay in beginning puberty in beginning puberty usually do not require treatment and they will eventually begin puberty and then progress through the stages of puberty normally. Some children, especially if they have hypogonadism, may benefit from treatment with sex hormones, either testosterone for boys or estrogen for girls.
It is also important to evaluate and manage the psychological effects of beginning puberty late. Children with a delay in beginning puberty are also usually shorter than other children their own age, and together, these factors can affect your child negatively.
Growth Disorder Resources:
- The Magic Foundation: "Major Aspects of Growth In Children for Children's Growth and Related Adult Disorders," a nonprofit organization providing support and education regarding growth disorders in children and related adult disorders, including adult growth hormone deficiency.