Girls enter puberty between the ages of 8-14. Boys enter this stage between the ages of 9-14. When this stage is late, it is called delayed sexual development.

For girls, delayed sexual development is defined as:

• Absence of breast development by the age of 13 or
• Absence of menstruation for five years or more after initial breast development

• Testicles that don’t enlarge by age 14 or
• Sex organs that don’t completely develop five years after they started to develop

This condition can be caused by:

• Chronic disease
• Abnormal chromosomes
• Constitutional delay—a variation of normal puberty (some simply take longer than their peers; they will at some point catch up)
• Other factors

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 (caused by 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
  • Chemotherapy
  • Athletes undergoing vigorous training

Factors that increase the chance of delayed puberty include:

• Delayed puberty can run in families
• Certain long-term diseases
• Increased lead exposure

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

The doctor will ask about your child’s symptoms and medical history. A physical exam will be done. An assessment of your child's milestones and growth will be done. An x-ray of the left wrist bone may be taken. This will help 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, and estradiol in girls; 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)
• Assessment of nutritional state
• Family history of pubertal delay
• Pelvic ultrasound (female)
• Skull x-ray
• Test of smell and vision

The treatment depends on the cause.

There is often no treatment for those who are healthy and just starting later than their peers. They will continue to be monitored.

For those who have a chronic underlying disease, treatment is aimed at the specific condition. Once the condition is treated, puberty often proceeds on its own.

For others treatments may include:

Sex hormones are given to those with chromosomal abnormalities. This can include Turner or Klinefelter syndrome. The hormones will help begin sexual development. Hormones may also be given to teens who are severely delayed or overly stressed by their lack of development.

This drug can increase the height in boys with constitutional delay of puberty.

Counseling may be suggested for adolescents who are struggling with the delay.

If a tumor is found in the head, the doctor may remove the tumor.

The doctor will continue to monitor your child’s height, weight, and sexual development. This will help determine if any treatment has been effective.