Delayed puberty -Quick review chart

Delayed puberty Hypothalamus starts pulsatile GNRG which stimulates pulsatile release of FSH , LH from anterior pituitary. FSH / LH stimulates germ cell maturation , LH produces oestrogen in in girls and testosterone in boys.

Early changes by age 10-13 Girls -budding of breasts , then pubic hair and menstruation starting between 11-14 yrs Girls – growth spurt happens earlier in puberty and about same time as onset of breast development , growth slows down after 1s period Boys- testicular enlargement ( 3-4 mL ) and then pubic hair ( 9-14 yrs ), axillary , facial hairs , deepening of voice Boys grow slowly at start of puberty , accelerate mid puberty and

Delayed puberty – about 95 % of G’s/B’s have commenced puberty by 13 and 14 yrs

Most common cause in more than 50 % of cases is a constitutional delay – Most common cause is a constitutional delay ( Constitutional delay of growth and development CDGP ) which runs in families Functional delay may also happen due to chronic illness ( systemic illnesses as CKD , CCF , chronic lung disease etc ) , excessive physical exercise , malnutrition , eating disorders , prolonged stress Hypogonadotrophic hypogonadism ie defect in hypothlamo-pituitary region. Partial or complete GNRH deficiency. Causes can be idiopathic or congenital ( Kallman syndrome – consider if patient c/o anosmia) Acquired causes may be due to drugs , infiltrative , infectious pituitary lesions , hyperprolactinemia , encephalic trauma , pituitary /brain radiation ,alcohol / drug abuse , conditions as haemochromatosis , sarcoidosis 
 Hyper gonadotrophic hypogonadism -primary gonadal failure ( E.g congenital disorders as cryptorchidism , chromosomal disorders Klinefelters , Turners , acquired causes as testicular torsion , chemotherapy , infections , testicular or ovarian surgery ) Both ( secondary to radio / chemotherpay ) Unclassified

Assessment – family history -pubertal timing ( genetic , chromosomal problems ) onset , progression body odour , acne , breast / testicular development history suggestive of any previous sig illness- chemotherapy , radiation therapy orchidopexy , treatment with exogenous steroids for e.g for asthma , nephrotic syndrome eating disorders , recent weight loss h/o viral infections as mumps , lack of smell

Initial testing – Primary 
Care FBC / UE / LFT / TFT , Coeliac screen Hormone profile LH , FSH , FT4 , TSH , prolactin , Estradiol , testosterone Bone age ( X Ray of wrist non dominant hand )

RESOURCES

Find Tanner staging and testicular measurement aid in this useful work from Paediatric Pearls Pubertal-stages-and-timings.pdf (paediatricpearls.co.uk)

REFERENCES

1. Delayed puberty Kingston Hospital NHS Trust Delayed Puberty – Kingston Hospital
2. Wei C, Davis N, Honour J, Crowne E. The investigation of children and adolescents with abnormalities of pubertal timing. Ann Clin Biochem. 2017 Jan;54(1):20-32. doi: 10.1177/0004563216668378. Epub 2016 Sep 28. PMID: 27555666.
3. Traggiai C, Stanhope R. Delayed puberty. Best Pract Res Clin Endocrinol Metab. 2002 Mar;16(1):139-51. doi: 10.1053/beem.2001.0186. PMID: 11987904. ( Abstract )
4. Dye AM, Nelson GB, Diaz-Thomas A. Delayed Puberty. Pediatr Ann. 2018 Jan 1;47(1):e16-e22. doi: 10.3928/19382359-20171215-01. PMID: 29323692. ( Abstract )
5. Fraietta, Renato et al. “Hypogonadotropic hypogonadism revisited.” Clinics (Sao Paulo, Brazil) vol. 68 Suppl 1,Suppl 1 (2013): 81-8. doi:10.6061/clinics/2013(sup01)09
6. Hormones and me delayed puberty *mer5334-saizen-hormones-and-me-delayed-puberty-v3.pdf (d192ha6kdpe15x.cloudfront.net)