puberty is defined as the lack of any pubertal signs by the age of 13 years in
girls and 14 years in boys. It affects
approximately 2% of adolescents and is more common in boys. Most patients seek medical assistance because
of slow growth rather than slow pubertal development.
of delayed puberty can be divided into central and peripheral.
Central causes – there is
nothing wrong with the testes or ovaries but there is no signal from the pituitary
to stimulate them to produce oestrogen and testosterone
developmental abnormalities of HP axis, trauma, tumours etc.
causes – the pituitary is producing LH and FSH but there is an impairment of the testes or ovaries which results in them
not being able to produce oestrogen or
disorders e.g. cryptorchidism
disorders e.g. Klinefelters, Turners
e.g. testicular torsion, chemotherapy, infections, testicular or ovarian
development absent, slow or arrested?
stage of puberty
stage 1) if all of the following:
In puberty (Tanner
stage 2-3) if any of the following:
(Tanner stage 4-5)
of nipple or breast development
enlargement so long as nipples also enlarged
or axillary hair growth
If all of the following:
(menarche) with breast, pubic and axillary hair development
of testes or penis
of scrotum with growth of the testes
testicular penile enlargement
pubic or axillary hair growth
If any of the following:
fully changed (broken)
of penis with pubic and axillary hair growth
RCPCH – The three phases of puberty
assessed by history
chronic medical condition can lead to delayed puberty
eating patterns or recent weight loss, intense exercise plans
or radiotherapy to the brain (causing gonadotrophin deficiency) or abdomen and
pelvis (gonadal damage)
infections e.g. mumps
suggestive of other hormone deficits
growth and puberty patterns
impact of delayed puberty on young person
by Tanner Staging if appropriate, however most screening information can come
from the history (see above)
Height and Weight
spurt occurs in mid-late puberty in boys and stage 3 breast development in
stature may be particularly important in girls
of chronic illness
Arrested puberty i.e. puberty begins but fails to progress adequately.
Examination including documented Tanner staging
Bloods to assess for chronic disease (FBC, U+E, LFT, TFTs, coeliac)
Baseline FSH and LH measurements can be helpful to distinguish between hypogonadotropic hypogonadism and hyper gonadotrophic hypogonadism
Bone age x-ray (request x ray for bone age which will be an x ray of hand and wrist of the left hand)
Further dynamic tests may be carried out in hospital.
with delayed puberty should be referred to general paediatric outpatients for
further assessment via ERS. They are
likely to be seen by a general paediatrician initially with support from
endocrinology if required.
Those children with arrested puberty should be referred urgently into our Rapid Access Clinics – this is currently via ERS marked urgent. If advice is required prior to referral then a paediatric consultant can be contacted via Advice & Guidance on ERS.
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