Delayed puberty Classification and external resources
ICD-10	E30.0
ICD-9	259.0
DiseasesDB	17462
MeSH	D011628

Puberty is described as delayed when a boy or girl has passed the usual age of onset of puberty with no physical or hormonal signs that it is beginning. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings E00-E35 - Endocrine diseases (E00-E07 Thyroid gland / Thyroid hormone ( Congenital iodine-deficiency syndrome ( The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body Puberty may be delayed for several years and still occur normally, in which case it is considered constitutional delay, a variation of healthy physical development. Delay of puberty may also occur due to undernutrition, many forms of systemic disease, or to defects of the reproductive system (hypogonadism) or the body's responsiveness to sex hormones. Malnutrition is a general term for a medical condition caused by an improper or insufficient diet. A disease is an abnormal condition of an organism that impairs bodily functions and can be deadly The reproductive system is a system of organs within an Organism which work together for the purpose of Reproduction. Hypogonadism is a medical term for a defect of the Reproductive system that results in lack of function of the Gonads ( ovaries or testes) Sex steroids, also known as gonadal steroids, are Steroid hormones that interact with Vertebrate Androgen or Estrogen receptors

Contents 1 Normal timing 2 Evaluation 3 Possible causes 4 Constitutional delay 5 Medical evaluation 6 Management 7 See also 8 References

Normal timing

Approximate mean ages for onset of various pubertal changes are as follows. Ages in parentheses are the approximate 3rd and 97th percentiles for attainment. For example, less than 3% of girls have not yet achieved thelarche by 13 years of age. Thelarche is the first stage of secondary (postnatal Breast development usually occurring at the beginning of Puberty in girls Developmental changes during puberty in girls occur over a period of 3 – 5 years, usually between 9 and 14 years of age. They include the occurrence of secondary sex characteristics beginning with breast development, the adolescent growth spurt, the onset of menarche – which does not correspond to the end of puberty – and the acquisition of fertility, as well as profound psychological modifications. Menarche (American English məˈnɑrki British English mɛˈnɑːki is the first menstrual period, or first menstrual bleeding in the females of Human beings Fertility is the natural capability of giving life As a measure "Fertility Rate" is the number of children born per couple person or population

The normal variation in the age at which adolescent changes occur is so wide that puberty cannot be considered to be pathologically delayed until the menarche has failed to occur by the age of 17 or testicular development by the age of 20.

For North American, Indo-Iranian (India, Iran) and European girls

• Thelarche 10y5m (8y–13y)
• Pubarche 11y (8. Thelarche is the first stage of secondary (postnatal Breast development usually occurring at the beginning of Puberty in girls Pubarche refers to the first appearance of Pubic hair in a child 5–13. 5y)
• Growth spurt 10–12. 5y
• Menarche 12. 5y (10. 5–14. 5)
• Adult height reached 94y

For North American, Indo-Iranian (India, Iran) and European boys

• Testicular enlargement 11. 5y (9. 5–13. 5y)
• Pubic hair 12y (10–14y)
• Growth spurt 12–14y
• Completion of growth 16. 0y

The sources of the data, and a fuller description of normal timing and sequence of pubertal events, as well as the hormonal changes that drive them, are provided in the principal article on puberty. Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body

Evaluation

Obviously anyone who is later than average is late in the ordinary sense. There are three indications that pubertal delay may be due to an abnormal cause. The first is simply degree of lateness: although no recommended age of evaluation cleanly separates pathologic from physiologic delay, a delay of 2-3 years or more warrants evaluation.

• In girls, no breast development by 13 years, or no menarche by 3 years after breast development (or by 16).
• In boys, no testicular enlargement by 14 years.

The second indicator is discordance of development. In most children, puberty proceeds as a predictable series of changes in specific order. In children with ordinary constitutional delay, all aspects of physical maturation typically remain concordant but a few years later than average. If some aspects of physical development are delayed, and others are not, there is likely something wrong. For instance, in most girls, the beginning stages of breast development precede pubic hair. If a 12 year old girl were to reach Tanner stage 3 pubic hair for a year or more without breast development, it would be unusual enough to suggest an abnormality such as defective ovaries. The Tanner stages (also known as the Tanner scale) are stages of physical development in Children, Adolescents and Adults The stages Similarly, if a 13 year old boy had reached stage 3 or 4 pubic hair with testes that still remained prepubertal in size, it would be unusual and suggestive of a testicular abnormality.

The third indicator is the presence of clues to specific disorders of the reproductive system. The reproductive system is a system of organs within an Organism which work together for the purpose of Reproduction. For example, malnutrition or anorexia nervosa severe enough to delay puberty will give other clues as well. Malnutrition is a general term for a medical condition caused by an improper or insufficient diet. Anorexia Nervosa is a psychiatric Diagnosis that describes an Eating disorder characterized by low Body weight and Body image distortion Poor growth would suggest the possibility of hypopituitarism or Turner syndrome. Hypopituitarism is the decreased ( hypo) secretion of one or more of the eight Hormones normally produced by the Pituitary gland at the base of the Brain Turner syndrome or Ullrich-Turner syndrome encompasses several conditions of which monosomy X is the most common Reduced sense of smell (hyposmia) suggests Kallmann syndrome. Hyposmia is a reduced ability to smell and to detect Odors A related condition is Anosmia, in which no odors can be detected Kallmann syndrome is an example of Hypogonadism (decreased functioning of the sex hormone-producing glands caused by a deficiency of Gonadotropin-releasing hormone

Possible causes

• Variation of normal (constitutional delay)
• In females, prolonged high level of physical exertion / being an athlete
• Systemic disease, e. g. Inflammatory bowel disease, chronic renal failure
• Undernutrition e. In Medicine, inflammatory bowel disease ( IBD) is a group of inflammatory conditions of the large intestine and Small intestine Chronic kidney disease (CKD also known as chronic renal disease, is a progressive loss of renal function over a period of months or years g. anorexia nervosa, zinc deficiency
• Hypothalamic defects and diseases e. Anorexia Nervosa is a psychiatric Diagnosis that describes an Eating disorder characterized by low Body weight and Body image distortion g. Prader-Willi syndrome,Kallmann syndrome
• Pituitary defects and diseases e. Prader-Willi syndrome (abbreviated PWS) is a very rare Genetic disorder, in which seven genes (or some subset thereof on chromosome 15 are missing or unexpressed Kallmann syndrome is an example of Hypogonadism (decreased functioning of the sex hormone-producing glands caused by a deficiency of Gonadotropin-releasing hormone g. hypopituitarism
• Gonadal defects and diseases e. Hypopituitarism is the decreased ( hypo) secretion of one or more of the eight Hormones normally produced by the Pituitary gland at the base of the Brain g. Turner syndrome, Klinefelter syndrome
• Absence or unresponsiveness of target organs e. Turner syndrome or Ullrich-Turner syndrome encompasses several conditions of which monosomy X is the most common Klinefelter's syndrome, 47XXY or XXY syndrome is a condition caused by a Chromosome Aneuploidy. g. androgen insensitivity syndrome, mullerian agenesis
• Other hormone deficiencies and imbalances e. Androgen insensitivity syndrome (AIS also referred to as androgen resistance syndrome, is a set of disorders of Sexual differentiation caused by Mutations g. hypothyroidism, Cushing's syndrome

Constitutional delay

Children who are healthy but have a slower rate of physical development than average have constitutional delay in growth and adolescence. Hypothyroidism is the disease state in humans and animals caused by insufficient production of Thyroid hormone by the Thyroid gland. These children have a history of stature shorter than their age-matched peers throughout childhood, but their height is appropriate for bone age, and skeletal development is delayed more than 2. 5 SD. They usually are thin and often have a family history of delayed puberty. Children with a combination of a family tendency toward short stature and constitutional delay are the most likely to seek evaluation. They quite often seek evaluation when classmates or friends undergo pubertal development and growth, thereby accentuating their delay.

Medical evaluation

Pediatric endocrinologists are the physicians with the most training and experience evaluating delayed puberty. Pediatric Endocrinology ( British: Paediatric is a medical subspecialty dealing with variations of physical Growth and sexual development in childhood

A complete medical history, review of systems, growth pattern, and physical examination will reveal most of the systemic diseases and conditions capable of arresting development or delaying puberty, as well as providing clues to some of the recognizable syndromes affecting the reproductive system. In Medicine and Psychology, the term syndrome refers to the association of several clinically recognizable features signs (observed by a physician

Since bone maturation is a good indicator of overall physical maturation, an x-ray of the hand to assess bone age usually reveals whether the child has reached a stage of physical maturation at which puberty should be occurring. Bones are rigid organs that form part of the Endoskeleton of Vertebrates They function to move support and protect the various organs of the body produce X-radiation (composed of X-rays) is a form of Electromagnetic radiation. Bone age is a way of describing the degree of maturation of a child's Bones As a person grows from fetal life through childhood Puberty, and finishes growth Visible secondary sexual development usually begins when girls achieve a bone age of 10. Bone age is a way of describing the degree of maturation of a child's Bones As a person grows from fetal life through childhood Puberty, and finishes growth 5 to 11 years, and boys achieve a bone age of 11. 5 to 12 years.

The most valuable blood tests are the gonadotropins, because elevation confirms immediately a defect of the gonads or deficiency of the sex steroids. Gonadotropins are Protein Hormones secreted by Gonadotrope cells of the Pituitary gland of Vertebrates Gonadotropin is sometimes The gonad is the organ that makes Gametes The gonads in males are the Testes and the gonads in Females are the Ovaries. Sex steroids, also known as gonadal steroids, are Steroid hormones that interact with Vertebrate Androgen or Estrogen receptors In many instances, screening tests such as a complete blood count, general chemistry screens, thyroid tests, and urinalysis may be worthwhile. A complete blood count ( CBC) also known as full blood count ( FBC) or full blood exam ( FBE) or blood panel, is The thyroid is one of the largest Endocrine glands in the body A urinalysis (or "UA" is an array of tests performed on Urine and one of the most common methods of Medical Diagnosis.

More expensive and complicated tests, such as a karyotype or magnetic resonance imaging of the head, are usually obtained only when specific evidence suggests they may be useful. A karyotype is the characteristic Chromosome complement of a Eukaryote Species.

Management

If a child is healthy but simply late, reassurance and prediction based on the bone age can be provided. No other intervention is usually necessary. In more extreme cases of delay, or cases where the delay is more extremely distressing to the child, a low dose of testosterone or estrogen for a few months may bring the first reassuring changes of normal puberty.

If the delay is due to systemic disease or undernutrition, the therapeutic intervention is likely to focus mainly on those conditions.

If it becomes clear that there is a permanent defect of the reproductive system, treatment usually involves replacement of the appropriate hormones (testosterone for boys, estradiol and progesterone for girls). Testosterone is a Steroid hormone from the Androgen group In mammals testosterone is primarily secreted in the testes of males and the Ovaries Estradiol (17β-estradiol (also oestradiol) is a Sex hormone. Progesterone is a C-21 Steroid Hormone involved in the Female Menstrual cycle, Pregnancy (supports Gestation

See also

• Endocrinology
• Menarche
• Precocious puberty
• Puberty
• Tanner stage
• Developmental milestones

References

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