Delayed sexual development is a big problem for teenagers. Due to the lack of pubertal signs, they feel alienated and stand out from their peer group. They may develop mood disorders and depression. Low levels of sex hormones lead to growth inhibition and infertility. Learn about the causes, symptoms, and treatments for delayed puberty.
Delayed puberty
Delayed sexual development (ICD-10 code - E30.0) occurs if the first symptoms of puberty (breast enlargement and an increase in the volume of the ovaries or testicles) do not appear in girls after 13 years and in boys after 14 years. Maturity is also considered delayed when the first symptoms of puberty occurred at the right time but have not developed since. These patients may develop pubic and axillary hair because their developmentdepends on androgens produced in the adrenal glands.
Delayed puberty classification
Delayed sexual development in children can be caused by genetically determined diseases (syndromes) or can be acquired. The classification of delayed puberty is as follows:
- Hypergonadotropic hypogonadism - the cause of problems is damage to the gonads: testicles or ovaries. Although the hypothalamus and pituitary produce their own hormones (GnRH, FSH, and LH), damaged gonads are unable to produce sex hormones. Hypergonadotropic hypogonadism is always permanent.
- Hypogonadotropic hypogonadism - delayed sexual development in children occurs due to damage or inhibition of the function of the hypothalamus or pituitary gland. Although the ovaries and testicles are capable of secreting sex hormones, due to the lack of FSH and LH, they cannot take over the function of producing these hormones. Hypogonadotropic hypogonadism may be temporary.
Causes of delayed puberty
The most common cause of delayed puberty is the so-called constitutional delay in growth and maturation, which is classified as hypogonadotropic hypogonadism. It is observed in approximately 0.6-2% of children. This is a physiological variant of normal puberty.
At about 5 years old, a child begins to grow more slowly than his peers. His body begins to develop and grow properly later than that of his peers (usually from 14 to 17 years). However, the maturation process remainscorrect.
The constitutional delay in sexual and physical development is determined genetically, very often the parents of the child also mature late. Therefore, the medical history is important in the diagnosis. Information that the mother had her first menstruation at a later age than most of her peers, and her father began to grow at 15-16 years old, may indicate a constitutional delay in the growth and maturation of the child.
Hypergonadotropic hypogonadism can be caused by, among others, the following pathologies:
- Turner Syndrome - a syndrome caused by the absence or damage of the X chromosome. This leads to abnormal development of the ovaries, which are unable to produce sex hormones. Women reach short stature (average 143 cm) and suffer from infertility. Turner syndrome is one of the most common causes of delayed puberty in girls.
- Klinefelter syndrome is a syndrome caused by the presence of an extra X chromosome in boys. Men at the same time reach very high growth, have a female silhouette and are barren. Initially, puberty in boys with Klinefelter syndrome may be normal, but testosterone levels rapidly decline and puberty is suppressed. The testicles do not increase in size. Klinefelter syndrome is one of the most common causes of delayed puberty in boys.
- Ovarian insufficiency - the ovaries are devoid of reproductive cells, they produce a small amount of estrogen. The silhouette of the body is correct, the chest is underdeveloped. Infertility occurs.
- Inbornmissing testicles - a developmental disorder causes a boy to fail to develop testicles. Another reason for delayed sexual development in males.
- Complete testicular atrophy - they may disappear as a result of trauma or untreated keratoplasty.
- Cryptorchism - the testicles are located in the inguinal or abdominal canal, and not in the scrotum. Untreated cryptorchidism leads to permanent testicular damage and delayed sexual development.
- Damage to the testicles or ovaries from radiation therapy to the pelvis or cytostatics (anti-cancer drugs).
Hypogonadotropic hypogonadism can result from among other things:
- Constitutional stunting and maturation.
- Undernutrition and/or overexertion. An undersupply of calories can be caused by anorexia nervosa or a chronic, debilitating illness. This leads to temporary inhibition of FSH and LH secretion by the pituitary gland. After making up for nutritional deficiencies and avoiding physical overwork, the function of the pituitary gland and gonads returns to normal. And as a result, a further delay in sexual development in a teenager is excluded and good puberty becomes possible.
- Damage to the hypothalamic-pituitary region. Damage can be caused by cancer (especially the so-called craniopharyngioma) that develops in this area, by an inflammatory process (during meningitis and inflammation of the brain), or by trauma. Radiation therapy to the head can also cause damage to the hypothalamus and pituitary gland.
- Disturbances in the development of the central nervous system. Abnormal growth of the hypothalamus or pituitary prevents hormone production. The most common pathology associated with impaired development of this area is Kallman's syndrome. In addition to inadequate secretion of GnRH in the hypothalamus, there is also a deterioration in the sense of smell.
- Genetic disorders associated with the occurrence of various syndromes. These syndromes are very rare and, among other symptoms, also include impaired secretory functions of the hypothalamus and pituitary gland.
Delayed puberty: types of maturity
Sexual maturation (puberty) is a period in a person's life in which there are significant changes leading to the achievement of maturity. There are several areas of development in which a person reaches maturity. They include:
- Physical maturity. This is the end of the development of the size and proportions of the body and the acquisition of the ability to reproduce (the so-called puberty).
- Mental maturity. It includes, in particular, the formation of the character of a given person, the acquisition of the ability to control one's behavior and emotions, taking responsibility for one's actions.
- Social maturity. Determines the ability to fulfill appropriate roles in society (parent, worker, etc.).
Maturation process
The process of puberty is extended in time (for girls it takes an average of 4 years, for boys - 6-7 years). The rate of this process and the age at whichsubsequent changes occur, are very diverse in individuals and depend on many factors.
An important role is played by genetic factors - the same maturation of parents and children is often observed (the age of the first menstrual period in girls especially coincides). Place of residence also plays some role (the first menstruation for girls living in big cities occurs earlier than those living in villages) and socioeconomic status.
The tables below show the approximate course of changes that occur during puberty in girls and boys. The so-called typical age, that is, the one at which the observed symptoms of puberty most often occur statistically. It should be added that deviations from these values may be something normal for a given person and are not always associated with a pathological delay in sexual development in girls and boys.
The process of puberty in girls
Puberty of girls is a change in the developmental processes of the body of a teenage girl, which leads to growing up and the emergence of reproductive function. The launch of these processes is carried out with the help of signals sent by the brain to the sex glands of girls - the ovaries.
| Typical age, years | Observed changes |
| 9-12 | Breast development begins. There are only straight hairs on the labia. During this period, there isalso a growth spurt (accelerated growth rate) with a peak around 12 years of age. The peak of growth usually occurs a year before the start of the first menstrual cycle |
| 12-14 | Further development of the breasts, external genitalia (large and small genitals, clitoris) and pubic hair continues. On average, within 2 years from the onset of breast development, the first menstruation occurs (the so-called menarche). Cycles can be regular (but not necessarily), regular, and anovulatory. After 2-3 years, the menstrual cycle should stabilize. During this period, the growth rate decreases - the average increase in body height after the first menstrual cycle is 6 cm. The silhouette of the body becomes more feminine, the width of the hips increases |
| 12-16 | Chest, external genitalia, pubic and axillary hair slowly acquire the typical developed appearance of adults. Adipose tissue "settles" on the buttocks and thighs, giving the figure a feminine shape. Disproportion between limb length and torso is disappearing |
Boy maturation process
During puberty, boys may experience gynecomastia or breast enlargement. This phenomenon is observed in 30% of boys. Gynecomastia usually disappears spontaneously within a few months and is a physiological phenomenon during this period of a boy's life.
| Typical age, years | Observedchanges |
| 10-13 | The testicles increase in volume. The skin covering the scrotum is thin and pink. Sexual organs are growing. Single straight hairs appear at the base of the external genitalia. During this period, there is also a growth spurt - the growth rate is accelerating |
| 13-15 | The testicles produce sperm. Around the age of 14 years, there is a peak growth (the largest annual increase in growth). The silhouette of the body changes, the width of the shoulders and torso increases. During this period, a change in voice or its mutation also begins. Laryngeal parts develop. This may be accompanied by voice disturbances, often hoarseness. The mutation lasts about 1 year |
| 15-17 | The male reproductive organs are finally developing. The final testicular volume in Europeans is 12 to 30 ml. Growth rates are declining. There is hair on the face, limbs and torso |
Sexual maturation: hormonal changes
Sexual maturation is associated with the influence of sex hormones produced in the gonads - the ovaries and testicles. The ovaries produce estrogens and progesterone, while the testes produce mainly testosterone. The adrenal glands produce a certain amount of sex hormones (mainly the so-called male androgens). They play a role in the development of axillary and pubic hair. The secretion of sex hormones in the gonads is controlled by two organs located in the brain: the hypothalamus and the pituitary gland. Hypothalamus(beginning with puberty) produces GnRH (so-called GnRH) in a pulsatile manner. GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinotropin (LH). They, in turn, affect the testicles and ovaries, i.e., the secretion of sex hormones.
Specific scales are used to assess puberty. The degree of development of sexual characteristics (testicles, penis and scrotum in boys, breasts in girls and pubic hair in both sexes) is determined using the Taner scale. An important role is also played by the so-called bone age. Based on the X-ray of the left wrist, the presence of so-called bone ossification is observed. The resulting image is compared with drawings from special atlases. The bones appear in a specific order, making them a good tool for assessing the stage of skeletal maturation in children and adolescents.
When to go to the doctor?
If parents suspect that their child may be suffering from delayed puberty, they should contact their pediatrician. The medical history should answer the question of whether the child really has any symptoms of puberty deviation and determine how puberty occurred in the parents. Child observation and physical examination may reveal the characteristics of a particular body (eg Turner or Klinefelter).
For accurate diagnosis and detection of signs of delayed sexual development, hormonal tests are needed (estrogen, progesterone, LH, FSH are determined and tests are carried outstimulation). Sometimes imaging is needed, such as CT or head MRI, pelvic ultrasound. Genetic studies should also be carried out, in particular, the determination of the so-called karyotype (an image of the complete set of chromosomes) is necessary for the recognition of Turner and Klinefelter syndrome. In the case of other genetic diseases, appropriate studies are carried out to identify certain mutations.
Delayed Puberty Treatment
Treatment for delayed puberty depends on the type.
In hypogonadotropic hypogonadism, treatment involves the administration of sex hormones. In girls, therapy begins with small doses of estrogen (preferably in the form of patches). Thanks to this, the shape of the breast and the female body will develop. After the onset of menstruation, you should also take a drug containing progesterone. In boys, the treatment is to provide the body with testosterone.
Treatment of hypogonadotropic hypogonadism also includes the administration of sex hormones. In addition, the use of chorionic gonadotropins or human menopausal gonadotropins leads to an increase in testicular volume, and as a result, there is no further delay in sexual development in men.
Because hypergonadotropic hypogonadism is associated with damage to the gonads - testicles and ovaries, patients cannot produce reproductive cells (sperm or eggs). Despite the replacement of sex hormones (which allow you to get the right shapebodies and other gender-specific characteristics), patients remain infertile.
Hypogonadotropic hypogonadism can be completely reversible. Removal of a factor that causes inhibition of hormone secretion in the hypothalamus and pituitary gland (for example, proper supply of calories, removal of a tumor without damaging surrounding tissues), or an appropriate supply of sex hormones, allows the child's body to develop properly and avoid delaying sexual development.
However, it should be remembered that some congenital malformations or genetically determined syndromes may be associated with the appearance of a number of other anomalies that cause impaired growth, physical and mental maturation.
