Dr. Babu

Puberty results from activation of gonads (testes in boys/ ovaries in girls) by pituitary hormones LH and FSH. Activated gonads produce sexual hormones (testosterone in boys and estrogen in girls ) which are responsible for gender specific physical changes at puberty along with behaviour changes. Testosterone in boys is responsible for hair growth over pubic area and face with maturation of genital organs, breaking of voice, development of muscular and skeletal system. Similarly, estrogen in girls is responsible for breast development, maturation of genital organs with feminisation of body. Bone maturation with rapid height gain is seen at puberty both in boys and girls. Various systemic and hormonal disorders can result in either late or early puberty. 

LATE PUBERTY - 

Most of the boys show signs of puberty latest by age of 14 years and most girls start showing signs of puberty latest by age of 13 years. The earliest sign of puberty in boys is enlargement of testes and in girls is height spurt/breast development. When boys older than 14 years and girls older than 13 years don't have any signs of puberty it is called delayed puberty. 

CAUSES OF DELAYED PUBERTY - 

1. Constitutional delay is most common cause of delayed puberty. The constitutional delay means child is not having any illness and he is going to develop puberty spontaneously at later age. But diagnosis of this condition can be made only after physical examination and investigations so that other causes of delayed puberty are ruled out. 
2. Functional hypogonadotropic Hypopogonadism - Delayed but spontaneous puberty develops. This condition can be seen in systemic illnesses like chronic infections, poor nutritional status etc. 
3. Hypogonadotropic Hypogonadism - Disorders of pituitary gland result in low LH and FSH so that testes/ovaries are not stimulated and sex hormone is not produced. This can be caused by various genetic disorders, brain tumours, head injury, brain radiation etc. 
4. Hypergonadotropic Hypogonadism - In this scenario, LH and FSH levels are normal but gonadal are not able to produce sex hormones resulting in delayed puberty. 

CONSEQUENCES OF DELAYED PUBERTY - 
The absence of age specific pubertal changes cause anxiety and distress in children and their parents. These children may develop low self-esteem and are teased by their peers. Along with the poor development of physical signs of puberty, fertility is also affected in hypogonadism. And most importantly, delayed puberty can be the symptom of serious underlying illness like intracranial tumours etc. These children deserve medical attention to get best results. 

INVESTIGATIONS - 
Serum testosterone/estradiol with LH and FSH is done to find out where is defect i.e. whether at the level of pituitary gland or at the level of testes/ovaries. Further investigations depend on levels LH, FSH, estradiol/testosterone. Other useful investigations include prolactin, T4, TSH, ray hand for bone age, ultrasound pelvis, MRI pituitary gland etc. 

TREATMENT - 
After diagnosis is established, Testosterone/estrogen replacement should be started to boys older than 14 year and girls older than 13 years respectively. Hormone replacement is very effective and usually safe. In adulthood those with hypogonadotropic hypogonadism can be treated with LH and FSH to produce sperms/ eggs so that they can achieve fertility. If you wish to discuss about any specific problem, you can ask a free question.