• Dr Andy Raffles

Puberty Disorders (Part 2)

In this article, part of our series on common problems in puberty we are looking at some of the more frequently encountered timing problems.


Delayed Pubertywhich usually is noted by parents and young people as falling behind in height, particularly in boys, compared to their classmates. It is more common in boys than girls and usually genetically determined. Boys can start puberty at a wide range of ages, with 95% starting between the ages of 9 and 14, so puberty is considered delayed when it has not started by age 14. The earliest sign of puberty in boys is an enlargement of the testicles, followed by growth of the penis and pubic hair. Although these are the physical signs, the symptom which causes the most concern is falling behind in height. But, be reassured that delayed puberty isn't harmful. Still, if your child feels as though he's not keeping up with his peers in growth and physical development, it can be very upsetting. Of note is that boys entering puberty will often have a weight spurt in a year or two before the height spurt, and as a result develop what is commonly called ‘puppy fat’. This on its own can result in teasing at school.


When to ask for advice?

Since there can be medical causes, young people with delayed puberty should be assessed by a Paediatrician, but most of the time it's not a medical problem. Family history is very important in the assessment of causes, and often this is not something families have discussed with their children.


For girls, delayed puberty means no breast development by age 13 or no menstrual periods by age 16. Again, one of the most frequent causes is family history. However, in girls investigations are usually undertaken early on to ensure that there are no underlying hormonal or genetic causes for the delay.


Duration of Puberty is also important, and if the onset of puberty in boys, to the completion of the growth of the genitals is more prolonged than 5 years from the start, this is also in need of investigation.


In girls, delayed puberty is also considered when there is an interval of more than 3 years from the beginning of breast growth to the first menstrual period


What to expect?

In the majority of cases, delayed puberty represents a normal variation, which may run in the family (also called constitutional delay of growth at puberty). These adolescents, sometimes referred to as "late bloomers," have a normal growth rate and are otherwise healthy. Although the growth spurt and puberty are delayed, they eventually proceed normally. Remember, the later puberty the greater the potential for height to increase.

During puberty, boys and girls will have a growth spurt and grow to their adult height. So that means girls who start puberty latest will still be getting taller in their mid-teens. For boys, those who are the latest to reach puberty will still be getting taller into their late teens or even early twenties.


What could be the cause?

Various disorders, such as poorly controlled diabetes, inflammatory bowel diseases, kidney diseases, cystic fibrosis, and anaemia, can delay or prevent sexual development. Development may be delayed or absent in adolescents receiving radiation therapy or cancer chemotherapy. Puberty may also be delayed by autoimmune disorders (such as Hashimoto thyroiditis, Addison disease, and some disorders that directly affect the ovaries). Rarely a tumour that damages the pituitary gland or the hypothalamus can lower the levels of gonadotropins, hormones that control the onset of puberty or stop production of the hormones altogether.


Treatment

A young person who is naturally late in developing needs no treatment, but if he or she is severely stressed by delayed or absent development, some doctors may give supplemental sex hormones to begin the process sooner. This treatment is much more common among boys. Children with delayed puberty often need additional support from parents, family members, and friends to ensure they have a healthy body image and self-esteem.


If boys show no sign of puberty by age 14, they may be given a 4-to 6-month course of testosterone injections once a month. At low doses, testosterone starts puberty, causes the development of some masculine characteristics (virilisation), and does not prevent adolescents from reaching their adult height potential.


In girls, low doses of oestrogen may be started with pills or skin patches.


Next time we will provide information on the other extreme in puberty called

Precocious Puberty (Early Puberty), when puberty starts in one way or another 2-3 years earlier than peers and siblings. This can be divided up into whether it is true puberty i.e. normal but early, or is disordered puberty where the physical changes happen in the wrong order and too early, which is much more concerning.


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