Delayed Puberty

Delayed puberty is when your child doesn’t show signs of sexual development at the expected age. This is sometimes called “delayed sexual development” or being a “late bloomer.” But delayed puberty doesn’t just mean a late start. It can also mean puberty starts on time but then stops or slows down so your child doesn’t complete all the stages as expected.

Delayed puberty often runs in families, and there’s no underlying medical issue that’s causing it. It’s just the way your child’s body is wired. In some cases, though, delayed puberty is a sign of a medical condition that needs treatment.

What age is considered delayed puberty?

It varies by sex. Here are the definitions healthcare providers use:

Delayed puberty in females:

• Breasts don’t begin developing by age 13

OR:

• Menstruation doesn’t begin by age 15 or within three years of breast development

Delayed puberty in males:

• Testicles don’t begin enlarging by age 14

OR:

• It’s been at least five years since testes began enlarging, but puberty isn’t complete yet

Signs and symptoms of delayed puberty

Lack of breast development and testicular growth are the main signs of delayed puberty. Other possible signs include:

• Your child is shorter than expected for their age. This is because puberty comes with a growth spurt that your child hasn’t hit yet.
• Your child’s bones aren’t as mature as expected for their age (delayed bone age). This is something only a provider can notice through an X-ray.
• Your child doesn’t develop pubic hair.

It’s possible for your child to have pubic hair but still meet the definition of delayed puberty. They might also have underarm hair or begin to have body odor. These features are part of a natural process called adrenarche, which happens before puberty. The hormones that jumpstart adrenarche are different than the ones that control puberty. So, your child might go through adrenarche but still not start puberty at the expected time.

What is the most common cause of delayed puberty?

The most common cause of delayed puberty is a harmless gene variant. In other words, delayed puberty runs in the family. Some kids inherit genes that tell their bodies to start puberty a bit later than expected. There’s nothing wrong with your child’s organs, glands or hormones. Everything is capable of working just fine. Your child’s body is just following a different schedule from most other kids.

Constitutional delay of growth and puberty (CDGP) is the medical name for this inherited tendency. Some providers prefer to call it self-limited delayed puberty. Puberty will still happen and proceed normally without medical treatment.

But sometimes, other things can be happening in your child’s body that affect when puberty starts or how it progresses. These causes of delayed puberty typically need treatment.

Other causes of delayed puberty

There are many other possible causes of delayed puberty, including:

• Addison’s disease
• Chronic kidney disease
• Cystic fibrosis
• Genetic disorders, including chromosomal disorders like Turner syndrome and Klinefelter syndrome
• Excessive exercise, which can greatly reduce body fat and disrupt hormone function
• Growth hormone deficiency
• Hypothyroidism
• Inflammatory bowel disease
• Malnutrition from various causes, including eating disorders
• Medications or treatments, including corticosteroids, chemotherapy or radiation therapy
• Trauma to your child’s brain or sex glands (testes or ovaries)
• Tumors affecting your child’s brain or spinal cord
• Type I diabetes

You might wonder how such a wide variety of things can affect puberty. The answer has to do with hormones.

The role of hormones in delayed puberty

Hormones are chemical messengers that work behind the scenes to make puberty start and continue. Endocrine glands release these hormones. Your child might notice changes to their body, like breast development or underarm hair. But here’s what you can’t see:

• Your child’s hypothalamus (part of their brain) makes and releases gonadotropin-releasing hormone (GnRH).
• GnRH tells your child’s pituitary gland to make and release luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Together, these are known as gonadotropins.
• Gonadotropins tell your child’s sex glands (ovaries or testes) to release sex hormones (estrogen or testosterone). The release of these sex hormones causes the physical signs of puberty, like breast or testicle growth.

That’s a big team of glands and hormones. And anything that affects one teammate can have a ripple effect. Healthcare providers use these terms to describe what’s happening behind the scenes with delayed puberty:

• Hypogonadotropic hypogonadism. Your child’s hypothalamus or pituitary gland isn’t working right. They’re not making or releasing enough hormones. This is often due to a medical condition. And once providers treat that condition, puberty can proceed normally. Intense exercise and malnutrition are other common causes.
• Hypergonadotropic hypogonadism. Your child’s hypothalamus and pituitary gland are working fine. But their sex glands (testicles or ovaries) aren’t. This is what happens in children with Turner syndrome and Klinefelter syndrome. It can also occur as a complication of cancer treatments or for other reasons.

How doctors diagnose this condition

Healthcare providers diagnose delayed puberty by:

• Doing a physical exam
• Talking to you about your child’s medical history and their biological family history
• Running some tests

One of the main things providers will want to know is if delayed puberty runs in your child’s biological family. If so, then it’s likely that your child is a “late bloomer,” and there’s no medical condition that’s causing the delay.

But providers often run tests to rule out other causes of delayed puberty, even if they think it just runs in the family. This is because constitutional delay of growth and puberty is what providers call a “diagnosis of exclusion.” This means the only way to know that’s what’s happening is by ruling out all other possible scenarios.

Tests are also important in situations where delayed puberty doesn’t run in the family and providers are trying to figure out the cause.

Tests to diagnose delayed sexual development

Possible tests include:

• Blood tests to check hormone levels and look for signs of certain medical conditions
• Genetic testing to look for gene changes known to cause delayed puberty
• Imaging tests, like MRI or ultrasound, to diagnose or rule out certain conditions

Your pediatrician may refer you to a pediatric endocrinologist or other specialists to help with diagnosis and treatment.

How is delayed puberty treated?

Treatment depends on what’s causing the delay. Your child’s care team might recommend:

• A “wait and see” approach. This is a common approach for adolescents with no medical conditions or other known causes for the delay. Providers want to see if puberty can start naturally on its own. If so, then your child likely won’t need any treatment and puberty should progress as expected.
• Treatment for medical conditions. If a specific condition is causing the delay, providers treat that condition. This should help puberty start and continue as expected.
• Hormone replacement therapy. Your child might need medicines that give them hormones (testosterone or estrogen) if their body isn’t able to make enough to support puberty. Your child’s care team will explain how long they’ll need hormone therapy based on their unique needs.

Adolescents who appear to be “late bloomers” without a known medical cause don’t need hormone therapy. But it may be an option if delayed puberty is very upsetting for your child. Some teens have a hard time waiting for puberty to happen, and the delay might cause social issues or affect their self-confidence. If you’re concerned this is happening with your child, talk to their care team.

When should I seek medical care for my child?

Take your child to their routine well-checks and share any concerns with your pediatrician. They’ll check your child’s growth and development and may ask some questions about family history. If your child doesn’t start puberty at the expected time, your pediatrician will explain what tests and follow-ups they might need.

Care for your child’s mental health

Delayed puberty can take a toll on your teen’s mental health — and at a time when they’re already going through lots of emotions and changes. You may want to arrange for your child to speak with a therapist. Therapy may help your child work through their feelings about puberty and anything else that’s on their mind.

What questions should I ask my child’s healthcare providers?

Puberty is a unique experience for every child, whether it happens “on time” or later than expected. Your pediatrician and any specialists providing care can share details specific to your child. Here are some questions to start the conversation:

• How can I know if my child is starting puberty?
• How can I know if puberty has stopped moving along as it should?
• Does my child have delayed puberty? If so, what signs show this?
• Does my child need any tests?
• Do you recommend any treatments?
• How can I best support my child?

What can I expect if my child has delayed puberty?

Your child’s care team can tell you more about what you might expect based on the causes of delayed puberty and any treatments your child receives. It’s hard to predict when puberty will begin. Adolescents with constitutional delay of growth and puberty typically start puberty by age 18. But your child may start much sooner than this. Each child’s experience is a little different.

Just remember that delayed puberty is temporary and, if necessary, treatable.

Does delayed puberty make you taller?

It’s difficult to predict how delayed puberty might affect your child’s adult height. Some adolescents reach an adult height that’s shorter than expected based on their biological parents’ height. But for other adolescents, delayed puberty doesn’t seem to affect their adult height.

Providers sometimes do an imaging test called a bone age X-ray to help predict your child’s adult height. Your pediatrician can tell you more about this test and what it shows.

Does melatonin delay puberty?

Melatonin may delay puberty, but we need more research to know for sure. Researchers continue to study the adverse (unwanted) effects of melatonin treatments on kids and adolescents. Talk to your pediatrician about the benefits and risks of melatonin for your child.