Delayed Puberty in Children

00:01 So causes of delayed puberty in boys are multiple, but generally if they are central they are more likely to be a cancer.

00:14 In boys, we're gonna suspect this if there is no testicular enlargement after 14 years of age.

00:22 In girls, we're gonna suspect delayed puberty if there's no thelarche by the age of 13.

00:28 So boys are allowed the next 3-year delay.

00:31 They start later, they finish later.

00:34 Keep in mind though that 2.5% of healthy boys and girls do have delayed puberty We're using this cut-off so that we can check kids as early as we can without having to test too many children.

00:47 So what are the types of delayed puberty? Well, we have constitutional delay.

00:53 This is by far the most common.

00:55 These are simply children who are having their puberty later.

00:59 Much like they might have a later growth spurt.

01:02 This is common if there is a family history of delay, if the parents don't have a delay on their pubertal development, or also in children who have excessive exercise or work very hard at the sports. Sometimes this will happen.

01:15 There may be a problem with the gonadotropin.

01:18 The gonadotropins are FSH and LH.

01:21 This would be hypogonadotrophic hypogonadism.

01:25 In other words, their gonads are less productive because of a hypogonadotrophic state.

01:30 This is a problem with the brain or they might have primary gonadal failure which is hypergonadotrophic hypogonadism.

01:38 This is because they have lots of gonadotrophs and very little response.

01:43 So let's drill down on causes of hypogonadism.

01:48 When the gonadotropins are the problem, there are some central issues that we might see.

01:56 One classic example is Kallmann syndrome.

01:59 This is an isolated deficiency in the pituitary and also these patients often have anosmia.

02:07 So, they are not smelling very well because of the problem with the first cranial nerve and they will have isolated deficiency of production of their gonadotropins.

02:16 This can be functional as well, patients with eating disorder, excessive exercise, some of our real-star athletes, will have a delay in their puberty and that's a central process.

02:28 Remember the 'athlete triad' in girls: the female athlete triad is a combination of three conditions: disordered eating, amenorrhea, and osteoporosis.

02:39 Like we stated in boys, often it is a pituitary lesion so we need to worry about pituitary lesions in these children.

02:47 And certainly, we would worry about it in a child who has a history of pituitary surgery.

02:52 Remember, resection of pituitary adenomas carries with it about a 15% chance of being having problems with pituitary endocrine function afterwards.

03:04 Flip side, if there's primary gonadal failure we have to think about some other potential causes of what's going on.

03:12 There are some genetic causes such as Klinefelter's, which is XXY or Turners syndrome which is just one X.

03:20 And in both those genetic situations, children have a decreased responsiveness of their gonads to the gonadotropin that's trying to get them stimulated.

03:31 Also, patients may have a history of a radiation of the testis, or chemotherapy, or rarely children can have autoimmune ovary disease which will result in a hypogonad state where there is hypergonadotropic levels of hormone, FSH and LH, which are trying to stimulate a diseased ovary.

03:52 So if we have delayed puberty in a healthy child, we're going to check LH, FSH, estradiol in girls, and testosterone in boys.

04:03 If the child has a concern, it's gonna be largely guided by our exam.

04:08 What is the problem? Consider thyroid hormone levels, prolactin levels, and CBC, and sed rate as a way of measuring chronic malingering condition.

04:19 Delayed puberty, if there's constitutional delay we're gonna manage it simply by reassurance.

04:27 Eventually your child is gonna have their period, don't you worry about a thing.

04:31 For boys, we typically treat this with testosterone injections.

04:36 Typically, this happen about once a month. It's not too troublesome.

04:41 Families don't usually have a problem with it but it is expensive and so you probably will have to document testosterone deficiency prior to the insurance company being willing to pay for the therapy.

04:51 For girls with delay, you can consider initiation of estrogen therapy.

04:57 Usually, we simply put them on an estrogen pill like an oral contraceptive pill and that will start to promote the puberty and get them regular.

05:05 So that's all I have today about delayed puberty and how we deal with that problem.

05:11 Thanks for your attention.