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.