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Diagnosis and treatment of delayed puberty

William F Crowley, Jr, MD
Nelly Pitteloud, MD
Section Editors
Peter J Snyder, MD
Amy B Middleman, MD, MPH, MS Ed
Mitchell E Geffner, MD
Deputy Editors
Alison G Hoppin, MD
Kathryn A Martin, MD


Delayed puberty is defined clinically by the absence or incomplete development of secondary sexual characteristics bounded by an age at which 95 percent of children of that sex and culture have initiated sexual maturation. The clinical staging of puberty is performed by the criteria established by James Tanner. According to the National Center for Health Statistics, the upper 95th percentile in the United States for age for boys is 14 (ie, an increase in testicular size being the first sign) and for girls is 12 (breast development being the first sign) (table 1). (See "Normal puberty".)

Delayed puberty usually results from inadequate gonadal steroid secretion which, in turn, is most often caused by a defective gonadotropin secretion from the anterior pituitary, due to defective production of gonadotropin-releasing hormone (GnRH) from the hypothalamus, the key functional defect in patients with constitutional delay of puberty. It can, however, also be caused by a variety of hypothalamic, pituitary, and gonadal disorders. (See "Evaluation and management of primary amenorrhea".)


Dating back to the time of Fuller Albright and his colleagues, it has been useful to classify the syndrome pathophysiologically according to the circulating levels of the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) (table 2):

High serum concentrations of LH and FSH are associated with various causes of gonadal disease, called primary hypogonadism and/or defects in their receptors on the membrane of the gonadal cells. (See "Causes of primary hypogonadism in males" and "Pathogenesis and causes of spontaneous primary ovarian insufficiency (premature ovarian failure)".)

Low or normal serum LH and FSH concentrations are associated with various causes of diminished GnRH-induced gonadotropin secretion, called secondary hypogonadism. This defect can be because of hypothalamic dysfunction (either anatomic or functional), hypopituitarism, hypothyroidism, or hyperprolactinemia. (See "Causes of secondary hypogonadism in males".)

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Literature review current through: Oct 2017. | This topic last updated: Mar 03, 2016.
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