Delayed sexual development is a big problem for teens. Due to the lack of pubertal symptoms, they feel alienated and stand out from the group of peers. They may develop mood disorders and depression. Low levels of sex hormones lead to growth inhibition and infertility. Learn about the causes, symptoms and treatment options for delayed puberty.
Delayed sexual development
Delayed puberty (code ICD-10 - E30.0) occurs if the first symptoms of puberty (breast enlargement and an increase in the volume of the ovaries or testicles) do not appear in girls after 13 years and in boys after 14 years. Maturation is also considered delayed when the first symptoms of puberty occurred at the right time, but have not developed since. Such patients may have pubic and axillary hair, because their development depends on the androgens produced in the adrenal glands.
Delayed puberty: classification
Delayed sexual development in children can be caused by genetically caused diseases (syndromes) or can be acquired. The classification of delayed sexual development is as follows:
- Hypergonadotropic hypogonadism is the cause of the problems - damage to the gonads: testicles or ovaries. Although the hypothalamus and pituitary gland produce their hormones (GnRH, FSH, and LH), damaged gonads are not able to produce sex hormones. Hypergonadotropic hypogonadism is always permanent.
- Hypogonadotropic hypogonadism - delayed sexual development in children appears due to damage or inhibition of the function of the hypothalamus or pituitary gland. Although the ovaries and testes are capable of secreting sex hormones, due to the lack of FSH and LH, they cannot assume the function of producing these hormones. Hypogonadotropic hypogonadism may be temporary.
Reasons for delayed sexual development
The most common reason for delaying puberty is the so-called constitutional growth retardation and maturation, which is classified as hypogonadotropic hypogonadism. It is observed in approximately 0.6-2% of children. This is a physiological variant of normal puberty.
From about 5 years old, a child begins to grow more slowly than his peers. His body begins to properly develop and grow later than that of peers (usually from 14 to 17 years old). However, the ripening process remains correct.
The constitutional delay in sexual and physical development is determined genetically, very often the child's parents also mature late. Therefore, the medical history is important in the diagnosis. Information that the mother had her first menstruation at a later age than most of her peers, and her father began to grow at 15-16 years old, may indicate a constitutional delay in the growth and maturation of the child.
Hypergonadotropic hypogonadism can be caused, inter alia, by the following pathologies:
- Turner syndrome - the syndrome is caused by the absence or damage of the X chromosome. This leads to abnormal development of the ovaries, which are not able to produce sex hormones. Women reach short stature (average 143 cm) and suffer from infertility. Turner syndrome is one of the most common causes of delayed sexual development in girls.
- Klinefelter's syndrome is a syndrome caused by the presence of an additional X chromosome in boys. At the same time, men achieve very high growth, have a female silhouette and are infertile. Initially, puberty in boys with Klinefelter syndrome may be normal, but testosterone levels are rapidly declining and puberty is suppressed. The testicles do not increase in size. Klinefelter syndrome is one of the most common causes of delayed sexual development in boys.
- Ovarian insufficiency - the ovaries are deprived of reproductive cells, they produce a small amount of estrogen. The silhouette of the body is correct, the chest is underdeveloped. Infertility occurs.
- Congenital missing testes - developmental disorder leads to the fact that the boy does not develop testicles. Another reason for the delay in male sexual development.
- Complete testicular atrophy - they may disappear as a result of trauma or untreated keratoplasty.
- Cryptorchidism - the testes are located in the inguinal or abdominal canal, and not in the scrotum. Untreated cryptorchidism leads to irreversible damage to the testicle and delayed sexual development.
- Damage to the testicles or ovaries as a result of radiation therapy in the pelvic area or cytostatics (anti-cancer drugs).
Hypogonadotropic hypogonadism may be the result, among other things:
- Constitutional growth retardation and maturation.
- Malnutrition and / or excessive physical exertion. Inadequate delivery of calories to the body can be caused by anorexia nervosa or a chronic, debilitating disease. This leads to a temporary inhibition of FSH and LH secretion by the pituitary gland. After filling in the deficiencies in nutrition and avoiding physical overwork, the function of the pituitary and gonads returns to normal. And as a result, further delay in puberty in a teenager is excluded and good puberty becomes possible.
- Damage to the hypothalamic-pituitary region. Damage can be caused by cancer (especially the so-called craniopharyngioma), which develops in this area, the inflammatory process (during meningitis and inflammation of the brain) or trauma. Radiation therapy of the head area can also lead to damage to the hypothalamus and pituitary gland.
- Disorders of the development of the central nervous system. Abnormal growth of the hypothalamus or pituitary gland prevents the production of hormones. The most common pathology associated with the impaired development of this area is Callman's syndrome. In addition to inadequate secretion of GnRH in the hypothalamus, olfactory deterioration is also observed.
- Genetic disorders associated with the occurrence of various syndromes. These syndromes are very rare, in addition to other symptoms, they also include a violation of the secretory functions of the hypothalamus and pituitary gland.
Delayed puberty: types of maturity
Sexual maturation (puberty) is a period in a person’s life in which significant changes occur leading to maturity. There are several areas of development in which a person reaches maturity. They include:
- Physical maturity. This is the end of the development of the size and proportions of the body and the acquisition of the ability to reproduce (the so-called puberty).
- Mental maturity. It includes, in particular, the formation of the character of a given person, the acquisition of the ability to control their behavior and emotions, taking responsibility for their actions.
- Social maturity. It determines the ability to fulfill the relevant roles in society (parent, employee, etc.).
Ripening process
The process of puberty is extended over time (for girls it takes an average of 4 years, for boys - 6-7 years). The speed of this process and the age at which subsequent changes occur are very diverse among individuals and depend on many factors.
An important role is played by genetic factors - often the same maturation of parents and children is observed (the age of the first menstrual period in girls is especially the same). The place of residence (the first menstruation in girls living in big cities, occurs earlier than in those living in villages) and socio-economic status also play a role.
The tables below show the approximate course of changes occurring during puberty in girls and boys. The so-called typical age, that is, the one in which the observed symptoms of puberty most often occur statistically. It should be added that deviations from these values may be something normal for a given person and are not always associated with pathological delay in sexual development in girls and boys.
The process of puberty in girls
Girls puberty is a change in the developmental processes of the teenage girl’s body, which leads to the maturation and reproductive function. The start of these processes is carried out using signals sent by the brain to the sex glands of girls - the ovaries.
Typical age, years | Observed changes |
9-12 | Breast development begins. On the labia there is only straight hair. During this period, there is also a growth spurt (accelerated growth rate) with a peak at the age of about 12 years. Peak growth usually occurs a year before the start of the first menstrual cycle |
12-14 | Further development of the breast, external genitalia (large and small genital organs, clitoris) and pubic hair continues. On average, within 2 years from the beginning of the development of the mammary gland, the first menstruation (the so-called menarche) occurs. Cycles can be regular (but not necessary), regular, and anovulatory. After 2-3 years, the menstrual cycle should stabilize. During this period, the growth rate decreases - the average increase in body height after the first menstrual cycle is 6 cm. The silhouette of the body becomes more feminine, the width of the hips increases |
12-16 | The chest, external genitalia, pubic and axillary hair slowly acquire a typical developed appearance, as in adults. Adipose tissue "settles" on the buttocks and hips, giving the figure a female form. The imbalance between the length of the limbs and the torso disappears |
Boys ripening process
During puberty, boys may experience gynecomastia or breast enlargement. This phenomenon is observed in 30% of boys. Gynecomastia usually disappears spontaneously within a few months and is a physiological phenomenon in this period of the boy’s life.
Typical age, years | Observed changes |
10-13 | The testicles increase in volume. The skin covering the scrotum is thin, pink. The genitals are growing. Single straight hair appears at the base of the external genitalia. During this period, a growth spurt is also observed - growth rates are accelerating |
13-15 | Sperm are produced in the testes. At the age of about 14, there is a peak in growth (the largest annual increase in growth). The silhouette of the body changes, the width of the shoulders and torso increases. During this period, a change in voice or its mutation also begins. The laryngeal parts develop. This may be accompanied by impaired voice, often hoarseness. The mutation lasts about 1 year. |
15-17 | Male genital organs finally develop. The final testicular volume in Europeans is from 12 to 30 ml. Growth rates are declining. There is hair on the face, limbs and torso |
Sexual maturation: hormonal changes
Sexual maturation is associated with the influence of sex hormones produced in the gonads - ovaries and testicles. The ovaries produce estrogens and progesterone, and the testes produce mainly testosterone. The adrenal glands produce a certain amount of sex hormones (mainly the so-called male androgens). They play a role in the development of axillary and pubic hair. The secretion of sex hormones in the gonads is controlled by two organs located in the brain: the hypothalamus and the pituitary gland. The hypothalamus (starting from puberty) produces gonadoliberin (the so-called GnRH) in a pulsating manner. GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinotropin (LH). They, in turn, affect the testes and ovaries, i.e., the secretion of sex hormones.
Certain scales are used to evaluate puberty. The degree of development of sexual characteristics (testicles, penis and scrotum of boys, breast in girls and pubic hair in both sexes) is determined using the Taner scale. An important role is also played by the so-called bone age. On the basis of the x-ray of the left wrist, the presence of the so-called bone ossification is observed. The resulting image is compared with drawings from special atlases. The bones appear in a strictly defined order, thanks to which they are a good tool for assessing the stage of maturation of the skeleton of children and adolescents.
When to go to the doctor?
If parents suspect that their child may suffer from delayed sexual development, they should contact their pediatrician. The medical history should answer the question of whether the child really has any symptoms of puberty deviation and determine how the maturation occurred in the parents. Observation of the child and physical examination can reveal the characteristics of a particular body (for example, Turner or Klinefelter).
For accurate diagnosis and determination of signs of delayed sexual development, hormonal tests are needed (estrogen, progesterone, LH, FSH are determined and stimulation tests are performed). Sometimes imaging methods, such as CT or head MRI, pelvic ultrasound, are necessary. Genetic studies should also be carried out, in particular, the determination of the so-called karyotype (image of a complete set of chromosomes) is necessary for the recognition of Turner and Klinefelter syndrome. In the case of other genetic diseases, appropriate studies are being conducted to identify specific mutations.
Delayed puberty: treatment
Treatment for delayed sexual development depends on its type.
With hypogonadotropic hypogonadism, treatment includes the introduction of sex hormones. In girls, therapy begins with small doses of estrogen (preferably in the form of patches). Thanks to this, the shape of the breast and the female body will develop. After the onset of menstruation, a drug containing progesterone should also be taken. In boys, the treatment is to provide the body with testosterone.
Treatment for hypogonadotropic hypogonadism also includes the administration of sex hormones. In addition, the use of chorionic gonadotropins or human menopausal gonadotropins leads to an increase in testicular volume, and, as a result, there is no further delay in sexual development in men.
Since hypergonadotropic hypogonadism is associated with damage to the gonads - the testes and ovaries, patients cannot produce reproductive cells (sperm or egg). Despite the replacement of sex hormones (which allow you to get the right body shape and other characteristics specific to a particular sex), patients remain infertile.
Hypogonadotropic hypogonadism can be completely reversible. Removing a factor that causes inhibition of hormone secretion in the hypothalamus and pituitary gland (for example, the correct supply of calories, removal of the tumor without damaging the surrounding tissues), or the corresponding supply of sex hormones allows the child to develop properly and avoid delayed sexual development.
However, it should be remembered that some congenital malformations or genetically caused syndromes may be associated with the appearance of a number of other abnormalities that cause growth disorders, physical and mental maturation.