Taking Charge of Your Health

Puberty is the time in an individual’s life
when they physically become sexually mature and able to have children. Generally speaking, it’s considered delayed
if puberty hasn’t started for a female by age 13 and for a male by age 14. The hypothalamic-pituitary-gonadal axis is
a system of hormonal signaling between the hypothalamus, pituitary gland, and gonads,
the gonads are either the testes or the ovaries, and this will control sexual development and
reproduction. Gonadotropin-releasing hormone is released
into the hypophyseal portal system, which is a network of capillaries connecting the
hypothalamus to the hypophysis, or pituitary. When gonadotropin-releasing hormone reach
the pituitary gland, it stimulates cells in the anterior pituitary, called gonadotrophs,
to release gonadotropin hormones: luteinizing hormone and follicle-stimulating hormone which
then enter the blood. These gonadotropin hormones then stimulate
the gonads to produce sex specific hormones. These are estrogen and progesterone in females
and testosterone is the major sex specific hormone in males. Early on in male development, testosterone
helps the external sex organs to differentiate into male genitals and causes the testes to
descend from the abdomen into the scrotal sac. Beginning at puberty, the Leydig cells of
the testes respond to the luteinizing hormone by converting more cholesterol into testosterone. In addition, the Sertoli cells of the testes
respond to follicle-stimulating hormone by producing more sperm. The major sex specific hormones in women are
estrogen and progesterone. Beginning at puberty, the theca cells of the
ovary respond to luteinizing hormone by producing progesterone and androstenedione. Then, follicle stimulating hormone causes
the granulosa cells convert the androstenedione into estrogen. Waves of estrogen and progesterone regulate
monthly changes to the ovary stroma to promote egg maturation and ovulation, and as well,
it changes to the uterine wall lining as part of the menstrual cycle. The increased production of sex hormones drives
the development of primary and secondary sex characteristic that we see during puberty. Primary sex characteristics refers to the
genitals, which are the organs directly involved in sexual reproduction. Secondary sex characteristics refers to any
sex-specific physical characteristic that is not directly involved or necessary in sexual
reproduction, like pubic hair and breasts, in females. The Tanner scale, or Tanner stages, is a predictable
set of steps that males and females go through as they develop primary and secondary sex
characteristics and become sexually mature. The Tanner scale centers on two, independent
criteria: the appearance of pubic hair in both sexes; and the increase in testicular
volume and penile size and length in males, and breast development in females. There are five stages:
In stage 1, the pre-pubertal stage, no pubic hair is present in either sex. Males have a small penis and testes. Females have a flat-chest. In stage 2, pubic hair appears and there’s
a measurable enlargement of the testes; and breast buds appear. In stage 3, pubic hair becomes coarser; the
penis begins to enlarge in both size and length; and breast mounds form. In stage 4, pubic hair begins to cover the
pubic area; the penis begins to widen; and breast enlargement continues to form something
called a “mound-on-mound” contour. In stage 5, pubic hair extends to the inner
thigh; the penis and testes have enlarged to adult size; and the breast takes on an
adult contour. Puberty is delayed if progression through
the Tanner scale hasn’t begun by the time 95% of an individual’s peers have begun
to sexually mature. Generally, that means puberty has not started
by age 13 in females and age 14 in males. Hypogonadism, or lower levels of sex hormones
from low gonad activity, is central to a delay in puberty. As a result, sex characteristics are under-developed. Permanent infertility can occur if puberty
never begins or fails to complete and sexual maturity is never reached. There are two main causes of hypogonadism. The first is primary hypogonadism which is
caused by dysfunction of the gonads – for example, the gonad’s receptors may not respond
to gonadotropin hormones, or the gonads might not have healthy cells that are capable of
producing hormone. Some acquired causes of primary hypogonadism
are radiation therapy, chemotherapy, and trauma to the gonads. Some congenital causes of primary hypogonadism
are genetic diseases like Klinefelter or Turner syndrome. Regardless of the cause, the result is a decrease
or absence of testosterone in males, or estrogen and progesterone in females, which means there’s
no negative feedback on the hypothalamus. This leads to an overproduction of luteinizing
and follicle stimulating hormones so primary hypogonadism is also called hypergonadotropic
hypogonadism. The second cause of hypogonadism is secondary
hypogonadism, which is also called hypogonadotropic hypogonadism because there are low levels
of luteinizing and follicle stimulating hormones. Secondary hypogonadism can be due to hypothalamus
or pituitary gland dysfunction; either from an inability to produce gonadotropin-releasing
hormone or luteinizing and follicle stimulating hormones, or suppression from other hormones,
like prolactin or thyroid hormone. Some acquired causes are similar to primary
hypogonadism, radiation therapy, chemotherapy, and trauma to the gonads. Other ones include a tumor of the pituitary
gland and hypothalamus, and congenital causes include Kallmann syndrome and panhypopituitarism. And general causes include chronic illness,
like cystic fibrosis or celiac disease, excessive exercise, malnutrition or obesity, and stress
– all of which affect the way the hypothalamus and pituitary release hormones. A third category, called constitutional delay,
is a temporary delay in puberty which does not typically result in infertility. Just like in secondary hypogonadism, there’s
a lack of gonadotropin-releasing hormone, but the key difference is that it’s not
considered pathologic – instead, it’s thought to be a naturally slowed rate of maturation. The onset of puberty can still occur naturally
and puberty can progress normally after onset, it just all happens at a later age. Typically, there’s a genetic component to
constitutional delays and it runs in families. A delay in puberty is usually diagnosed by
comparing an individual’s sexual development with the Tanner scale. Blood tests of hormone levels can give an
idea of the type of hypogonadism. And a detailed medical history, including
evaluating any underlying medical conditions and family history for constitutional delay
can be helpful. The treatment for a delay in puberty depends
on the cause. A constitutional delay can resolve on its
own with a natural onset of puberty, and does not typically require medical intervention. If an underlying medical condition is the
cause, hormone therapy is necessary to ensure the onset and normal progression of puberty. Infertility treatments may also be needed
to make reproduction possible. So, to recap: Delayed puberty usually means
that it hasn’t started for a female by age 13 and for a male by age 14. Though there are different causes which result
in different levels of gonadotropin hormones, they all ultimately result in hypogonadism
and a deficiency in testosterone or estrogen and progesterone. In contrast, a constitutional delay is when
the onset of puberty might still occur naturally with puberty progressing normally after onset,
but it just occurs at a later age.

38 thoughts on “Delayed puberty – causes, symptoms, diagnosis, treatment, pathology

  1. Someone help, I'm gonna turn 14 in exactly a month, I can't produce sperm and my height is exactly 5 foot. I have very less body hair but I think that's genetical, I am stage 2 and my voice is high to normal. I feel like I'm never gonna hit it or I will be infertile !!!

  2. I started hitting pubert around 14. I'm 16 right now, almost 17, and I'm only on tanner stage 3 fml

  3. I'm 15, but I look like I'm 8 years old. I don't know how much longer I can take. I just really don't feel like living right now.

  4. when puberty hit me my cock started doing push ups every morning and making me look like ah twat in public especially at swimming pools lol

  5. Well I'm 13 and i don't have my period yet, and im only on stage 2 of my boobss but I'm stage 3 of pubic hairr so yeah idk if it is normal that it takes so much timee

  6. Am 12 and probably 4,8 and i haddent hit puberty 🙁 and at my school iam one of the shortest am in midfle school about to go to 7 and a have a sqeacky voice

  7. I’m only at stage two (in woman)when I’m turning 13 in December , all my friends have started and even gave their period or are more devolved in the chest area. Am I normal ?

  8. Everyone in the comment section be like "I'm 12 and I didn't reach puberty" yet I'm 24 YEARS OLD male and I sometimes sound like Spongebob or a genderless 18 year old.

  9. Im 13 running 14.. I didnt had menstruation and breast.. I feel so jelious to those girls who s younger thn me who already hits there puberty.. What should i do

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