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Late Puberty

Late puberty (delayed puberty) is when the body's timing for sexual maturity is later than usual. The concern may be that puberty hasn’t started or that it stalled after it started.

For many teens, puberty just happens later. There’s no medical problem. Later puberty is normal in many families. Signs that the delay may be due to a disease include an abrupt change in growth or arrested development, in which puberty starts then stalls. Headaches, vision problems and other neurological symptoms might mean there’s a problem in the central nervous system. In case a medical condition is causing the delay, a teen who is late in experiencing puberty should see a doctor. Concerned parents can make an appointment with the specialists in our Division of Endocrinology.

Negative social and psychological effects are another reason families seek medical help. Among peers, the teen may feel pressure for not developing like others. The teen may also be noticeably shorter than others. The teen may need help coping with and managing social problems and concerns.

For some older teens, the doctor may advise “jump starting” puberty with a few months of hormone therapy. More often, the teen needs solid reassurance that the body is getting ready to mature sexually.

A pediatric endocrinologist is an excellent resource to families concerned about a late puberty. Your pediatrician may refer you if there are any concerns about the teen’s development or well-being. Talk to your pediatrician if you have a concern.

Expected Changes

  • Girls:  Develop breasts, grow pubic hair and underarm hair and start menstruating (having periods). Their hips widen and they have a growth spurt.
  • Boys: Grow pubic, facial and underarm hair. Their testicles and penis get larger. Their shoulders widen, their bodies become more muscular and they have a growth spurt.

Puberty happens over several years. The age at which it starts and ends varies widely. 

Caus​es

Usually, a delay in starting puberty is quite normal. By determining what’s causing the delay, the pediatric endocrinologist learns if there is an underlying medical condition and what treatment can help.

  • Constitutional delay: Some teens are just late bloomers (late in developing). This “constitutional delay” of growth, development or puberty is the most common reason puberty is overdue, especially in boys.
  • A medical condition: A chronic disease — such as diabetes, cystic fibrosis, celiac disease, kidney disease or asthma — can delay puberty. A common culprit is malnutrition, which may be due to a medical condition, eating disorder or medication (for attention deficit hyperactivity disorder, for example). Other conditions that interfere with puberty include genetic disorders, chromosome abnormalities and tumors.
  • Certain medicines: Some chemotherapy and psychiatric medicines can delay puberty.

Typ​es

The problem may be in the ovaries or testicles, or in the parts of the brain involved in sending hormones to them — the hypothalamus and pituitary. We call these two types primary and secondary hypogonadism.

Primary Hypogonadism

This is when the sex glands don’t make enough or don’t make any sex hormones. In affected boys, the testicles don’t make testosterone well. In affected girls, the ovaries don’t make estrogen well. The cause may be one of these conditions:

  • A genetic disorder (for example, Turner syndrome in girls, Klinefelter syndrome in boys)
  • Certain autoimmune disorders
  • A developmental disorder
  • Radiation or chemotherapy
  • An infection
  • A surgery

Secondary (Central) Hypogonadism

In these types of hypogonadism, the ovaries or testicles (the gonads) aren’t the problem; the hypothalamus or pituitary gland in the brain is. The gonads don’t get the message to secrete hormones because of a problem earlier in the chain of commands.

  • The hypothalamus: At the start of the process, the hypothalamus may be making too little or no gonadotropin-releasing hormone (GnRH)
  • The pituitary: The middleman, the pituitary, may be making too little follicle-stimulating hormone (FSH) or luteinizing hormone (LH)

Diagnosis

At your first visit, the pediatric endocrinologist listens to your concerns. The doctor learns your medical history and does a physical examination. Late puberty often can be diagnosed with a physical exam. The doctor can order blood tests and imaging tests to look for the cause. 

We take a careful history. When did the mother and father start puberty? At what age did developments occur (pubic hair, acne, underarm hair, body odor, breast development or increase in testicular size)? Are there other medical conditions? Allergies? Recent changes in weight or height? Any history of headaches, vision changes or changes in the ability to smell? Is the child able to eat enough?

A thorough physical examination includes the genitalia (private areas) and breasts (for girls’ development). The doctor looks for the stages and signs of puberty. The exam is done with sensitivity and respect for the teen’s privacy and comfort. The endocrinologist may notice important things the pediatrician did not. Often, the endocrinologist can reassure the teen by noting the changes that are happening.

We can learn the amount of hormones made in the brain and in the ovaries or testicles through blood tests. Hormone levels are best checked in samples of blood collected in early morning (because hormone levels change throughout the day). So a blood draw is usually separate from your first visit. We use a karyotyping test if chromosome damage is a concern.

We can use other tests as needed. If we need more information on puberty hormones from the brain, we can do a stimulation test. The tests helps identify late developers (teens with constitutional delays). This test requires careful medical supervision. You come to the infusion center at the hospital, and a child life specialist helps you through the experience. We usually administer a hormone or other stimulating agent and take blood samples at intervals for testing.

We can also use imaging procedures such as an ultrasound. It shows the size and appearance of ovaries or testicles. An MRI scan lets us see inside the brain, to the pituitary gland where LH and FSH are made. The scan can show us a tumor or other abnormality in the pituitary gland — without exposing the teen to radiation. Medicine lets the patient sleep comfortably while we get the picture.

We can use this a bone age x-ray (of the hand and wrist) to see how mature the bones are. The bones’ “age” tells us, better than the teen’s age, if it’s time for puberty in the body.

Treatment

The endocrinologist learns if a medical condition is causing the delay — for example, a chronic illness, chromosome abnormality, genetic disorder or tumor. A problem — structural or hormonal —  may be found in the ovaries or testicles or with the pituitary or hypothalamus in the brain.

In most cases, treatment isn’t needed. Usually, families just need the medical assurance that things are okay. The lateness may just be inherited. Our doctors and nurses can suggest strategies to help the teen cope and manage more effectively. Other times, the matter requires or benefits from medical attention. Hormone therapy may help, or surgery if the problem is anatomical. Our care team (endocrinologists, pediatric nurses, advanced nurse practitioners) is very good at explaining what’s happening and what can help.

The endocrinologist helps find the best treatment plan for the teen. A lot of information goes into this. The doctor considers the individual and the condition. The teen’s age, health and medical history and how well this person may tolerate a specific treatment are important. The parents’ perspective is part of the decision making, too.

Hormone Therapy

Estrogen or testosterone medication can “jump start” puberty. In some situations (when the pituitary isn’t working well enough), growth hormone may be appropriate to prescribe. The endocrinologist helps you learn about the appropriateness of each treatment for your situation. Sex hormone therapy can, for example, help a naturally late bloomer who’s troubled by social and emotional difficulties. The therapy helps those whose bodies are unable to make the hormone that’s needed.

  • Girls: If the ovaries aren’t able to make the estrogen needed to start puberty, the girl can begin estrogen medication. This can be pills you swallow or a patch, lotion or gel put on the skin. Puberty then starts. Some girls need the medication through young adulthood.
  • Boys: If the testicles aren’t able to make the testosterone needed to start puberty, the boy can take testosterone medication. This can be a monthly injection or a [daily?] patch, lotion or gel put on the skin for several months. This starts puberty. Some boys need the medication for the rest of their life.

Ongo​ing Care

The Division of Endocrinology cares for teens with concerns about delayed puberty, and our team provides medical care for all forms of delayed puberty. With appropriate assurances and medical attention, teens generally begin and complete puberty in a healthy time frame. The adolescent’s health and well-being are our primary concern.

Resour​ces

Learn more about delayed puberty by visiting these physician-recommended websites:

  • American Academy of Pediatrics
  • Hormone Health Network
  • KidsHealth article on Delayed Puberty
  • National Institute of Child Health and Human Development article on Puberty
  • Society for Endocrinology
  • The MAGIC Foundation for Children’s Growth
    te Puberty 

    Overview
    Late puberty (delayed puberty) is when the body's timing for sexual maturity is later than usual. The concern may be that puberty hasn’t started or that it stalled after it started.

    For many teens, puberty just happens later. There’s no medical problem. Later puberty is normal in many families. Signs that the delay may be due to a disease include an abrupt change in growth or arrested development, in which puberty starts then stalls. Headaches, vision problems and other neurological symptoms might mean there’s a problem in the central nervous system. In case a medical condition is causing the delay, a teen who is late in experiencing puberty should see a doctor.
     
    Negative social and psychological effects are another reason families seek medical help. Among peers, the teen may feel pressure for not developing like others. The teen may also be noticeably shorter than others. The teen may need help coping with and managing social problems and concerns.
    For some older teens, the doctor may advise “jump starting” puberty with a few months of hormone therapy. More often, the teen needs solid reassurance that the body is getting ready to mature sexually.

    A pediatric endocrinologist is an excellent resource to families concerned about a late puberty. Your pediatrician may refer you if there are any concerns about the teen’s development or well-being. Talk to your pediatrician if you have a concern.

    Expected Changes
    •    Girls:  Develop breasts, grow pubic hair and underarm hair and start menstruating (having periods). Their hips widen and they have a growth spurt.
    •    Boys: Grow pubic, facial and underarm hair. Their testicles and penis get larger. Their shoulders widen, their bodies become more muscular and they have a growth spurt.

     
    Puberty happens over several years. The age at which it starts and ends varies widely. Doctors consider puberty developments to be late at the ages listed in the table below.
     


    Signs of Late Puberty
    ANNE GRAPH OR TABLE once CSS is fixed

    Causes
    Usually, a delay in starting puberty is quite normal. By determining what’s causing the delay, the pediatric endocrinologist learns if there is an underlying medical condition and what treatment can help.
    •    Constitutional delay: Some teens are just late bloomers (late in developing). This “constitutional delay” of growth, development or puberty is the most common reason puberty is overdue, especially in boys.
    •    A medical condition: A chronic disease —such as diabetes, cystic fibrosis, celiac disease, kidney disease or asthma — can delay puberty. A common culprit is malnutrition, which may be due to a medical condition, eating disorder or medication (for attention deficit hyperactivity disorder, for example). Other conditions that interfere with puberty include genetic disorders, chromosome abnormalities and tumors.
    •    Certain medicines: Some chemotherapy and psychiatric medicines can delay puberty.

    Types
    The problem may be in the ovaries or testicles, or in the parts of the brain involved in sending hormones to them — the hypothalamus and pituitary. We call these two types primary and secondary hypogonadism.

    Primary Hypogonadism
    This is when the sex glands don’t make enough or don’t make any sex hormones. In affected boys, the testicles don’t make testosterone well. In affected girls, the ovaries don’t make estrogen well. The cause may be one of these conditions:
    •    A genetic disorder (for example, Turner syndrome in girls, Klinefelter syndrome in boys)
    •    Certain autoimmune disorders
    •    A developmental disorder
    •    Radiation or chemotherapy
    •    An infection
    •    A surgery

    Secondary (Central) Hypogonadism
    In these types of hypogonadism, the ovaries or testicles (the gonads) aren’t the problem; the hypothalamus or pituitary gland in the brain is. The gonads don’t get the message to secrete hormones because of a problem earlier in the chain of commands.
    •    The hypothalamus: At the start of the process, the hypothalamus may be making too little or no gonadotropin-releasing hormone (GnRH)
    •    The pituitary: The middleman, the pituitary, may be making too little follicle-stimulating hormone (FSH) or luteinizing hormone (LH)

    Diagnosis and Treatment

    Diagnosis
    At your first visit, the pediatric endocrinologist listens to your concerns. The doctor learns your medical history and does a physical examination. Late puberty often can be diagnosed with a physical exam. The doctor can order blood tests and imaging tests to look for the cause. 
    We take a careful history. When did the mother and father start puberty? At what age did developments occur (pubic hair, acne, underarm hair, body odor, breast development or increase in testicular size)? Are there other medical conditions? Allergies? Recent changes in weight or height? Any history of headaches, vision changes or changes in the ability to smell? Is the child able to eat enough?
    A thorough physical examination includes the genitalia (private areas) and breasts (for girls’ development). The doctor looks for the stages and signs of puberty. The exam is done with sensitivity and respect for the teen’s privacy and comfort. The endocrinologist may notice important things the pediatrician did not. Often, the endocrinologist can reassure the teen by noting the changes that are happening.
    We can learn the amount of hormones made in the brain and in the ovaries or testicles through blood tests. Hormone levels are best checked in samples of blood collected in early morning (because hormone levels change throughout the day). So a blood draw is usually separate from your first visit. We use a karyotyping test if chromosome damage is a concern.

    We can use other tests as needed. If we need more information on puberty hormones from the brain, we can do a stimulation test. The tests helps identify late developers (teens with constitutional delays). This test requires careful medical supervision. You come to the infusion center at the hospital, and a child life specialist helps you through the experience. We usually administer a hormone or other stimulating agent and take blood samples at intervals for testing.
    We can also use imaging procedures such as an ultrasound. It shows the size and appearance of ovaries or testicles. An MRI scan lets us see inside the brain, to the pituitary gland where LH and FSH are made. The scan can show us a tumor or other abnormality in the pituitary gland — without exposing the teen to radiation. Medicine lets the patient sleep comfortably while we get the picture.
    We can use this a bone age x-ray (of the hand and wrist) to see how mature the bones are. The bones’ “age” tells us, better than the teen’s age, if it’s time for puberty in the body.

    Treatment
    The endocrinologist learns if a medical condition is causing the delay — for example, a chronic illness, chromosome abnormality, genetic disorder or tumor. A problem — structural or hormonal —  may be found in the ovaries or testicles or with the pituitary or hypothalamus in the brain.
     
    In most cases, treatment isn’t needed. Usually, families just need the medical assurance that things are okay. The lateness may just be inherited. Our doctors and nurses can suggest strategies to help the teen cope and manage more effectively. Other times, the matter requires or benefits from medical attention. Hormone therapy may help, or surgery if the problem is anatomical. Our care team (endocrinologists, pediatric nurses, advanced nurse practitioners) is very good at explaining what’s happening and what can help.

    The endocrinologist helps find the best treatment plan for the teen. A lot of information goes into this. The doctor considers the individual and the condition. The teen’s age, health and medical history and how well this person may tolerate a specific treatment are important. The parents’ perspective is part of the decision making, too.

    Hormone Therapy
    Estrogen or testosterone medication can “jump start” puberty. In some situations (when the pituitary isn’t working well enough), growth hormone may be appropriate to prescribe. The endocrinologist helps you learn about the appropriateness of each treatment for your situation. Sex hormone therapy can, for example, help a naturally late bloomer who’s troubled by social and emotional difficulties. The therapy helps those whose bodies are unable to make the hormone that’s needed.
    •    Girls: If the ovaries aren’t able to make the estrogen needed to start puberty, the girl can begin [daily?] estrogen medication. This can be pills you swallow or a patch, lotion or gel put on the skin. Puberty then starts. Some girls need the medication through young adulthood.
    •    Boys: If the testicles aren’t able to make the testosterone needed to start puberty, the boy can take testosterone medication. This can be a monthly injection or a [daily?] patch, lotion or gel put on the skin for several months. This starts puberty. Some boys need the medication for the rest of their life.

    Ongoing Care
    We care for teens with concerns about delayed puberty, and our team provides medical care for all forms of delayed puberty. With appropriate assurances and medical attention, teens generally begin and complete puberty in a healthy time frame. The adolescent’s health and well-being are our primary concern.

    Resources
    Learn more about delayed puberty by visiting these physician-recommended websites:
    •    American Academy of Pediatrics
    •    Hormone Health Network
    •    KidsHealth article on Delayed Puberty
    •    National Institute of Child Health and Human Development  article on Puberty
    •    Society for Endocrinology
    •    The MAGIC Foundation for Children’s Growth