Delayed puberty – causes, symptoms, diagnosis, treatment, pathology

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.


  1. No need to worry guys i was also facing this delayed puberty every single year after 14 I thought i will start puberty next year but it doesn't…..and i am 16 now and i look like 13 years old boy but now Alhamdulillah i have started puberty as I know what are the symptoms of puberty and within few years i will be same like them in sha ALLAH… Hope we get proper puberty !!

  2. I’m 5’4 I’m 15 with no puberty hair (such as arm pit hair and mustache) anywhere except my lower area (nuts) and my voice is light. It’s hard for me to gain weight and I am super skinny. I don’t think ill ever hit puberty

  3. I’m worried, I’m basically 14 but have like no pubic hair, squeaker voice, but always get erections? Idk I hope I hit puberty soon 🙁

  4. I"m 21, yet my puberty seems to have stopped during my early teens. I've grown pubic hair,, yet THAT area has seen almost no growth, I don't get morning wood and my libido is basically nonexistent. In fact my testicles feel like their getting smaller, and I've barely had less than thirty nocturnal emissions ever. Is it too late for me to get help?

  5. My friends won’t talk to be because apparently they don’t talk to people who aren’t woman they told me I can talk to them when I get my period

  6. I’m 14, never had a period, small chest, have discharge, pubic hair, armpit hair, but I shave my pubic hair cause it’s hella annoying and gross to me and just kdkskakksdkssks and yeah so idk how much I’m supposed to have by now☕️

  7. somethings wrong with me… I’m about to turn 15 in basically 2 months. Im stage 5 and have low t. Im skinny too weighing about only 100 pounds and 5ft 3. my voice hasnt changed since 13 when it kinda started to get deep and just now i sound like a kid still. i also have a twin brother same age we were both born premature at birth. he’s 5ft 7 and weighs 140 pounds. his voice isnt like deep but hes matured way faster than me and im pretty sure has gone through puberty way before me and i just dont know whats wrong with me. any advice?? 😔

  8. I’m 17 and I have not grown breast yet. At all. I’ve never once felt pain in my chest like if they were growing. I’m straight up flat chested. What does that mean? Will they ever grow? Help.

  9. I am fucking Triggered cuz' all my friends already have a fucking beard but I have hair anywhere except for my face FUCK THIS!

  10. I was called a "late bloomer" as a teenager an was told to "wait and see". However, I still did not start puberty, even after leaving University. It was not until the age of 23 that I was correctly diagnosed as having Kallmann syndrome.

    Kallmann syndrome is a rare genetic hormonal condition (occurs in about 1 in 10,000 people) that causes people not to start or fully complete puberty. It affects both males and females and can be associated with a lack of sense of smell.

    People will this condition will have no or very little signs of puberty and will be infertile. Life long hormone replacement therapy is required.

  11. I am 13 and I started puberty when I was 12 but now my pubic hair is dark and course but right now my ball sack it is larger and my penis is larger and I have lots of erections and I am more moody

  12. I’m 14 and recently went to the doctor to treat a stomach ache and asked about puberty because I have shown no signs and now I have to go to the hospital because I possibly have a really slow growth and I have to get X-rays done and bone tests😩

  13. I’m stage 2 on the tanner scale I think I’m a late bloomer and it will maybe come later I still want hormones tho

  14. carl johnson your answer is just because testosterone is making your larynx may be still growing and it does take time

  15. I am 15 and my birthday is in 2 months and then I’ll be 16. I still haven’t gotten my period I’m a Sophmore in high school and I’m super athletic and weigh 102 pounds. Am I delayed?? Cause I had discharge everyday since freshman year. And I started growing boobs in 6th grade and then they stopped growing and I’m a Sophmore in high school now and my chest is still flat. Is this normal??

  16. All my friends are taller, thinner and has deeper voices while im standing as a short, fat sounding like a 8 yr old guy whose actually 13

  17. I am 15 years boy but not hit yet i am at 2nd stage when will i am getting taller or my voice changes 😢😢😢😢

  18. Well, I am 12. I have all the signs of puberty (discharge, breast development, vaginal and underarm hair, occasional mood swings, etc.)
    The problem is I haven’t started my period yet. Both of my sisters got theirs when they were ten and my mother got he’s at 12. I am going to be 13 in two months and still no period. What’s wrong?

  19. bruh im actually scared i'll never get my period and im at the age of 13 ;-; someone else with me?

  20. i'm gonna be 14 in 4 days but i haven't hit puberty, i'm in stage one, no hair in my private part nor changes in my voice, my height is 5' ft, what do i do? help me please

  21. I am 15 years 2 month old now i am looking like a 12 years old boy my height is just 4 .10 inches no voice change i was hit puberty till 2 months so what can i do its affect my self esteem & confindence 😭😭😭😭😭😭😭😭😭😭😭😭😭

  22. I’m only 12 and will turn to 13 in october I was so dissappointed that my cousin that is a boy is now taller than me he only turned 12 a few months ago like I’m older half a year than him but he hits puberty and I have not he is 2 inches taller than me is this normal?

  23. 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 !!!

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

  25. 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.

  26. 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

  27. 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

  28. 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

  29. 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 ?

  30. 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.

  31. 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

  32. I was honestly worried about myself but apparently I’m just retarded I’m stage 4 and 13 but thought I was behind my voice is just not as deep as others and can go really deep or really high

  33. Okay so I'm 13 and am at stage 2 or 3 (boy) and I am 58.6614 inches or 149 cm or 4.88845 feet tall. Is this all normal for my age?

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