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Lost In The Crowd: Delayed Puberty

Dr Adeyeri Adetola

15th Mar, 2016

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A group of people, of different backgrounds, philosophies and identities, when together makes a crowd. Crowds come into existence for a variety of purposes. No matter the reason for the togetherness, even if transient, anything is possible. It is everyone’s desire to have a sense of belonging with a set of people for individual reasons. Dreams, aspirations and wishes can be synergistically achieved with a crowd of the same flow.

Imagine when the inverse is the case? When due to a dearth of a characteristic or a few differences, one doesn’t fit into a chosen crowd of friends, colleagues or associates? What will one do or how will one cope? This scenario is typical in delayed puberty especially in the female individual.

Puberty is the body’s natural process of sexual maturation. It involves the occurrence of secondary sexual characteristics beginning with breast development, then adolescent growth spurt, the onset of menarche, acquisition of fertility and profound psychological modifications. The first sign of puberty in females is breast development, which occurs as a result of the ovaries becoming active and producing the female hormone, oestrogen.

When there is no secondary sexual maturation or any sign of puberty by 13 years, delayed puberty occurs. Delayed puberty has many causes but in most cases, constitutional delay in growth and puberty (CDGP) is the cause. In this case, the female child is healthy but has a short stature compared to her peers and may have a family history of delayed puberty. The affected individual feels odd when classmates or friends undergo pubertal development and growth, thereby necessitating assessment.

Delayed puberty warrants evaluation and maybe categorized accordingly into three classes; lateness, discordance and indicators of specific disorders. Lateness occurs when there is a delay of 2-3years, girls with no breast development by 13years and absence of menarche by 3years after breast development or by 16years of age. When puberty in a girl does not proceed as a predictable series of changes, discordance is evident.

Delayed puberty could be a pointer to specific disorders of the reproductive system, malnutrition, chronic illness as diabetes mellitus, excessive physical exercise, hormonal imbalance as in hypopituitarism, and congenital anomaly like turner syndrome or reduced or absent sense of smell in kallman syndrome.

Puberty is initiated by the increasing production of gonadotropins - luteinizing hormone and follicle stimulating hormone from the pituitary gland which act on the ovaries. This is initially driven by the increasing release of gonadotropin-releasing hormone from the hypothalamus. When something goes wrong with this controlled sequence, delayed puberty occurs.

Delayed puberty occurs in about 3% of children, majority caused by constitutional delay. The defining signs are no breast development and occasionally slow linear growth.

The diagnosis of delayed puberty should be relatively straightforward because a physical examination will reveal whether puberty is occurring or not. Pubertal staging, also referred as tanner stages is the key to diagnosis. It however becomes a multidisciplinary approach involving paediatric endocrinologists when identifying the exact cause.  

Management would entail a thorough medical history, physical examination, investigations and treatment. A review of growth patterns, details of chronic illness, surgery, radiation or any relevant fact entails the medical history. The individual is physically examined and classified into her appropriate tanner stage.

Investigations include an assessment of the bone age, blood tests and chromosomal analysis. The bone age is assessed by taking X-ray of the wrists and comparing the images against an atlas of normal bone maturation- bone age maybe delayed in constitutional delayed growth and puberty. Blood tests may be taken to measure hormonal levels. Chromosomal analysis is done when turner syndrome is suspected.

Treatment is usually watchful waiting with regular checks on height, weight, tanner pubertal staging measurements and measurement of levels of relevant hormones. In cases of significant psychosocial concerns, a short course of an anabolic steroid is administered to increase growth and puberty may be induced by giving a short course of oestrogen. Hormonal therapy, usually reserved for true cases of hormonal deficiency, failure or damage of the ovaries, could be short course or a lifelong treatment.

Delayed puberty carries a good prognosis if diagnosed early as majority is constitutional and prompt treatment instituted.

Thus, remedies abound for any female individual that is presently lost in the crowd due to delayed puberty. As a matter of fact, it may just be constitutional. So brace up, ladies and stand tall!

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