REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)
Delayed Puberty - StatPearls (NCBI Bookshelf NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/
No medicine is started in primary care. Puberty induction with testosterone or oestradiol is an endocrinologist's decision and the cached article gives it only in specialist terms, so no prescribing row is offered. What primary care owns is recognising the age cut-offs, sending the first tests, and not calling it constitutional delay without looking for the causes that are not.
- THE AGE CUT-OFFS - conventionally, puberty is called delayed at 13 years in a girl and at 14 years in a boy. In a girl that means no breast development by 13; or a gap of more than 5 years - some authors put it at 4 - between thelarche and menarche; or no periods by 16, which some experts bring down to 15. In a boy it shows as testes that have not enlarged by 14.
- PUBIC HAIR IS NOT PUBERTY - hair alone does not mark the start of puberty; it can come from adrenal androgens instead, which is adrenarche. What does mark it: in a girl, the breast bud - thelarche; in a boy, the testis growing, a volume of 4 mL or more, or a length above 2.5 cm. An orchidometer answers this; an impression does not.
- PUBERTY THAT STARTS AND THEN STOPS ALSO COUNTS - puberty can begin and then stall, progressing no further, and that arrest is itself abnormal. Where it takes longer than 4 years - other authors put the figure between 3 and 5 - to reach full puberty in a boy, or menarche in a girl, counting from the first sign, the child needs a full evaluation.
- THE FIRST BLOOD TESTS ARE ORDINARY ONES - LH and FSH taken in the morning, with testosterone or oestradiol, ideally on an ultra-sensitive assay, give the first clues. Alongside them, the ordinary screen: TSH and free T4; anti-tissue transglutaminase, which is looking for coeliac disease; ESR or CRP, or both, for chronic inflammation; a metabolic panel; and a full blood count. Coeliac disease and chronic inflammation present this way and are findable from a clinic.
- ADD THE WRIST FILM - a radiograph of the hand and the wrist on the non-dominant side gives a bone age. It helps predict the height the child will reach as an adult, and it places where the child currently sits in the sequence.
- THE RED FLAGS THAT CHANGE THE URGENCY - suspect a mass in the brain, a craniopharyngioma among them, and the child needs an MRI of the brain. Ask for olfactory cuts as well: in Kallmann syndrome the olfactory sulcus is missing, and the olfactory bulb is absent or underdeveloped. Ask the boy whether he can smell; headaches and visual change move this to the front of the queue.
- NO SINGLE TEST SETTLES IT, SO ARRANGE TO SEE THEM AGAIN - nothing on the list separates these diagnoses on its own, so the child is usually followed over months, and it is that passage of time which makes the answer clear. Booking a review in six months is a decision, not a delay.
- WHEN WAITING STOPS BEING REASONABLE - where constitutional delay is the likely explanation, waiting for puberty to arrive by itself is sensible up to roughly 15 to 15.5 years of age in a girl, and about 16 in a boy. Past those ages the odds of it starting spontaneously fall away steadily, and the case for treating grows.
- TAKE THE DISTRESS SERIOUSLY - being visibly out of step with the year group costs these teenagers: they withdraw socially, get bullied, think little of themselves, become anxious or low in mood, and struggle at school. The article treats bullying and falling school performance as part of the indication for treatment, not as a soft complaint.
- WHAT REASSURANCE ACTUALLY SOUNDS LIKE - in constitutional delay, tell the teenager and the parents two things. That the timing is a normal variant, not a disease. And that treating is unlikely to change the adult height he was going to reach anyway - which is often exactly what the family is most anxious about.
- GROWTH HORMONE IS NOT THE ANSWER TO THIS - for a teenager wanting height rather than puberty: growth hormone has never been shown to change the final adult height in constitutional delay, and the paediatric endocrine societies do not recommend it for that purpose. Saying no here is evidence-based, not obstructive.
- NO HORMONE DOSE IS PRINTED HERE - the article does state induction regimens for testosterone and for transdermal oestradiol, but they are chosen after the cause is known, titrated against pubertal signs, and monitored by an endocrinologist. Starting one from a primary-care card would be prescribing without the diagnosis that the dose depends on.