# Delayed puberty - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Delayed Puberty - StatPearls (NCBI Bookshelf NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/ · Delayed puberty - disease-level clinical article (delayed-puberty-full.txt) · Delayed puberty - disease-level clinical article (delayed-puberty-clinical.txt) · No dose - referral pathway, no medicine given in primary care - Verified date: 2026-08 ## Verified against - Delayed Puberty - StatPearls (NCBI Bookshelf NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/ - Delayed puberty - disease-level clinical article (delayed-puberty-full.txt) - Delayed puberty - disease-level clinical article (delayed-puberty-clinical.txt) - No dose - referral pathway, no medicine given in primary care ## Treatment metadata - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text DELAYED PUBERTY Sources: Delayed Puberty - StatPearls (NCBI Bookshelf NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/ · Delayed puberty - disease-level clinical article (delayed-puberty-full.txt) · Delayed puberty - disease-level clinical article (delayed-puberty-clinical.txt) · No dose - referral pathway, no medicine given in primary care Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (9) - A birth history of breech delivery, prolonged jaundice, low blood sugar, or a very small penis raises concern for combined pituitary hormone deficiency [hypoglycaemia · jaundice] - Missed developmental milestones or a known developmental delay can point toward an underlying genetic syndrome [developmental delay] - Ask directly whether breast growth, testicular enlargement, body odor, underarm or pubic hair, or acne have been noticed [acne] - Headache with blurred vision or visual field loss in a child warrants work-up for a brain mass [blurred vision · headache] - Milky nipple discharge unrelated to nursing suggests a prolactin-secreting cause of the delay [nipple discharge] - Very low caloric intake combined with heavy physical training can stall pubertal progress - Ask whether siblings or parents were themselves late developers - A history of alkylating chemotherapy or radiation to the pituitary region or gonads is directly relevant - Prior surgical correction of undescended testes or brain surgery near the pituitary can cause gonadal failure SIGNS - what you find (7) - Tanner stage must be documented at every visit to track pubertal progression - A normal Tanner stage can reassure the family and avoid an extensive work-up - An arm span more than 5 cm longer than height, or an upper-to-lower segment ratio under 0.85 to 0.80, points to hypogonadism - Slowed linear growth with weight preserved can point to a pituitary hormone deficiency - A midline facial defect or a single central upper incisor can signal pituitary involvement - CHARGE-syndrome features are linked to hypogonadotropic hypogonadism - Dysmorphic features of Turner, Noonan, Bardet-Biedl, or Prader-Willi syndrome accompany delayed puberty with short stature [dysmorphic features · short stature] TESTS (12) - Morning LH, FSH, and testosterone or estradiol using ultrasensitive assays indicate the current pubertal state and whether the cause is central or gonadal - A CBC, metabolic panel, thyroid function, celiac antibody, and inflammatory markers screen for systemic illness - Serum prolactin is checked, especially when the history or exam suggests hypogonadotropic hypogonadism - IGF-1 and growth hormone stimulation testing are needed if panhypopituitarism or GH deficiency is suspected - A GnRH stimulation test can separate isolated hypogonadotropic hypogonadism from constitutional delay when LH and FSH are unclear - No single test reliably tells these entities apart, so following the patient over time is often what settles the diagnosis - FSH-stimulated inhibin B above specific male and female cutoffs was 100 percent sensitive and specific for the start of puberty in one study - Karyotype, microarray, or next-generation sequencing is considered when a syndrome or genetic cause is suspected - A wrist and hand x-ray for bone age helps predict adult height and the stage of the process - Testicular ultrasound evaluates for an undescended testis or a palpable mass - Brain MRI is obtained when a mass such as a craniopharyngioma is suspected - Olfactory-cut brain MRI showing an absent olfactory sulcus or hypoplastic olfactory bulb supports Kallmann syndrome IF NOT THIS - what else fits (10) - A range of long-standing medical problems - low blood counts, gut, heart, kidney, or liver disease, or poor nutrition - can delay puberty - Anorexia nervosa, excessive exercise, depression, or anxiety are psychosocial contributors, especially noted in girls - Hypothyroidism, Cushing syndrome, or another endocrinopathy can slow pubertal onset - Constitutional delay of growth and puberty is suggested by a family history of late developers - Kallmann syndrome causes hypogonadotropic hypogonadism and is marked by absent olfactory structures on MRI - A brain mass or tumor is suggested by headache with visual field loss - Hyperprolactinemia is suggested by a history of galactorrhoea - Klinefelter syndrome is a genetic cause of hypergonadotropic hypogonadism in males - Turner syndrome is a genetic cause of hypergonadotropic hypogonadism in females - Prior radiation therapy or gonadal surgery is an acquired cause of hypergonadotropic hypogonadism Source Delayed puberty - disease-level clinical article (delayed-puberty-full.txt) Status traced to the source above 1. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Delayed Puberty - StatPearls (NCBI Bookshelf NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/ Why 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. Caution 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. 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