Definition

Puberty is the period when an adolescent undergoes physical changes to become sexually mature. Generally, puberty occurs between the ages of 8 and 14 for girls and 9 and 15 for boys. Puberty is a process governed by several organs, including the brain, pituitary gland, and gonads (sex glands). These organs produce hormones that trigger the signs of puberty in the body.

In girls, puberty is dominated by the hormone estrogen, while in boys, it is dominated by the hormone testosterone. An imbalance in the processes regulated by these organs can lead to delayed puberty.

Delayed puberty is a condition where the signs of puberty appear later than the maximum expected age. In girls, it means the absence of puberty signs after the age of 13. Although delayed puberty is more common in boys than in girls, there is no exact age at which each child will experience puberty, as each child's condition is different. Signs of delayed puberty include the absence of secondary sexual characteristics such as the onset of menstruation (menarche).

The exact incidence of delayed puberty is unknown due to the lack of reported cases in Indonesia. The opposite of delayed puberty is precocious puberty, where the puberty process occurs too early.

In general, delayed puberty is not dangerous, and almost all children will eventually grow up healthy. However, for children with delayed puberty who have certain diseases, treating the underlying disease thoroughly is necessary to ensure healthy development into adulthood.

Read more about menarche here: Menarche - Definition, Causes, Symptoms, and Treatment

Causes

There are various reasons why a child may experience delayed puberty. Most causes are not precisely known, but common causes include:

• Genetic diseases
• Chromosomal complications
• Tumors in the hypothalamus or pituitary gland
• Chronic illnesses
• Hypopituitarism (underactive pituitary gland)
• Hypothyroidism (underactive thyroid gland)
• Excessive exercise
• Anorexia or other eating disorders such as bulimia
• Androgen insensitivity syndrome (the body's inability to use androgen hormones)
• Abnormal development of the reproductive system
• Low body fat composition
• Diabetes mellitus
• Celiac disease
• Kidney or liver disease
• Turner syndrome
• Inflammatory bowel disease
• Autoimmune diseases, such as Addison's disease
• Undergoing chemotherapy or radiation therapy

If you want to know more about celiac disease, you can read it here: Celiac Disease - Definition, Causes, Symptoms, and Treatment

Risk Factor

Several risk factors for delayed puberty include:

• Family history

If one parent experienced delayed puberty, the child is more likely to have delayed puberty as well.

• Functional factors

Functional causes of delayed puberty include hypogonadotropic hypogonadism, where there is a delay in the production of sex hormones by the pituitary gland. As a result, estrogen and testosterone are not produced, delaying puberty.

• Constitutional growth delay

This condition affects bone growth, causing the child to be shorter than their peers. More than half with delayed puberty have constitutional growth delay. However, these children will eventually reach puberty and normal growth over time.

• Chronic diseases

Any long-term diseases can affect a child's growth and development, leading to delayed puberty. Examples include cystic fibrosis, diabetes, kidney disease, asthma, and sickle cell anemia.

• Malnutrition

Poor nutrition can hinder growth and puberty.

• Genetic diseases

Chromosomal abnormalities can delay puberty.

Read more about hypogonadism, here: Hypogonadism - Definition, Causes, Symptoms, and Treatment

Symptoms

Symptoms of delayed puberty in girls include:

• Breasts not developing by age 13
• No pubic hair
• No menstruation by age 16
• Short stature and stunted growth
• Uterus not developing
• Bone age younger than the child's actual age

Diagnosis

The diagnosis of delayed puberty involves taking a patient's medical history, physical examination, and additional tests.

Medical History

During the anamnesis, the doctor will ask about the patient's main complaints, accompanying symptoms, when the complaints started, family medical history, previous illnesses, specific treatments, diet, and daily activities.

Physical Examination

The doctor will check vital signs such as blood pressure, respiratory rate, pulse, and body temperature. A thorough examination from head to toe, height and weight measurements, and the development of breasts and pubic hair as indicators of puberty progression will be conducted.

Diagnostic Tests

The doctor may perform the following additional tests:

• Blood tests to check for chronic diseases and chromosomal abnormalities
• X-ray of the hand to estimate bone age
• CT scan
• MRI

Management

Treatment depends on the cause of delayed puberty. If there is a family history of delayed puberty, no specific treatment may be necessary.

If a girl has low body fat, gaining weight to increase body fat may help stimulate puberty. If delayed puberty is caused by a disease or eating disorder, treating the underlying cause can help normalize puberty.

In girls, treatment may include hormone therapy to stimulate puberty. Monitoring growth and administering birth control pills to stabilize sex hormone levels may also be considered, depending on the patient's condition.

All medications should be prescribed by a pediatric specialist. Parents play a crucial role in providing physical and psychological support to children with delayed puberty, aiding their treatment, and boosting their confidence and sense of security.

Complications

Complications of delayed puberty in girls are similar to those in boys. Adolescents with delayed puberty may experience stress and decreased self-esteem. Early emotional support can prevent these complications. If untreated, delayed puberty can lead to psychological issues.

Other complications may arise from hormone replacement therapy. Additional complications can include early menopause, infertility, and low bone density, increasing the risk of fractures and osteoporosis.

Read more: Osteoporosis - Definition, Causes, Symptoms, and Treatment

Prevention

There is no definitive way to prevent delayed puberty, but early detection can facilitate quicker management and prevent further complications. Early detection can be achieved through routine check-ups with a pediatrician and awareness of delayed puberty symptoms.

When to See a Doctor?

If your child does not experience menarche (first menstruation) by age 16 or has no breast development by age 13, consult a pediatrician for evaluation.

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