DELAYED PUBERTY
Puberty is the process of physical development from the first signs
of adolescence to full adult maturity. It is brought about by a series
of chemical signals (hormones), conveyed from the brain to the pituitary
gland in the head, then from the pituitary to the sex glands, the ovaries
in girls and the testes in boys. These in turn secrete the sex hormones,
oestrogen in girls and testosterone in boys, that cause the physical changes
of puberty. Normal puberty takes from 4 to 5 years in both sexes but it
is an earlier event in girls than in boys.
Typically girls show breast budding, pubic hair growth and an increased
rate of growth in height at 11- 12, reach their fastest rate of growth
at 12, start menstruating at 13 and finish growing at 15.
In boys enlargement of the testes and penis starts around 12 but the
growth spurt is delayed, reaching a maximum at 14, and final height is
not reached until 17 or later.
Variation in the timing of the changes of puberty and some variation
in the sequence is common but in the great majority of children the changes
occur within a span of 2 years before or after the average. Thus 95% of
girls start their periods between the ages of 11 and 15. The greater the
deviation from the average age of puberty the more likely is there to be
malfunction or disease of some part of this complex process. Problems most
commonly arise through "mistiming" of puberty which is either
early ("precocious") or delayed. Delayed puberty is a frequent
problem but affects boys more often than girls. It may also cause more
distress in boys since at this age physical prowess is so important for
the male sex. However, both boys and girls may be much distressed by the
physical contrast with their peers and, since sex hormones work on the
brain as well as the body, the physical immaturity of delayed puberty is
typically also associated with emotional and intellectual immaturity.
Simple delay, a more or less extreme delay in the normal process of
puberty, proves to be the problem in the great majority of children who
present with delayed puberty When this is the case the problem will of
course resolve in time without any intervention. However, as will be apparent
from the account above, delay in puberty can also arise from a malfunction
at the level of the brain, the pituitary or the ovaries or testes.
Investigations to assess the function, by blood tests, and the structure,
by scans, of these organs may be needed. These investigations often fail
to reveal any abnormality and then it is necessary to allow time to pass
to demonstrate whether the problem is simply a mattter of delay.
Treatment.
Treatment for the delay may be appropriate, whatever the cause, if the
lack of development is causing serious distress or underachievement. It
is fortunately a simple matter to accelerate the changes of puberty by
treatment. The simplest option is to give testosterone or a related compound
in boys and oestrogen in girls.
Boys.
Testosterone, or another anabolic steroid, can be given by mouth (Restandol
capsules, stanozolol or oxandrolone tablets) or by depot injections (Sustanon,
Primoteston). The injections each last for a month to six weeks and are
generally considered more effective than the oral preparations. (Note:
the bad press received by the anabolic steroids, of which testosterone
itself is the most important, is due to the fact that some athletes whose
events rely on strength have abused these preparations by taking massive
overdoses, clearly this is not relevant to the small doses used in this
context). A course of treatment for from three to six months can be given
and then the situation reassessed. The response is usually gratifying with
a good acceleration in growth and in physical and emotional development.
Spontaneous development often starts during such a course of treatment
although it is not clear whether it is truly precipitated or whether it
would have happened without the treatment.
Girls.
Oestrogen preparations are also available as tablets and ethinyloestradiol
is most commonly used. In very low dosage (2 microgrammes (ug)daily) the
main effect is to accelerate growth and in higher dose (10-20 ug daily)
female pubertal changes are induced. As in boys, a relatively short course
of treatment, from three to six months, is often associated with the onset
of spontaneous puberty.
Outlook.
Permanent problems are relatively unusual and in general also respond
well to replacement treatment. If puberty does not start after a course
of treatment further investigation is likely to be needed and it may then
be necessary to resume replacement of sex hormones on an indefinite basis,
in boys using continuous testosterone and in girls cyclical oestrogen and
progesterone (another hormone) in order to induce monthly periods which
are required to shed the lining of the womb. Even if permanent treatment
is needed, with appropriate management the prospects for future development,
sexual function and fertility are good for the great majority of children.
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