Understanding Delayed Puberty

Delayed puberty is when a child does not start puberty during the expected age range. Most children who develop later than their peers ultimately go on to have normal development. However, in some children, delayed puberty is due to underlying conditions that need to be treated, for example, hormonal disorders, genetic disorders, and other chronic medical conditions.

What is Puberty?

Puberty is a process of physical, hormonal, and emotional changes that occurs during adolescence as a child moves toward adulthood and becomes sexually mature and capable of reproduction. This natural process is triggered by rising levels of sex hormones in the body (estrogen in girls and testosterone in boys). It occurs through the hypothalamus-pituitary-gonadal (HPG) axis as follows:

A part of the brain called the hypothalamus releases a hormone called gonadotropin-releasing hormone (GnRH).
GnRH stimulates the pituitary gland in the brain to release hormones called follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
FSH and LH signal the gonads (ovaries and testes) to release sex hormones (estrogen in females and testosterone in males).
Sex hormones then trigger puberty.

In girls, physical signs of puberty (secondary sexual characteristics) include breast development, growth of pubic hair, a growth spurt, the start of menstruation, and changes in body shape to a curvier body with wider hips.

In boys, physical signs of puberty (secondary sexual characteristics) include the growth of facial hair, pubic hair, a growth spurt, an increase in the size of the penis and testicles, and changes in body shape to wider shoulders and a more muscular build.

Puberty is assessed using the Tanner scale, which measures physical development stages in adolescents.

Typical Age Range for Puberty

The changes of puberty happen gradually and typically start between:

8 and 13 years of age in children that are assigned female at birth.
9 and 14 years of age in children that are assigned male at birth.

Delayed puberty is when sexual maturation does not start within these expected timeframes.

Note: When a child displays signs of early puberty it is called precocious puberty (before age 8 years in females and age 9 years in males).

Overview of Delayed Puberty Signs

Signs of delayed puberty in girls include a lack of breast development and menstrual periods and, in boys, a lack of increase in testicular size.

Learn about the stages of puberty in females vs males.

Causes of Delayed Puberty

Genetic Factors

Chromosomal abnormalities (genetic disorders in which there are problems in one or more of the 23 pairs of chromosomes) can cause delayed puberty. Examples include:

Turner syndrome in females (missing X chromosome).
Klinefelter syndrome in males (extra X chromosome).
Kallmann syndrome (an underdeveloped hypothalamus in the brain that cannot properly stimulate the pituitary gland to release certain hormones called gonadotropins that are necessary for sexual development).

Medical Conditions and Disorders

Chronic disorders can be responsible for delaying puberty. For example:

Nutritional deficiencies such as anemia
Poorly controlled diabetes mellitus
Inflammatory bowel disease (IBD)
Celiac disease
Liver disease
Kidney disease
Thyroid disorders
Autoimmune disorders such as Hashimoto’s thyroiditis
Addison disease
Cystic fibrosis
Hypopituitarism (underactive pituitary gland)
Tumors of the hypothalamus or pituitary gland
Hemochromatosis (excess iron in the body)
Certain infections
An eating disorder such as anorexia nervosa
Rapid and significant weight loss, for example, from bariatric surgery

Medical Treatments

Delayed pubertal development can also occur in children who receive chemotherapy or radiation therapy for cancer. It can also be the result of taking certain medications, such as glucocorticoids and opioids or stopping anabolic steroids.

Environmental and Lifestyle Factors

Excessive exercise causes delayed puberty, especially in girls, which can lead to amenorrhea (lack of menstrual periods).
Exposure to chemicals and toxins can interfere with hormone levels and delay puberty.

Symptoms of Delayed Puberty

Physical Signs in Boys

It is called delayed puberty in boys when there is a:

Lack of testicular enlargement by age 14.
Delay of 5 years or more between initial testicular enlargement and completion of puberty with adult genitals.

Physical Signs in Girls

It is called delayed puberty in girls when there is a:

Lack of thelarche (breast development) by age 13.
Lack of menarche (start of menstrual periods) by age 16.
Delay of more than 4 years between breast development and completion of puberty with adult genitals.

Keep in mind that different resources may show slightly different milestone time frames. Talk to your child’s doctor if you have questions or concerns regarding the child’s development.

Constitutional Growth Delay: Differentiating Normal Variation from Delayed Puberty

In many children, delayed puberty is a variation of normal and not a result of an underlying health condition. This is called constitutional growth delay (CGD) and is an inherited pattern of growth and development that runs in families. It can result in a temporary delay in the growth spurt, such that the child is not as tall as their peers for a period of time and takes longer to reach their final adult height.

Such children are typically called “late bloomers.” They often have a family history of CGD (parents, siblings, cousins, and other relatives who also developed later than usual and were late bloomers). Constitutional growth delay does not require any treatment, and kids ultimately catch up and develop normally. However, CGD can cause mental distress for a child.

Constitutional growth delay is twice as common among boys than girls. In about 60% of boys, delayed puberty is due to constitutional growth delay. A healthcare provider can diagnose CGD based on an X-ray of the left hand and wrist. In children with constitutional growth delay, bone age lags behind chronological age by 2-4 years.

How is Delayed Puberty Diagnosed?

Initial Assessment and Medical History

A pediatric endocrinologist (a specialist in treating hormonal disorders in children) will obtain a complete medical history and perform a physical exam to look for secondary sexual characteristics (signs of puberty) such as breast growth, testicular enlargement, pubic hair, axillary hair, body odor, and acne. They will also order certain tests before making a diagnosis of delayed puberty.

Diagnostic Tests and Procedures

Blood tests such as complete blood count, tests to identify chromosomal disorders, tests to measure hormone levels, and tests to diagnose chronic illnesses that could delay puberty or cause growth problems.
X-ray of the left hand and wrist to assess the child’s bone age. In children with delayed puberty, the bone age lags behind the chronological (calendar) age.
Other imaging studies like CT (computed tomography) scans and MRI (magnetic resonance imaging) scans to find the cause of delayed puberty and rule out differential diagnoses (conditions that can look similar).

How is Delayed Puberty Treated?

Medical Interventions

The treatment for delayed puberty depends on the underlying cause. For example, if a child has a chronic illness such as diabetes mellitus, the treatment will be for diabetes.

For children with constitutional delay in growth (CGD), the child’s doctor may recommend close monitoring. However, if CGD is leading to bullying because of short stature or abnormal development, it can affect a child’s self-esteem and/or academic performance. In this case, the child’s healthcare provider may recommend a short course of low doses of hormone treatment with testosterone in boys and estrogen in girls.

Hormone therapy can be given in the form of oral pills or intramuscular injections. It can help to increase the rate of growth and sexual maturation and improve the child’s mental health status.

Children diagnosed with hypogonadism due to primary gonadal failure or problems in the hypothalamus-pituitary-gonadal (HPG) axis require more prolonged treatment with sex steroid therapy. Growth hormone therapy can also be used to stimulate physical development.

Find out common low estrogen symptoms to look for.

Lifestyle and Nutritional Adjustments

Nutrition is a vital factor in the onset and progression of puberty. During puberty, children need more calories and nutrients such as protein, iron, calcium, vitamin D, zinc, and folate to support their growth spurt and bone development. A well-balanced diet with fruits, vegetables, whole grains, lean proteins, and low-fat dairy can help children get all the nutrients they need. Discover what vitamins your child should take daily.

If a child is diagnosed with nutritional deficiencies or an eating disorder as the cause of delayed puberty, the child’s doctor will treat these underlying conditions.

Psychological and Emotional Support

Delayed puberty can cause psychosocial issues such as body image concerns, low self-esteem, anxiety, depression, and social isolation. Psychological support and emotional encouragement can help adolescents with delayed puberty deal with the challenges they face through reassurance and encouragement. A licensed therapist or counselor can help your child learn to manage the emotional and social stress of delayed puberty.

Implications and Living with Delayed Puberty

Possible Complications

The complications from pubertal delay depend on the underlying cause. In addition, as noted, delayed puberty can affect a child’s emotional and social wellbeing and academic and athletic performance. It is therefore important to get timely evaluation and treatment for delayed puberty.

Supporting a Child with Delayed Puberty

If a child has a constitutional growth delay, you can support them by helping them understand that they will eventually reach a tall stature like their friends, just a little bit later. You can also support your child by helping them develop the confidence to accept their body at every stage of life.

Key Takeaways and Advice for Parents and Caregivers

Delayed puberty is when puberty happens later than the usual timeline of 8 to 13 years in girls and 9 to 14 years in boys. There can be many causes of delayed puberty. Some of these causes only require the child to be monitored frequently, while others might result in the child’s doctor advising treatment with hormone therapy. The important thing is to seek timely diagnosis and treatment if you think your child is delayed compared to the normal ages at which puberty proceeds. Without treatment, pubertal delay can lead to psychosocial issues and health complications from undiagnosed and untreated medical conditions.

Check out more tips for parents with children going through puberty.

Common Questions

How Late Can Puberty Start?

Puberty usually starts by age 13 years in girls and age 14 years in boys.

Why Haven't I Hit Puberty At 16?

There can be many reasons for not hitting puberty at 16, including nutritional deficiencies, other medical problems that can affect growth and development, hormonal disorders, and genetic conditions. Your healthcare provider can perform a thorough evaluation to identify the cause of delayed puberty.

What Is The Main Cause of Delayed Puberty?

The three main causes of delayed puberty are:

Constitutional growth delay.
Hypogonadotropic hypogonadism or gonadotropin deficiency (problems in the hypothalamus-pituitary-gonadal axis where the hypothalamus and pituitary don’t produce enough hormones to stimulate the testes and ovaries).
Primary gonadal failure or hypergonadotropic hypogonadism (problems with the gonads (testes or ovaries) where they don’t respond properly to gonadotropins and don’t make enough sex hormones).

How Late Can A Late Bloomer Be?

Late bloomers may have growth spurts anywhere from age 13 years to 16 years or even older.

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