Girls enter puberty between the ages of 8-14. Boys enter this stage between the ages of 9-14. When this stage is late, it is called delayed sexual development.

For girls, delayed sexual development is defined as:

• Lack of breast development by the age of 13 or
• Lack of menstruation for five years or more after initial breast development

Delayed sexual development for boys is defined as:

• Testicles that don’t enlarge by age 14.
• Sex organs that don’t completely develop within five years after they started to develop.

This condition can be caused by:

• Constitutional delay—some children simply take longer than their peers; they will at some point catch up
• Chronic disease
• Abnormal chromosomes
• Other factors

To understand the reason for the delay, it is necessary to look at potential causes including:

• Underlying disease:
  • Diabetes mellitus
  • Inflammatory bowel disease
  • Kidney disease
  • Cystic fibrosis
  • Anemia
  • Hypopituitarism (caused by infection, trauma, central nervous system lesions)
  • Chronic infections
  • Anorexia nervosa
  • Malnutrition
  • Kallman’s syndrome
  • Cancer
  • Autoimmune disease

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• Chromosomal abnormalities:
  • Turner syndrome (girls)
  • Klinefelter syndrome (boys)
  • Prader-Willi syndrome (boys and girls)
  • Noonan syndrome (boys and girls)
• Other factors:
  • Radiation therapy
  • Chemotherapy
  • Athletes undergoing vigorous training

Factors that may increase the chance of delayed puberty include:

• Family history
• Having certain long-term diseases

One common symptom for both boys and girls is shortness in height. Other symptoms by sex include:

• Symptoms in boys:
  • Lack of testicular enlargement by age 13 ½
  • Lack of pubic hair by age 15
  • Genital enlargement that takes more than five years from start to completion
• Symptoms in girls:
  • Lack of breast development by age 13
  • Lack of pubic hair by age 14
  • Failure to menstruate by age 16
  • Time lag of more than five years from breast development to first period

The doctor will ask about your child’s symptoms and medical history. A physical exam will be done. Your doctor will review your child's milestones and growth record. An x-ray of the left wrist bone may be taken. This will help to assess if bone growth is normal for your child’s age.

Depending on these results, other tests may be ordered, including:

• Chromosome studies
• Hormonal levels: FSH, LH, and estradiol in girls; testosterone in boys
• GnRH stimulation test
• MRI scan of head and pituitary gland to exclude tumors or lesions
• Additional tests (eg, T4, insulin-like growth factor or IGF-1, IGFBP-3, TSH, prolactin)
• Assessment of nutritional state
• Family history of pubertal delay
• Pelvic ultrasound (female)
• Skull x-ray
• Test of smell and vision

There is often no treatment for those who are healthy and just starting later than their peers. They will continue to be monitored.

Other treatment depends on the cause. For those who have a chronic underlying disease, treatment is aimed at the specific condition. Once the condition is treated, puberty often proceeds on its own.

For others treatments may include:

Most causes of delayed sexual development cannot be prevented. To help reduce the chance, make sure your child is kept as healthy as possible. This includes making sure they are eating well and getting all the nutrients they need. Make sure any underlying illness is treated.