Puberty is said to be delayed when a girl or a boy has gone through the usual age of onset ofpubertywithout any physical or hormonal signs that it is beginning. The typical signs of puberty normally appear by age 13 for girls and age 14 for boys. However, puberty may be delayed for a number of years yet progress normally, such a case is regarded as constitutional delay and is a modification of healthy physical development.

Delayed puberty can be hereditary, meaning the late onset of puberty may run in the family. It may also occur due to undernutrition, genetic disorders, several forms of systemic and chronic diseases, pituitary defects and diseases (e.g.hypopituitarism), hypothalamic defects and diseases (e.g.Prader-Willisyndrome,Kallmannsyndrome), gonadal defects and diseases (e.g.Turner syndrome,Klinefeltersyndrome), various forms ofcongenital adrenal hyperplasia, and other hormone deficiencies and imbalances.

A lack of symptoms of puberty is the main indicator that a child may be suffering from delayed puberty. Below are the most commonsymptoms of delayed puberty. However, it is important to note that symptoms vary among affected children. Symptoms may include:

· girls:

o no breast development by age 13

o over five years between breast development and menstrual period

o nomenarcheby age 16

o lack of pubic hair by age 14

· boys:

o no testicular enlargement by age 14

o lack of pubic hair by age 15

o over five years to complete genital enlargement

Delayed puberty can be accurately diagnosed bypediatricendocrinologistssince they are the physicians with an extensive training and experience in evaluating the disorder. He/she may conduct a thoroughphysical examinationas well as a complete review of the patient’smedical historyand growth pattern.

Blood tests may also be ordered, particularly for thegonadotropins, because high levels immediately confirm gonadal defects or deficiency of the sex steroids. In most cases, screening tests such as a complete blood count, general chemistry screens, thyroid tests, and urinalysis may also be valuable to check for chromosomal abnormalities, diabetes, anemia, and other conditions that may delay puberty.

A bone x-ray of the wrist or hand may also be performed to determine whether the child has reached a stage of physical maturation at which puberty should be underway. Notable secondary sexual development typically starts when girls reach a bone age of 10.5 to 11 years, and boys reach a bone age of 11.5 to 12 years. Other more sophisticated and more expensive tests such as computed tomography scan or magnetic resonance imaging may be done when specific evidence suggests they may be useful.

Thetreatment for delayed pubertywill be determined by the physician based on the following factors:

· the child's age, medical history and overall health

· the child's tolerance for certain medications, procedures or therapeutic approach

· extent and expectations for the course of the condition

· the parents’ opinion or preference

If the patient is healthy but simply late, no intervention is usually required. But in more pronounced cases of delay, a low dose of estrogen or testosterone for a few months may induce puberty to proceed normally. If the delay is caused by a disease, then the medical intervention is likely to focus on treating the disease. Often, when the underlying illness is treated, puberty proceeds normally. In case it becomes evident that there is a permanent defect of the reproductive system, therapeutic intervention usually involves hormone replacement orhormonetherapyto stimulate the development of secondary sexual characteristics.