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so causes of delayed puberty and boys
are multiple but generally the if
they're central they are more likely to
be a cancer in boys we're gonna suspect
these if there's no testicular
enlargement after 14 years of age
in girls we're gonna suspect delayed
puberty if there's no thigh larkey by
the age of 13 so boys are allowed an
extra year delay they start later they
finish later keep in mind though that
two and a half percent of healthy boys
and girls do have delayed puberty we're
using this cut-off so that we can check
kids as early as we can without having
to test too many children so what are
the types of delayed puberty well we
have constitutional lay this is by far
the most common these are simply
children who are having their puberty
later much like they might have a later
growth spurt this is common if there's a
family history of delay if the parents
don't have a delay in their pubertal
development or also in children who have
excessive exercise or work very hard at
a sport sometimes this will happen there
may be a problem with the ganado trophy
the ganado troph ins are FSH and LH this
would be hypo ganado trophic
hypogonadism in other words their gonads
are less productive because of a hypo
ganado trophic state this is a problem
with the brain or they might have
primary go nan-oh failure which is hyper
go now to trophic hypogonadism this is
because they have lots of ganado troughs
and very little response so let's drill
down on causes of hypogonadism when the
when the ganado troph ins are the
problem there are some central issues
that we might see one classic example is
calman syndrome this is an isolated
deficiency in the pituitary and also
these patients often have a nas mia so
they're not smelling very well because
of a problem with the first grail nerve
they will have isolated deficiency of
production of their gonadotrophins this
can be functional as well patients with
eating disorder excessive exercise some
of our real star athletes will have a
delay in their puberty and that's a
central process like we stated in boys
often it's a pituitary lesion so we need
to worry about the tuatara lesions in
these children and certainly we would
worry about it in a child who has a
history of pituitary surgery
remember resection of the two eteri
adenoma z' carries with it about a 15%
chance of being having problems with
pituitary endocrine function afterwards
flipside if there's primary go nate'll
failure we have to think about some
other potential causes of what's going
on there are some genetic causes such as
Klinefelter's which is X X Y or Turner
syndrome which is just one X and in both
those genetics situations children have
a decreased responsiveness of their
gonads to the ganado trophy that's
trying to get them stimulated also
patients may have a history of
irradiation of the testes or
chemotherapy or rarely children can have
autoimmune ovary disease which will
result in a hypokinetic gun gonads state
where there's hyper ganado trophic
levels of hormone FSH and LH which are
trying to stimulate a diseased ovary
so if we have delayed puberty in a
healthy child we're going to check LH
FSH estradiol and girls and as
testosterone boys if the child has a
concern it's going to be largely guided
by our exam what is the problem consider
thyroid hormone levels prolactin levels
and CBC and sed rate as a way of
measuring chronic malingering condition
delayed puberty if there's
constitutional delay we're gonna manage
them simply by reassurance eventually
your child's going to have their period
don't you worry about a thing for boys
we typically treat this with tests all
drone injections typically these happen
about once a month it's not too
troublesome families don't usually have
a problem with it but it is expensive
and so you probably will have to
document testosterone deficiency prior
to the insurance company being willing
to pay for the therapy for girls with
delay you can consider initiation of
estrogen therapy usually we simply put
them on an estrogen pill like an oral
contraceptive pill and that will start
to promote the puberty and get them
regular so that's all I have today about
delayed puberty and how we deal with
that problem thanks for your attention
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