What is delayed puberty?
Absence of breast enlargement by 13 years or absence of menses 5 years after breast enlargement is called delayed puberty in a girl.
What should be expected in girls?
- Breasts grow bigger – 1st sign
- Pubic hair /underarm hair appears
- Start of menstruation (periods) within 2 years of breast development- Menarche. This may not be regularly occurring i.e. may skip a month or two, in the first 2-3 years of menarche.
- Feel bloated and mood swings
- A white, clear discharge may occur in some girls.
What are the causes of delayed puberty?
- Sometimes normal – especially if one of the parent has matured late- “late bloomers”
- Long term illness/stress/emotional issues
- Abnormally low hormones- due to problems with the testes, ovary, brain and pituitary Genetic causes
What the problems related to sex hormone production?
The under production of Oestrogen hormones could be either because of problem in the pituitary gland or in the testes. If the problem lies in the pituitary gland then it is not giving enough LH and FSH, called hypogonadotrophic hypogonadism.
If the problem is in the Ovaries, despite enough of LH and FSH Ovaries can not produce Oestrogen, called hypergonadotrophic hypogonadism.
What are the causes for the hypogonadotrophic hypogonadism?
They are: Kallaman’s syndrome: Sense of smell is also affected, tumors or radiation in the region of pituitary, genetic problems.
Prolactin secreting tumour of the Pituitary gland called prolactinoma can cause this type of defect and the good news is that it can be treated by medicine to reduce Prolactin in 90% of cases.
Why does hypergonadotrophic hypogonadism happen?
It is because of Turner’s syndrome, destruction of ovaries because of local radiotherapy, chemotherapy.
What are the features of delayed puberty?
The girls fail to develop breast enlargement, fail to experience pubertal growth spurt, menstrual periods.
What tests are done to know the cause?
The doctor orders for several hormones and scans. Some are done after giving stimulating hormones. LH and FSH, the two pituitary hormones responsible for stimulating testes to secrete the female sex hormones -estradiol and prgesterone, are measured at base line and post GnRH injection.
Blood levels of estradiol are done. To detect the genetic defect karyotyping is done (Turner Syndrome). This test tells about the genetic makeup of the individual. MRI scan of the brain and/or abdomen are also done.
How to treat these patients?
Improving nutrition in undernourished children is very important in that group. But if the problem is because of sex hormone deficiency then oral estrogen is given.
We usually initiate puberty by giving small doses of Oestrogen for 12-18 months, later we add Progesterone for regular periods.