Delayed Puberty
Delayed Puberty
N Engl J Med 2012; 366:443-453February 2, 2012
Mark R. Palmert, M.D., Ph.D., and Leo Dunkel, M.D., Ph.D.
Nice clinical practice article in NEJM today.
Has a clear and evidence-based approach to sequential evaluation of a child with Delayed Puberty.
The flow chart is very helpful.
A 14-year-old boy with an unremarkable medical history presents because of lack
of pubertal development. He has always been relatively short, but his growth velocity
is slowing as compared with that of his peers. His height is 146 cm (57.5 in., <3rd
percentile for age), and his weight is 37 kg (82 lb, 3rd percentile). His father, who is
168 cm (66.1 in.) tall, continued to grow until his second year in college; his mother is
153 cm (60.2 in.) tall and began menstruating at the age of 14.0 years. The patient’s
target height on the basis of the parental heights is 167 cm (65.8 in.). The physical
examination reveals Tanner stage 1 pubic hair and prepubertal-sized testes. How
should the boy be evaluated and treated?
Key Clinical Points
• Delayed puberty is diagnosed when there is no testicular enlargement in boys or breast development in girls at an age that is 2 to 2.5 SD later than the mean age at which these events occur in the population (traditionally, 14 years in boys and 13 years in girls).
• Constitutional delay of growth and puberty (CDGP) is the single most common cause of delayed puberty in both sexes, but it can be diagnosed only after underlying conditions have been ruled out.
• The cause of CDGP is unknown, but most patients with CDGP have a family history of delayed puberty.
• Management of CDGP may involve expectant observation or therapy with low-dose sex steroids.
• When treatment is given, the goals are to induce the appearance of secondary sexual characteristics or the acceleration of growth and to mitigate psychosocial difficulties associated with pubertal delay and short stature.
• The routine use of growth hormone, anabolic steroids, or aromatase inhibitors is not currently recommended.
The article is available at: http://www.nejm.org/doi/abstract/10.1056/NEJMcp1109290?query=TOC
Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia
