Delayed sexual development - girls; Pubertal delay - girls; Constitutional delayed puberty
Delayed puberty in girls occurs when breasts don't develop by age 13 or menstrual periods do not begin by age 16.
Puberty changes occur when the body starts making sex hormones. These changes normally begin to appear in girls between ages 8 to 14 years old.
With delayed puberty, these changes either don't occur, or if they do, they don't progress normally. Delayed puberty is more common in boys than in girls.
In most cases of delayed puberty, growth changes just begin later than usual, sometimes called a late bloomer. Once puberty begins, it progresses normally. This pattern runs in families. This is the most common cause of late maturity.
Another common cause of delayed puberty in girls is lack of body fat. Being too thin can disrupt the normal process of puberty. This can occur in girls who:
- Are very active in sports, such as swimmers, runners, or dancers
- Have an eating disorder, such as anorexia or bulemia
- Are undernourished
Delayed puberty also may occur when the ovaries produce too little or no hormones. This is called hypogonadism.
Certain medical conditions or treatments can lead to hypogonadism, including:
Girls begin puberty between ages 8 and 15. With delayed puberty, your child may have one or more of these symptoms:
- Breasts do not develop by age 13
- No pubic hair
- Menstruation does not start by age 16
- Short height and slower rate of growth
- Uterus does not develop
- Bone age is less than your child's age
There may be other symptoms, depending on what causes delayed puberty.
Exams and Tests
Your child's health care provider will take a family history to know if delayed puberty runs in the family.
The provider also may ask about your child's:
- Eating habits
- Exercise habits
- Health history
The provider will perform a physical exam. Other exams may include:
An x-ray of the left hand and wrist to evaluate bone age may be obtained at the initial visit to see if the bones are maturing. It may be repeated over time, if needed.
The treatment will depend on the cause of delayed puberty.
If there is a family history of late puberty, often no treatment is needed. In time, puberty will begin on its own.
In girls with too little body fat, gaining a bit of weight may help trigger puberty.
If delayed puberty is caused by a disease or an eating disorder, treating the cause may help puberty to develop normally.
If puberty fails to develop, or the child is very distressed because of the delay, hormone therapy can help start puberty. The provider will:
- Give estrogen (a sex hormone) at very low doses, either orally or as a patch
- Monitor growth changes and increase the dose every 6 to 12 months
- Add progesterone (a sex hormone) to start menstruation
- Give oral contraceptive pills to maintain normal levels of sex hormones
Delayed puberty that runs in the family will resolve itself.
Some girls with certain conditions, such as those with damage to their ovaries, may need to take hormones their entire lives.
The estrogen replacement therapy may have side effects.
Other possible complications include:
When to Contact a Medical Professional
Contact your provider if:
- Your child shows a slow growth rate
- Puberty does not begin by 13 years of age
- Puberty begins, but does not progress normally
Dickinson KM. Adolescent medicine. In: The Johns Hopkins Hospital; Hughes HK, Kahl LK, eds. The Johns Hopkins Hospital: The Harriet Lane Handbook. 21st ed. Philadelphia, PA: Elsevier; 2018:chap 5.
Haddad NG, Eugster EA. Delayed puberty. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 122.
Styne DM, Grumbach MM. Physiology and disorders of puberty. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 13th ed. Philadelphia, PA: Elsevier; 2016:chap 25.