Children's Hospital Colorado

Puberty Disorders

What are puberty disorders?

Puberty is the process in which children’s bodies change into adult bodies and become capable of reproduction. In girls, the onset of puberty usually happens between the ages of 8 and 13, and in boys, between the ages of 9 and 14.

Sometimes, puberty starts early (precocious puberty). Other times, it starts late (delayed puberty). Early or late starts do not always require treatment. In some cases, we may use medicines to help control this timing and put kids on track with their peers. This helps end the social and emotional difficulty of being far ahead of or far behind their friends. It also helps families that may struggle to support their children through these challenging times.

Puberty timing is also important because it affects a child’s growth. This is because puberty hormones spark a growth spurt, which at first, causes the bones to grow. Then, the growth plates close. Growth plates are the areas at the ends of the bones, which is where the body turns cartilage — the same soft material you feel in your nose — into bone to make the bone longer.

When the body is done growing, these growth plates close. When children have a puberty growth spurt too early, their growth plates may also close too early. This means children with early puberty seem tall at first, but then stop growing sooner than their friends, and they end up shorter than expected. Treatment can prevent this early growth and early end to growth.

What causes puberty disorders?

Puberty begins when the brain produces the hormone called gonadotropin-releasing hormone (GnRH). It prompts the pituitary gland to produce hormones called gonadotropins (LH and FSH). These gonadotropins then signal the ovaries to produce the hormone estrogen (in females) or the testicles to produce the hormone testosterone (in males).

There are two types of precocious puberty: central and peripheral. Central is the most common type. The brain begins hormone production that mimics the normal stages of puberty. The cause is often unknown, though sometimes there is an underlying condition. Peripheral precocious puberty is rare and does not involve the brain or pituitary gland. It happens when there’s a problem with the ovaries, testicles or other glands.

Delayed puberty usually runs in families or has unknown causes. We call this constitutional delay of growth and puberty. It is often a diagnosis of exclusion, meaning we can find no other cause.

Who gets puberty disorders?

Early or late puberty often runs in families. Some factors can make children more likely to experience early puberty. These include being female, African American or struggling with excess weight. Another factor is exposure to products that contain estrogen or testosterone.

Low body fat can be a cause of late puberty. This can happen with high athleticism, chronic illness, eating disorders or low appetite from ADHD medication. Sometimes, it’s due to problems with the ovaries, testicles or brain.

Helpful resources

  • Healthychildren.org: Ages and Stages is a resource to help parents talk to their child about the physical changes of puberty.
  • Parent Resources provides answers to common health questions for parents of young adolescents.
  • All About Puberty is a website for kids that explains what happens to both boys and girls during puberty.
  • Girlshealth.gov is designed specifically for girls and provides information on puberty, health and more.

What are the signs and symptoms of precocious puberty?

Early signs of puberty do not always mean full precocious puberty is beginning. Some children will just have pubic or underarm hair growth. We may diagnose this as benign premature adrenarche. Some girls will just have early breast development, called benign premature thelarche. If there is no increase in their growth rate or hormone production, it isn’t full puberty.

Full precocious puberty may be underway if girls younger than 8 years old or boys younger than 9 years old have any of the following symptoms:

  • Girls: breast development and growth spurt (or menstruation before age 10)
  • Boys: testicle and penis enlargement, facial hair and voice change
  • Girls and boys: growth spurt, pubic or underarm hair, acne and body odor

When it’s unclear whether your child’s symptoms indicate full puberty, we can do a blood test to check their hormones. This can help clarify the underlying cause.

What are the signs and symptoms of delayed puberty?

Delayed puberty is a possibility in children who have the following:

  • Girls: no breast development by age 13 or menstruation by age 15
  • Boys: lack of testicle and penis enlargement by age 14 (commonly associated with short stature)

We can provide an evaluation for children who show any of these puberty disorder symptoms.

What are puberty disorders diagnosed?

We base a puberty disorder diagnosis on a physical exam and review of your child’s medical history and blood tests to measure their hormone levels. We may also order an X-ray of your child’s hand and wrist to check their bone age. This is an estimate of your child’s skeletal maturity and remaining growth potential.

Blood tests may include checking hormone levels (LH, FSH, and testosterone or estrogen), thyroid function and sometimes genetic testing. Additional testing may check for anemia, liver and kidney dysfunction, and markers of chronic disease.

Other blood tests may include a gonadotropin-releasing hormone (GnRH) stimulation test. This can confirm precocious puberty and show whether it’s coming from the brain, the testicles (in males) or ovaries (in females). In this test, we give a hormone as a shot and then take several measurements of your child’s other hormones, to see how they respond.

If we find central precocious puberty, we may order a brain MRI. If we find peripheral precocious puberty, we may order blood tests and other radiology studies. For example, we may use an ultrasound to help examine a girl’s ovaries.

How are puberty disorders treated?

Puberty disorder treatment depends on the cause. Sometimes we will follow a child’s pace of development to make sure it doesn’t become too fast. This is common with benign premature thelarche and adrenarche.

When full precocious puberty happens, we can stop it until your child reaches an appropriate age. This helps ensure they will be emotionally ready, and that they will be able to grow to a typical adult height. Medicines called GnRH agonists can shut down puberty at the brain level. Other medicines can stop the growth plates from closing too early. When we find an underlying cause, such as a problem in the brain, we can treat that condition to delay puberty.

Treatment for delayed puberty also depends on the cause. It can include nutritional therapy or replacement of thyroid, growth or puberty hormones. If there is a problem in the ovaries, testicles, thyroid or brain, we will provide specific treatment for that condition.

If there is no underlying condition, we may watch your child's development to see if puberty will start on its own. We may also provide low doses of puberty hormones such as estrogen or testosterone to start the signs of puberty. This will usually cause your child’s growth rate to increase for a short time and may help set natural puberty in motion. It’s important to have a pediatric endocrinologist manage treatment because overtreatment can shorten the growth spurt and reduce your child’s final height.

Why choose us for treatment of puberty disorders?

Early and late puberty can be hard on kids. Our care team evaluates your child’s unique medical and emotional needs to provide a treatment plan tailored just for them.

Our Department of Pediatric Endocrinology takes a multidisciplinary approach to puberty disorder treatment. Depending on your family’s needs and preferences, we may include experts in nutrition, adolescent medicine and mental health.

We provide a full range of medical, radiologic and surgical therapies. We also provide nursing and medical support at all times for our patients and their families.

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