Delayed puberty?
Dear Dr Mitchell,
My daughter is 13 years old but there is no sign that she has reached puberty. There are no breast buds, no hair, no menstruation, nothing. She looks physically like an eight-year-old. Should I be concerned? I got my first period at 12, but had breast buds at 11. Is my daughter abnormal?
Puberty is the time of life when a girl or a boy achieves sexual maturity. The process starts between the ages 10 and 14 years for girls and 12 to 16 for boys. The first sign of puberty is usually breast development. Adolescent girls reach puberty at an earlier age these days than in former years. Over the years, the average age of the onset of the menstrual period (menarche) has gone down from 15 years in 1900. By the 1990s, the average age dropped to 12.5 years.
The timing of the onset of puberty is not completely understood. Reaching a critical body weight or composition may play an important role. An increase in childhood obesity may be related to the overall earlier onset of puberty in the general population in recent years. Girls who are obese tend to produce higher levels of the hormone leptin which acts at the level of the brain to signal the onset of puberty.
Genetic factors may also be involved in the timing of puberty. A gene has been identified and has appeared to be critical for the normal development of puberty. The gene is known as GPR54. This gene has an effect on the secretion of hormones by the hypothalamus in the brain. A child who does not have a copy of this gene is incapable of entering puberty normally.
The beginning of breast development occurs at approximately 11 years in girls. The growth of pubic hair begins next, followed by the growth of hair in the armpits. In a majority of girls, pubic hair develops before the breast. The first menstrual period usually begins 2.5 years after the onset of puberty.
Girls who have a later onset of menstruation tend to have lower rates of regular ovulation, and more than half of these adolescent girls do not ovulate regularly over the next 4.5 years.
A growth spurt usually accompanies puberty, and this rapid increase in height typically lasts two to three years. This occurs two years earlier in girls than boys and precedes the onset of menstruation by six months.
Puberty is considered delayed when there is no breast development by age 13.5 years. Sometimes this runs in families. Chronic medical conditions such as diabetes, asthma, and cystic fibrosis may also cause delayed puberty. Genetic problems involving the pituitary or thyroid glands, problems with the ovaries, and malnutrition are other factors causing delayed puberty. Excessive or strenuous activity can be associated with significant reduction in body fat and a delay in puberty. Competitive athletes may have delays in the onset of menstruation up to one year or more when compared with girls who are not athletes. Teens with the eating disorder anorexia nervosa may also have delayed puberty. Chromosomal disorders such as Turner Syndrome (missing or altered X chromosome) may also be a factor. In untreated cases women are shorter than usual and tend to be infertile.
You should take your daughter for a physical examination and blood test for thyroid, pituitary, and chromosomal problems. A bone age X-ray will show the doctor whether her bones are maturing normally. In many cases there is no underlying medical problem and it could be that your daughter is just later than normal. A short course of treatment with hormones may bring on the changes associated with puberty. Once the treatment is stopped then the child’s own hormones take over to complete the process of puberty.
If there is a medical problem, then this can be detected and specific treatment can be undertaken and the onset of puberty will follow in most cases. Consult your doctor who will do some blood investigation and X-rays to determine if any of the problems mentioned are relevant to your daughter so that she can be effectively treated to restore menstrual cycles and the onset of secondary sexual characteristics. Delayed puberty can be difficult for anyone to accept and deal with, but it is a problem that usually gets solved, and in most cases kids usually catch up with their peers.
Best wishes.
Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions via e-mail to allwoman@jamaicaobserver.com; write to All Woman, 40-42 1/2 Beechwood Ave, Kingston 5; or fax to 968-2025. All responses are published. Dr Mitchell cannot provide personal responses.
DISCLAIMER
The contents of this article are for informational purposes only and must not be relied upon as an alternative to medical advice or treatment from your own doctor.
