Last modified on October 2020
With inputs from Dr. Uma M - Consultant Family Physician, and Diabetologist
As an adult, you will remember how difficult and exciting puberty was. A time when your body went through several physical and emotional changes. Puberty is a process in which your body becomes sexually mature, therefore becoming capable of reproduction. However, this process can be delayed due to several underlying reasons. Puberty that occurs later than the expected time is called delayed puberty. As a parent, it is important to understand what your child is going through and ensure that you create a supportive environment.
Read on to learn about the signs of delayed puberty in Indian girls and boys, causes, and treatment for the same
To begin with, how does puberty take place?
As previously mentioned, puberty is a period when a child’s body begins changing as they become an adult. In medical terms, puberty starts when the hypothalamus gland produces a chemical signal called gonadotropin-releasing hormones. The pituitary gland releases a hormone called gonadotropins, in response to the chemical signal.
These hormones are responsible for stimulating the growth of the sex glands in the child (the ovaries of a girl, and the testes of a boy).
In general, puberty happens around 10 to 14 years for girls and 12 to 16 for boys. In some cases, children may pass through the age range for puberty without fully experiencing it. This is called delayed puberty and it may or may not be caused by underlying reasons. It’s completely natural for some children to mature slower than others.
It is also normal for the child to feel confused and frustrated.
Delayed puberty in girls:
Puberty in girls starts when the leutenizing hormone (LH) and the follicle-stimulating hormone (FSH) secreted by the pituitary gland in the brain, stimulate the growth of their ovaries and the production of sex hormones, primarily estrogen. Budding breast buds in girls begin to develop and shortly after, a growth spurt happens. Usually budding breast buds in below 7 year old girls are uncommon; most develop them by age 10-12. After a few years, the girl gets her first period. If she doesn’t, then the causes of delayed menarche should be identified.
No development of breast buds by age 13
The first sign of puberty in girls is the development of breast buds. A breast bud is a small disc-shaped bump under the nipple. Uneven growth in both breasts, tenderness, and soreness is completely normal. A delay in the process of breast development is a sign of delayed puberty in Indian girls.
No menstruation by age 16
While timelines differ from one girl to another, most girls get their first period approximately 2-3 years after developing teen breast buds.
“On average, girls get their first period
at around age 13 in India.”
A time period of more than 5 years between the development of breast bud and the first period
In addition to the first and second point, if a child starts their menstrual cycle long after the breast buds have developed, this can be called delayed puberty. The reasoning for this may or may not be related to serious health conditions; a few people are simply late bloomers. It is crucial to understand that each body is unique and develops at its own pace.
Puberty in boys also happens when the pituitary gland produces two hormones: the luteinizing hormone (LH) and the follicle-stimulating hormone (FSH). These hormones enlarge the testicles and produce testosterone (male hormone). If a child’s development does not fit into this timeline, it may be considered delayed puberty in Indian boys.
No enlargement of testicles by age 14
The first sign of delayed puberty in boys are under-developed testicles. This can be easily noted during a physical exam. In some cases, the testes would have started to develop, but the penis remains small. This could suggest that sexual maturation can occur in the next 6-12 months.
No growth spurt by age 15
As previously mentioned, each person’s body grows at a different pace. Young boys in India usually have a major increase in height by the time they are 15-16. Children affected by delayed growth spurt are usually short compared to their peers. In most cases, they tend to catch up by the time they are 18 and reach maximum adult height. A growth spurt can look different in males and females.
For boys, the following developments might occur:
For girls, these features will start to develop:
No development of pubic hair by the age of 15 in Indian children is a hallmark sign of delayed puberty.
A time period of more than 5 years between the start and completion of genital development
Similar to delayed puberty in girls, the reasoning for this may or may not be related to serious health conditions, a few people are simply late bloomers. It is crucial to understand that each of our bodies is unique and changes at its own pace.
Puberty is a period when a child’s body prepares for sexual maturation. In some cases, children may pass through the age range for puberty without fully experiencing it. This is called delayed puberty and it is caused by underlying medical reasons. Signs of delayed puberty in girls include no breast development by age 13 and no menstruation by age 16. Signs of delayed puberty in boys include no growth in testicle size by age 14 and no growth spurt by age 15.
Consult with an endocrinologist to assess your child’s delayed puberty symptoms
Most of us are aware of the tell-tale first signs of puberty in girls and boys. Puberty breast development and menstruation in girls; deepening of voice and muscle growth in boys. There are many more early signs of puberty in girls and boys and it’s important, as a parent, to comprehend the science behind these changes and support your child throughout this phase.
To learn these first signs of puberty in females and males better, Dr. James M. Tanner, a child development specialist, developed the widely known Tanner scale or sexual maturity ratings which measures a child’s sexual development during puberty.
Read on to learn the signs of puberty in each of these Tanner stages
Tanner stage 1:
Signs of puberty in boys and girls are similar during this stage. The brain starts to signal the body to prepare for puberty. The hypothalamus begins to produce gonadotropin-releasing hormones or GnRH. These stimulate the pituitary gland to release hormones that prompt the growth of reproductive organs.
These pre-puberty signs/ early puberty symptoms happen at around 8-9 years for Indian girls.
Tanner stage 2:
The first signs of puberty in females start during this stage.
Tanner stage 3:
Obvious physical signs start developing in an Indian girl’s body after the age of 12. These signs of puberty in girls include:
Tanner stage 4:
Symptoms of puberty in girls are very noticeable during this stage as changes happen rapidly. The following are the signs of puberty in girls:
Tanner stage 5:
The last stage of puberty marks the end of complete physical development and maturation in girls. This usually happens around age 15 in India.. The following are the signs:
Tanner stage 1:
Signs of puberty in boys and girls are similar during this stage. The brain starts to signal the body to prepare for puberty. The hypothalamus begins to produce gonadotropin-releasing hormones or GnRH. These stimulate the pituitary gland to release hormones that prompt the growth of reproductive organs. These pre-puberty signs/ early puberty symptoms happen at around 9-10 years of age for boys.
Tanner stage 2:
On an average, boys mature much slower than girls. The first signs of puberty in Indian boys start at around age 11. The testes and area around the testes (scrotum) starts growing. Also, fine pubic hairs grow at the base of the penis.
Tanner stage 3:
Any obvious physical changes in Indian boys usually start around age 13. These physical signs include:
Tanner stage 4:
Signs of puberty in boys are very noticeable during this stage as changes happen rapidly. The following are the early signs of puberty in girls at around age 14:
Tanner stage 5:
The last stage of puberty marks the end of complete physical development and maturation in boys. This usually happens around age 15. The following are the signs:
What is early puberty?
It is also important to know about early onset of puberty. Precocious puberty/ early puberty is when a child’s body changes into that of an adult’s sooner than expected.
Signs of early puberty in girls include early breast development. For instance, budding breast buds in a 7 year old or 8 year old may indicate an early onset of puberty. Signs of precocious puberty in boys include enlarged genitalia, body odour, growth of facial/ underarm hair before the age of 9.
To understand the signs of puberty better, the Tanner scale or sexual maturity ratings were developed. This scale measures a child’s sexual development
during puberty. Overall, during puberty, a girl experiences breast growth, first menstrual cycle, increase in height, underarm and pubic hair growth, widening of hips and fuller thighs. On the other hand, a boy experiences an increase in height, building up of muscles, broadening of shoulders, deepening of the voice, increase in testicle size, development of the penis, facial and pubic hair growth.
Consult top endocrinologists on the Mfine app to evaluate signs of delayed puberty in your children!
Most often, a child’s puberty may be delayed simply because of being a late bloomer, which usually does not need medical treatment. Once the stages of puberty start, they develop normally. However, there are other rare late puberty causes like chronic medical disorders, genetic disorders, and more. Read on to learn about the various late puberty causes in Indian girls and boys.
Constitutional delay in growth and puberty (CDGP)
Constitutional delay of growth and puberty is the most common reason for delayed puberty in Indian children. Children affected by this condition often have a family history of one or both parents being late bloomers. They tend to have a short-stature compared to peers of their age because of delay in bone growth. But once puberty starts, the pubertal stages progress as expected.
“60% of boys affected by delayed puberty are diagnosed
with a constitutional delay in growth and puberty.”
Since short stature is one of the main indications of delayed puberty in Indian girls and boys, medical experts will have to rule out the following conditions before making a diagnosis of CDGP:
In some cases, a chronic illness can affect the hormonal balance of a child and result in delayed puberty. The following are some of the most common chronic causes of delayed puberty in females and males.
Causes of delayed/ late puberty in females and males can also include Diabetes. Diabetes is a metabolic disorder in which decreased insulin production causes blood sugar levels to soar up, which is usually the case in Type I diabetes that affects children at a young age. Symptoms include excessive urination and thirst, extreme fatigue, frequent hunger, blurred vision, and more. If you find your child facing these symptoms, consult with a diabetes specialist to avoid any damage in the future. Treatment is based on the type of diabetes the child is diagnosed with but mostly includes changes in diet, exercise, medications, and in some cases, insulin injections. Management of diabetes in children must be strictly monitored as it is more complex. Deficiency of insulin could also indirectly lead to the suppression of gonadotropin releasing hormone (GnRH), which can lead to delayed puberty.
2. Inflammatory bowel disease:
Inflammatory bowel disease or IBD occurs when the intestines become inflamed, causing abdominal pain and diarrhoea. The causes of IBD are unknown, but evidence suggests that people with a genetic predisposition may be more prone to the disease because of abnormal immune reactions with the intestinal bacteria. This is a common cause of delayed puberty in females and males.
The two types of IBD are:
Crohn’s disease: Affects any part of the digestive tract and causes chronic diarrhoea and abdominal pain.
Ulcerative colitis: Affects only the large intestine and causes bloody diarrhoea and intermittent episodes of abdominal pain.
Hypothyroidism is also one of the main causes of delayed/ late puberty in males and females. It occurs when your thyroid gland produces an insufficient amount of thyroid hormones. Your thyroid gland is responsible for providing energy and controlling functions like how your digestive system works and your body’s metabolism. With a decrease in these hormones, your body’s processes begin to slow down. Thus, resulting in slow metabolism.
The most common signs of delayed puberty in males and females include feeling cold, fatigue, dry skin, dullness, weight gain, and in adolescents- delayed puberty. Treatment usually includes dietary modifications and medications that ensure adequate levels of thyroid hormones in the body. Ensure that you and your child have a full-body health check-up regularly to detect any health conditions early on.
Causes of late puberty in females and males can also include Anaemia. Anaemia is a condition in which your body lacks red blood cells (RBCs) to carry out oxygen to all parts of the body for daily functions. The haemoglobin in RBCs is a protein that enables the process of delivering oxygen to the body. When your haemoglobin count is low, there is an inadequate supply of oxygen in the body. Take a blood test from the comfort of your home to increase chances for treatment and cure.
Symptoms often include fatigue, weakness, pale skin, dizziness, and more. There are different types of anaemia with the most common one is iron deficiency anaemia that affects a large population of young girls and women in India. Treatment for anaemia includes dietary supplements and incorporating a balanced, nutritional diet and exercise.
Nutritional development is highly essential for growth during infancy, childhood, and puberty. This is the time when a child’s body is rapidly growing and preparing for adulthood. A healthy, balanced diet is necessary to ensure growth progresses as expected. A lack of essential nutrients can be one of the main causes of late puberty.
“India is home to about one-third of the world’s
Nutritional needs for adolescents:
Calories: Calories are used to measure the amount of energy delivered to your body. Due to rapid growth, the body demands more calories during adolescence than at any other phase of life.
The daily recommended calorie intake is 2,800 for boys, and 2,200 for girls. Intake of balanced nutrients will ensure good health for your child.
6. Sickle cell disease
Sickle cell disease is an inherited condition which can affect the haemoglobin molecules in the blood. Haemoglobin molecules turn into sickle-shaped cells and die early. This affects their capacity to carry oxygen. Children with sickle cell disease often develop at a slower pace than others their own age. They also experience puberty much later due to their decreased haemoglobin count.
7. Cystic fibrosis
Cystic fibrosis is a hereditary disease which affects the lungs. In this condition, the mucus naturally produced by the cells becomes thick and can block the ducts and tubes in the lungs and other organs. Cystic fibrosis can cause delayed puberty in both boys and girls.
The sex chromosomes determine whether a fetus will be biologically male or female. A pair of XX chromosomes results in a female fetus, and a pair of XY chromosomes results in a male fetus.
Turner syndrome is a sex chromosomal abnormality and is one of the causes of delayed puberty only in females. The complete or partial absence of one of the X chromosomes in females results in Turner syndrome. This condition can be diagnosed before birth, during infancy, or in early childhood.
One of the common signs of Turner syndrome in childhood and teenage years is delayed puberty. Other features identified to be associated with this condition are:
Individuals with Turner syndrome require ongoing medical care and monitoring from a variety of medical experts like hormone disorder specialists, heart specialists, and specialists in women’s health.
Regular follow-ups with an online doctor can ensure that these girls and women lead happy and healthy lives.
Klinefelter syndrome is another sex chromosomal abnormality that causes delayed puberty in males. As previously mentioned, a pair of XY chromosomes results in a male fetus. A person diagnosed with this condition is born with an extra copy of the X chromosome, resulting in adverse effects in their sexual maturation.
Signs and symptoms of Klinefelter syndrome include:
A slow development during puberty is mostly normal, but it is always best to consult with a doctor if you have any concerns. Young boys with Klinefelter syndrome may require reproductive treatments and therapy to ensure physical development progresses as expected.
Delayed puberty can be caused due to several reasons. The most common reason is a constitutional delay of growth and puberty (CDGP) which is inherited from the parents. There is no particular CDGP treatment as eventually, the child will catch up with their peers. Chronic diseases like diabetes, bowel disease, malnutrition, and anaemia can also contribute to a delay in puberty. Apart from this, hormonal and genetic disorders like Turner syndrome, Klinefelter’s syndrome and hypogonadism can also cause delayed puberty in girls and boys.
Consult with an endocrinologist to evaluate your child’s risk factors for delayed puberty
The most important step in treating your child for delayed puberty is to get a complete and accurate diagnosis. Before any test or scans, the doctor will ask questions regarding the child’s medical history or family’s medical history to understand the context better.
In the beginning, doctors perform a physical exam to check for any visible signs of puberty. They look for body weight, height, underarm and pubic hair growth in boys and girls, breast bud (small disc-shaped bump under the nipple) development in girls and testicular growth in boys.
A blood test is performed to look for signs of abnormal hormone levels, sex chromosome abnormalities, and underlying medical conditions, like diabetes, malnutrition, or anaemia.
Bone age examination
This is done by performing an x-ray, usually on the left hand, wrist and fingers to check for bone growth. A child’s bone age indicates their skeletal development and usually coincides with their calendar age. If their bone age is significantly younger, this could be a sign of delayed puberty.
Also called a computerized tomography scan, this procedure combines x-rays taken from multiple angles of the body and processes them using computer technology to produce cross-sectional images of the body. These are generally more detailed than a normal x-ray and are used to diagnose any underlying disease or injury.
Also called diagnostic sonography, this procedure uses high-frequency sound waves to gather information about the body’s internal organs and can detect any defects that need to be treated. Most ultrasound examinations use a probe or device that is placed on the skin of your body. A layer of gel is applied to your skin so that the ultrasound waves travel from the device, through the gel, and into your body.
Magnetic resonance imaging (MRI)
MRI scan is an imaging method that uses a magnetic field, computers, and radio frequencies to produce cross-sectional, detailed images of internal organs, blood vessels, and tissues of your body. The MRI machine can also produce three-dimensional images that can be viewed from multiple angles.
After completion of the required tests, your child’s healthcare providers will approach you with a detailed analysis and suggest treatment options for delayed puberty. As a guardian, it is important to ask questions regarding the reasons for your child’s delay in growth and development. Here are a few questions you need to ask your child’s healthcare provider during diagnosis and treatment:
The most important step in treating your child for delayed puberty is to get a complete and accurate diagnosis. Your child’s doctor will ask for medical history before performing any procedures. Diagnostic examinations for delayed puberty in Indian girls and boys include physical exams, blood tests, bone age x-rays, CT scans, ultrasound imaging, and MRI scans. Your child’s healthcare providers will approach
you with a detailed analysis of the diagnosis and suggest appropriate treatment options.
Book a consultation with the city’s top endocrinologists online to get a complete diagnosis
Your child’s doctor will advise appropriate treatment of delayed puberty based on age, overall health, and cause of delayed puberty.
Inherited delayed puberty
There is no treatment for constitutional growth delay as it is inherited. The puberty may start late but will progress naturally. However, it is advisable to follow-up with your child’s healthcare provider regularly to check the stages of pubertal development.
This reason is only considered when other possible reasons for delayed puberty have been ruled out.
Treatment of delayed puberty causes
As previously mentioned, delayed puberty in Indian girls and boys can be caused by various chronic illnesses like diabetes, anaemia, malnutrition, and more. If this is the case, the appropriate medical specialist will treat the cause to ensure the continuity of physical growth and development.
In some cases, a short course of hormone therapy is used to stimulate growth and development of secondary sexual characteristics in males and females. Puberty
is triggered by providing testosterone hormones to boys and estrogen hormones to girls. This type of therapy can be useful in management of delayed puberty.
If boys show no symptoms of sexual maturation, they may be prescribed testosterone treatment. Testosterone can help induce puberty by stimulating the development of masculine characteristics, such as:
The child may be prescribed a short-course of testosterone injections to be used once a month. This should be injected into a muscle on the arm or leg. In the beginning, low doses are prescribed but as a child develops, the dosage is increased.
Pregnant women, breastfeeding women, and children must avoid contact with testosterone injections. It is crucial to clean up any excess medication after the treatment is over.
Delayed puberty in females treatment using oestrogen/ progesterone
This is a commonly used form of delayed puberty in females treatment. If girls show no sign of sexual maturation, they may be prescribed an estrogen treatment as a form of management of delayed puberty. Oestrogen can help induce
puberty by stimulating the development of feminine characteristics, such as:
Doctors usually prescribe medications in the form of pills. Sometimes, doctors may also prescribe a transdermal patch that is placed on the skin twice a week. The estrogen travels through the skin and into the bloodstream. In the beginning, low doses of estrogen are given. As the child develops, the dosage is increased.
In some cases, doctors prescribe progesterone, in addition to the estrogen treatment for constitutional growth delay treatment. Progesterone helps in regulating the menstrual cycle, thus inducing a girl’s first period. In order to treat the causes of delayed menarche, this drug may be prescribed. Limited dosage is given in the beginning and is adjusted according to bodily needs.
Hormone therapy is usually done for cases affected by hypogonadism, Turner syndrome, Klinefelter’s syndrome, any failure of testes or ovaries caused by external damage
Life-long hormone therapy may be required if there is a deficit in sex hormones after the completion of induced puberty.
In very rare cases, surgery is performed as a treatment for delayed puberty. This may be due to the formation of tumours in the reproductive organs or endocrine glands that act as an inhibition in the child’s sexual development. However, surgery is avoided as much as possible as there are other forms of constitutional growth delay treatment available.
If delayed puberty is due to pituitary tumours, then this condition has to be treated surgically.
“Puberty progresses at a different pace in each child. I always remind parents that their first and foremost priority should be to help their child feel comfortable in their body. Puberty can be a challenging time for children and our job is to provide them a safe environment and boost their self-esteem.”
– Dr Uma M, Consultant Family Physician and Diabetologist
Management of delayed puberty in terms of emotional
support is just as important as physical treatment.
Parenting through delayed puberty is a tough journey. It’s normal for your child’s emotions to be intense and strong. They may be experiencing body image issues or low self-esteem as they compare themselves to their peers. Their moods change frequently and this can leave them feeling very confused and scared. The rational part of a child’s brain (prefrontal cortex) is not fully developed and will never be until they turn 25. As a guardian, it’s important to recognize their feelings as they don’t have the mental capacity to cope with them just yet. Here are a few tips to help your child through this journey:
Some children can experience gender dysphoria, a condition where the gender that a child identifies with and their biological gender do not match. Most children develop their gender identity by 3 years of age. Recognizing the gender they identify with and helping them become comfortable with it is extremely important.
It’s also crucial to note that intense and prolonged mood swings may be a sign of an underlying mental health issue. Here’s how to find if your child’s mood swings are something more serious:
If you notice these symptoms in your child, consult a mental health professional so that these issues can be brought under control.
Treatment of delayed puberty is dependent on the cause. Treatment for constitutional growth delay is not required. If it is caused by a chronic disease, the appropriate doctor needs to prescribe medications to treat the cause. If there is a deficit in sex hormones in the body, testosterone therapy (for boys) and estrogen therapy (for girls) is recommended. In very rare cases, surgery is performed to ensure puberty progresses as expected. Emotional support is just as important as any physical treatment. Creating a safe and supportive environment for your child will help them through this journey as they enter young adulthood.
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Q1. Is delayed puberty normal?
If your child is healthy but hasn’t shown any signs of puberty yet, he or she should get evaluated but it’s not necessarily an emergency. Our bodies develop at their own pace and it’s normal to be a ‘late bloomer’. If you do have concerns, consult a doctor to check your child’s growth and development. However, in most cases, it’s not something to worry about. Your child’s doctor may prescribe hormone therapy if there is an underlying medical condition. A short-course of this treatment will induce pubertal development.
Q2. Can being underweight delay puberty?
Body weight can affect a girl’s puberty. Girls with a higher Body Mass Index (BMI) show signs of puberty much earlier than girls with a lower BMI. This delay occurs due to a lack of body fat. This can happen in girls who:
Q3. What are the signs of delayed puberty?
Signs of delayed puberty in females:
Signs of delayed puberty in males
Q4. Does late puberty affect height?
If your child is affected by constitutional delay in growth and puberty (CDGP), it is normal to find him or her shorter than their peers as they haven’t experienced a growth spurt yet. Eventually, they will reach their maximum adult height when they get older. There is no particular CDGP treatment as eventually, the child will catch up with their peers. If you have any concerns, consider a
full-body health check-up to have him or her checked if there’s an underlying medical condition
Q5. Can someone not hit puberty?
A delay in puberty can be caused by a multitude of reasons like chronic diseases, CDGP, or genetic disorders. Identifying the cause and treating it early on will ensure puberty progresses naturally. In some cases, this doesn’t happen and can be treated by prescribing a short-course of testosterone treatment (for boys) or estrogen
treatment (for girls). Sometimes, our bodies lack sex hormones and just need a ‘push’ to start the process.
Q6. What is considered precocious puberty?
Precocious puberty/ early puberty is when a child’s body changes into that of an adult’s sooner than expected.
Signs of early puberty in girls include early breast development. For instance, budding breast buds in a 7-year-old or 8 year old may indicate an early onset of puberty. Signs of precocious puberty in boys include enlarged genitalia, body odour, growth of facial/ underarm hair before the age of 9.
Q7. Do sports delay puberty?
Participating in competitive sports or extreme physical training is shown to delay puberty in children, especially girls. It is uncertain if this is due to a mismatch between calorie input and calorie output, but it is always advisable to
check with a doctor to ensure maximum growth and development. However, in most cases, this is not required as they tend to catch up by the time they’re older.
Q8. When should I be worried about delayed puberty?
If your child shows no sign of breast buds development by age 13 or no testicular enlargement and other signs of growth spurts by age 14, then it is best to get evaluated by a doctor. Our bodies develop at their own pace and it’s normal to be a ‘late bloomer’. However, if there is an underlying medical condition, it needs to be treated immediately to continue pubertal growth.
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