Puberty is a common concern among young teens, and even when they undergo normal changes, they are likely to feel worried about their bodies and wonder if something is wrong with them. In the majority of cases, it takes a little longer than expected to experience the expected changes in puberty, but how much should we wait?
Delayed puberty in boys can be suspected around 14 years of age when they have not yet displayed signs of sexual maturation, and their testicle volume has not increased yet. Thus, it is not a diagnosis that should be made by just looking at teens and comparing them to the average boy.
In this article, we are going to talk about late puberty in males. Is it considered to be a disease? When should we worry, and what consequences could a delayed puberty cause to children in later life?
Is delayed puberty a disease and Can Testosterone Help?
Boys undergo sexual maturation signs and symptoms at different ages. Thus, we can talk about a normal age distribution that follows a bell-shaped curve in which the majority of boys undergo apparent changes by the age 13 years old. By this time (13 years old and 13 and a half years, respectively), most boys would have changed their voice tone and had their first ejaculation of semen, but we can see these traits a bit later, and it is still normal as long as their testicular volume reaches 4 mL or higher by the age 14 years.
However, even 14-year-old boys with a testicular volume lower than 4 mL do not necessarily have a concerning health problem. Thus, to differentiate delayed puberty from pathological conditions with long-term consequences, we should talk about constitutional growth and puberty delay (CDGP) and hypogonadism. The former is self-limited and not associated with significant consequences in later life, while the latter usually needs specialized treatment and may be indicative that there is something wrong that requires further medical assessment to prevent long-lasting and often severe consequences.
Unlike hypogonadism, CDGP is a variation of normal growth and development, and it is the most common cause of delayed puberty. In the clinical practice, it is difficult to differentiate CDGP from permanent conditions such as isolated hypogonadism and transient hypogonadism due to inflammatory bowel syndrome, anorexia, and other systemic diseases.
Will you have Testosterone problems in later life?
CDGP is often a diagnosis of exclusion. For example, it is suspected in patients who do not suffer from any systemic disease that may trigger delayed puberty and do not have clinical signs of genetic alterations associated with hypogonadism (Turner syndrome, Kallmann syndrome, and others). Having a family history of delayed puberty with normal growth and development afterward is strongly suggestive of CDGP, accounting for 50 to 75% of cases, and these children are not likely to have significant testosterone problems later in life. In their case, delayed puberty is just a late variant of normal puberty.
However, patients who have evidence of initial pubertal changes that became stagnant or started to reverse are strongly suggestive of permanent cases of hypogonadism, especially when testes are undescended or 1-2 mL in volume. It will be important to analyze levels of LH and FSH in the blood as well as testosterone concentration levels. Bone age is also determined through X-rays, and should not exceed 2 years younger than chronological age.
Children with delayed puberty due to permanent or transient hypogonadism should be assessed and treated with testosterone, and they are likely to depend on testosterone replacement therapy in the majority of cases. Otherwise, their levels of circulating testosterone would remain low and trigger long-lasting consequences associated with low levels of testosterone, which include low libido and impotence problems, obesity and metabolic problems, cardiovascular dysfunction, and a higher propensity to bone mineralization problems.
For example, delayed puberty due to Kallmann syndrome is caused by a reduction in the synthesis and release of gonadotropin-releasing hormones by the hypothalamus. In normal circumstances, this hormone contributes to testosterone synthesis and activates testicle growth during puberty, but patients with Kallmann syndrome need to induce their puberty with hormone replacement therapy and require long-term testosterone administration and especial treatment options to allow for fertility.
with thanks www.ncbi.nlm.nih.gov
Long-term consequences of delayed puberty without permanent Hypogonadism
The majority of cases of delayed puberty without permanent hypogonadism do not have major consequences, especially if we’re talking about a few months or one year. However, even self-limited delayed puberty may have long-term consequences because testosterone has protective effects in the musculoskeletal and cardiovascular system that every adult requires for good health. So, even though testosterone reaches normal levels in the majority of cases of CDGP, there are other consequences to consider later in life:
- A limited growth spurt: A shorter height is common among children with self-limited delayed puberty. This is because growth acceleration is delayed and many of them are unable to catch up with their peers’ height before their bone growth plates are closed. According to studies they are usually short by 4 to 11 cm compared to their predicted adult height, but there are disparate findings, and sometimes short stature is nothing more than a family trait.
- Bone mass density problems: Bone mass is important during puberty because it is consistently increased during these ages and reaches its peak by the mid-20s. According to studies, lower bone density at this age is a predictor of osteoporosis in later life. As a result, the risk of fractures in males increases by 39% for each year increase in age of puberty onset.
- Psychosocial consequences: Late-onset puberty causes anxiety and distress in young boys, and even if they ultimately undergo the expected changes, they are more likely to develop negative beliefs and attitudes, self-esteem problems, and adverse psychosocial outcomes, including early sexual behavior, depression, delinquency, and others.
- Metabolic and cardiovascular problems: After late-onset puberty, there’s a higher risk of metabolic syndrome and obesity among males, a higher risk of type 2 diabetes and various cardiovascular problems, including angina, heart attack and hypertension.
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Bozzola, M., Bozzola, E., Montalbano, C., Stamati, F. A., Ferrara, P., & Villani, A. (2018). Delayed puberty versus hypogonadism: a challenge for the pediatrician. Annals of pediatric endocrinology & metabolism, 23(2), 57.
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Harrington, J., & Palmert, M. R. (2012). Distinguishing constitutional delay of growth and puberty from isolated hypogonadotropic hypogonadism: critical appraisal of available diagnostic tests. The Journal of Clinical Endocrinology & Metabolism, 97(9), 3056-3067.