Boys With Delayed puberty

3. Boys With Delayed puberty Professor of Pediatric Endocrinology Isfahan University of Medical Sciences M. Hashemipour

4. Delayed puberty Girls Delay in onset of secondary sexual development by age12-13 primary amenorhoe at 15.5-16y Boys Delay in onset of secondary sexual development by age 14y

5. . mean duration from the onset of puberty to onset of menarche is 2.4 ±1.1 years

6. . Detained puberty Puberty has started but has not concluded after 5 years

7. Detained puberty A boy who has not completed his secondary sexual development, 4.5 years from the onset of puberty(T2) A girl who does not experience menses within 5 years from the onset of puberty(B2)

8. Delayed Puberty Types Constitutional Hypogonadotropin hypogonadism Hypergonadotropin hypogonadism

9. Medical history 14yr old boy Shortest in his class No problem at school Always looks small

10. What do you ask him?

11. No chronic disease Normal sense of smell Sexual function and patterns of body hair Known testicular abnormalities

12. : Social and family history • Student • Non-smoker • No siblings • Mother has arthritis • Father did not grow till he entered college

13. What's important in Physical examination?

15. Physical Examination No dysmorphic features CVS, Resp, Abd Exam are normal BP = 110/76 Ht= 135cm Zcore = -3.9 Wt= 30kg

16. Physical Examination Arm span – height span= 2cm Growth Velocity =5cm/yr

17. . Testicular volume =2.5ml Testicular length = 1.5cm Penis length = 6cm Normal Testicular consistency No Pubic & Axillary Hair No gynecomastia

18. What's your differential diagnoses?

19. What's your investigation?

20. Hormonal and Biochemical study Normal BUN & ESR Normal T4 &TSH Low IGF1& IGFBP3 for age Normal IGF1& IGFBP3 for BA Normal GH stimulation test

21. Hormonal and Biochemical study Testosterone= 0.15ng / ml Celiac test= ok Cortisol levels = ok GnRH test shows no response Low Gonadotropin Normal prolactin

22. imaging BA=11.5yr MRI= Normal

23. What's your treatment ?

24. We prescribed Oxandrolon for 6 months Zinc 12.5 mg/day Iron 12mg/day for 3 mo Vitamin A = 6000IU/week for 3 months

25. But Testicular volume &Testicular length did not change

26. , Diagnosis? Any comments?

27. Because of not response to treatment We prescribe : Testosteron 50mg every month for three months Letrozol 2.5mg/day

28. (Six month after stopping Testosteron) Testosteron level was 0.8ng/ml Testicular volume =5ml Testicular length = 3cm

30. Diagnosis? .

31. Constitutional Delayed puberty

32. . Discussion

33. . • CDGP is not a medical disorder, but a temporary condition • If treatment is necessary for a child, it must be emphasized that they are normal • Their “body clock” for puberty has just started later than their friends.

34. CDGP is a common condition Boys > girls Boys look young Normal physical examination No evidence for systemic disease No evidence for hormonal dysfunction Usually normal nutrition.

35. CDGP Short stature HT at or below 3rd percentile

36. CDGP

37. . p TH p p=BA p p p p HA < CA 8 8 8 8 8 8 8 BA < CA 8 8 8 8 8 BA=HA 8 8 8 8 8 8 8 8 GV= N 8

38. CDGP Delayed puberty and pubertal growth spurt Family history of delayed puberty

40. CDGP Normal growth rate for bone age Delay bone age 1 -3 years Normal height for bone age

41. Adult height HT reach within the lower part of mid parental target HT

42. p TH p p=BA p p p p HA < CA 8 8 8 8 8 8 8 BA < CA 8 8 8 8 8 BA=HA 8 8 8 8 8 8 8 8 GV= N 8

43. . HT deficit at onset of puberty

45. CDGP IGF-I is normal for BA Delayed Adrenarche

46. Nutrition CDGM Decreased vitamins A and D iron, and zinc deficiency

47. Diagnostic approach to delayed puberty

48. . Differentiation between HH and CDP is very difficult because: There is an overlap in physical and lab findings

49. Growth Chart Patients with HH have normal height in early or mid adolescence Patients with CDP are short

50. initialApproach Bone Age X-ray of the left hand and wrist to evaluate bone age