Delayed puberty

Last reviewed: 24 Aug 2023
Last updated: 23 May 2023



History and exam

Key diagnostic factors

  • boys: testes <4 mL
  • girls: absent breast development
  • absent pubic/axillary hair
  • absence of menarche >3 years from breast budding
  • absent growth spurt
  • anosmia
More key diagnostic factors

Other diagnostic factors

  • short stature
  • dysmorphic features
Other diagnostic factors

Risk factors

  • family history of delayed puberty
  • congenital pituitary structural abnormalities
  • gene mutations
  • chromosomal disorders
  • syndromic diagnosis
  • restrictive eating
  • chronic systemic illness
  • malnutrition
  • intense exercise
  • congenital testicular abnormalities
  • acquired gonadal abnormalities
  • pituitary surgery
  • adrenal hypoplasia
  • chemotherapy
  • radiation therapy
  • histiocytosis
  • sickle cell disease
  • iron overload (associated with transfusion)
More risk factors

Diagnostic investigations

1st investigations to order

  • Tanner staging
  • measurement of testicular size
  • nondominant wrist x-ray
  • basal follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
More 1st investigations to order

Investigations to consider

  • luteinizing hormone-releasing hormone stimulation test (LHRH)
  • inhibin B
  • anti-Mullerian hormone (AMH)
  • human chorionic gonadotropin (hCG) stimulation test
  • MRI brain
  • karyotype
  • ultrasound pelvis and abdomen
  • echocardiogram
  • serum ovarian autoantibodies
  • assessment of olfaction
  • thyroid function tests
  • serum prolactin
  • other pituitary hormone investigations
More investigations to consider

Emerging tests

  • overnight gonadotropin profile
  • genetic sequencing
  • measurement of LH following stimulation with kisspeptin

Treatment algorithm


constitutional delay

organic (permanent) cause: boys

organic (permanent) cause: girls

chronic illness or malnutrition


persistent hypogonadism postpuberty



Talat Mushtaq, ​BSc, MBCHB, MRCPCH, MD

Paediatric Endocrinology Consultant

Leeds Teaching Hospitals NHS Trust




TM has received support from Novo Nordisk and Pfizer to attend overseas conferences. He has also received honoraria from Kyowa Kirin for lectures and educational events.

​Sasha Howard, MBBS, MRCPCH, MSc, PhD

Senior Lecturer and Honorary Consultant in Paediatric Endocrinology

Queen Mary University of London

Barts Health NHS Trust




SH has received speaking honoraria from Sandoz and Novo Nordisk.


Dr Talat Mushtaq and Dr Sasha Howard would like to gratefully acknowledge Dr Ameeta Mehta and Professor Peter Hindmarsh, previous contributors to this topic.


AM and PH are authors of several references cited in this topic.

Peer reviewers

Nicola Bridges, DM, MRCP, FRCPCH

Consultant Paediatric Endocrinologist

Chelsea and Westminster Hospital

Honorary Senior Lecturer

Imperial College School of Medicine




NB declares that she has no competing interests.

Sara DiVall , MD

Associate Professor of Pediatrics

University of Washington




SD declares that she has no competing interests.

  • Delayed puberty images
  • Differentials

    • Premature ovarian failure
    • Premature testicular failure
    • Hypogonadotropic Hypogonadism
    More Differentials
  • Guidelines

    • Pubertal induction and transition to adult sex hormone replacement in patients with congenital pituitary or gonadal reproductive hormone deficiency
    • Society for Endocrinology UK guidance on the initial evaluation of a suspected difference or disorder of sex development (revised 2021)
    More Guidelines
  • Patient leaflets


    More Patient leaflets
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