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Expert Q&A

	By David L. Fay, M.D. Family Physician Associate Director, Waukesha Family Practice Residency Program

My son is 15 years of age, and he has not gone through puberty yet. I want to know if this is normal. I heard that some people do not go through puberty, and they need an operation to allow puberty to begin, but I am not sure if this is true. Is this normal?

Delayed puberty is variously defined as no sexual characteristic development by a certain age; depending on the author, this can be from 13 to 14 in females and 13.5 to 15 in males.

Pubertal changes are stratified into five stages called Tanner Stages 1-5. Stage 1 is prepubertal. Stage 2 is characterized by the first changes of puberty: slight enlargement of the testes and pigmentation of the scrotum, along with light hair growth at the base of the penis. During Stage 3 the penis begins to grow in length, and the scrotum develops wrinkles (rugae), while the pubic hair becomes coarser and curlier. Stage 4 brings other male-pattern hair (arms, chest, underarms) and further growth of the penis and testes. Stage 5 is adult development.

If a boy remains in Tanner Stage 1 after the age of 14, an evaluation is initiated which includes hormone levels (including testosterone), bone age studies and investigation of family history relevant to puberty. Occasionally imaging studies are done to look for tumors in or around the brain, although it is extremely rare for a tumor to be detected in patients without headache, weakness or visual defects. Bone age is the best predictor of puberty.

Surgery is generally only required in those rare instances of tumors. Most frequently the cause of delayed puberty is "idiopathic," or unknown, and the bone age is less than the chronological age. In the majority of these cases, family members have also had delayed puberty, and treatment is not necessary. The treatments used most often include testosterone and growth hormone, but are only useful if the patient has abnormal hormone levels.

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