# Delayed puberty - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/ · Egyptian drug register - availability only, no dose - Verified date: 2026-09 ## Verified against - Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/, Treatment / Management (testosterone 50-100 mg IM monthly for induction; 50 mg monthly rising to ~200 mg fortnightly for replacement; oestradiol at one-fourth to one-eighth of adult replacement) - Egyptian drug register (testosterone 250 mg/mL ampoules; undecanoate 750-1000 mg depots; no 25 microgram oestradiol patch) ## Treatment metadata - Testosterone oenanthate — 250 mg — injection - Estradiol valerate — 1 mg — oral.solid - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text DELAYED PUBERTY Sources: Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/ · Egyptian drug register - availability only, no dose Review status: REVIEWED against Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/, Treatment / Management (testosterone 50-100 mg IM monthly for induction; 50 mg monthly rising to ~200 mg fortnightly for replacement; oestradiol at one-fourth to one-eighth of adult replacement), Egyptian drug register (testosterone 250 mg/mL ampoules; undecanoate 750-1000 mg depots; no 25 microgram oestradiol patch) (2026-09) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (9) - A birth history of breech delivery, prolonged jaundice, low blood sugar, or a very small penis raises concern for combined pituitary hormone deficiency [hypoglycaemia · jaundice] - Missed developmental milestones or a known developmental delay can point toward an underlying genetic syndrome [developmental delay] - Ask directly whether breast growth, testicular enlargement, body odor, underarm or pubic hair, or acne have been noticed [acne] - Headache with blurred vision or visual field loss in a child warrants work-up for a brain mass [blurred vision · headache] - Milky nipple discharge unrelated to nursing suggests a prolactin-secreting cause of the delay [nipple discharge] - Very low caloric intake combined with heavy physical training can stall pubertal progress - Ask whether siblings or parents were themselves late developers - A history of alkylating chemotherapy or radiation to the pituitary region or gonads is directly relevant - Prior surgical correction of undescended testes or brain surgery near the pituitary can cause gonadal failure SIGNS - what you find (7) - Tanner stage must be documented at every visit to track pubertal progression - A normal Tanner stage can reassure the family and avoid an extensive work-up - An arm span more than 5 cm longer than height, or an upper-to-lower segment ratio under 0.85 to 0.80, points to hypogonadism - Slowed linear growth with weight preserved can point to a pituitary hormone deficiency - A midline facial defect or a single central upper incisor can signal pituitary involvement - CHARGE-syndrome features are linked to hypogonadotropic hypogonadism - Dysmorphic features of Turner, Noonan, Bardet-Biedl, or Prader-Willi syndrome accompany delayed puberty with short stature [dysmorphic features · short stature] TESTS (12) - Morning LH, FSH, and testosterone or estradiol using ultrasensitive assays indicate the current pubertal state and whether the cause is central or gonadal - A CBC, metabolic panel, thyroid function, celiac antibody, and inflammatory markers screen for systemic illness - Serum prolactin is checked, especially when the history or exam suggests hypogonadotropic hypogonadism - IGF-1 and growth hormone stimulation testing are needed if panhypopituitarism or GH deficiency is suspected - A GnRH stimulation test can separate isolated hypogonadotropic hypogonadism from constitutional delay when LH and FSH are unclear - No single test reliably tells these entities apart, so following the patient over time is often what settles the diagnosis - FSH-stimulated inhibin B above specific male and female cutoffs was 100 percent sensitive and specific for the start of puberty in one study - Karyotype, microarray, or next-generation sequencing is considered when a syndrome or genetic cause is suspected - A wrist and hand x-ray for bone age helps predict adult height and the stage of the process - Testicular ultrasound evaluates for an undescended testis or a palpable mass - Brain MRI is obtained when a mass such as a craniopharyngioma is suspected - Olfactory-cut brain MRI showing an absent olfactory sulcus or hypoplastic olfactory bulb supports Kallmann syndrome IF NOT THIS - what else fits (10) - A range of long-standing medical problems - low blood counts, gut, heart, kidney, or liver disease, or poor nutrition - can delay puberty - Anorexia nervosa, excessive exercise, depression, or anxiety are psychosocial contributors, especially noted in girls - Hypothyroidism, Cushing syndrome, or another endocrinopathy can slow pubertal onset - Constitutional delay of growth and puberty is suggested by a family history of late developers - Kallmann syndrome causes hypogonadotropic hypogonadism and is marked by absent olfactory structures on MRI - A brain mass or tumor is suggested by headache with visual field loss - Hyperprolactinemia is suggested by a history of galactorrhoea - Klinefelter syndrome is a genetic cause of hypergonadotropic hypogonadism in males - Turner syndrome is a genetic cause of hypergonadotropic hypogonadism in females - Prior radiation therapy or gonadal surgery is an acquired cause of hypergonadotropic hypogonadism Source Delayed puberty - disease-level clinical article (delayed-puberty-full.txt) Status traced to the source above Rx: Puberty induction and replacement in boys - specialist-initiated | Puberty induction in girls - specialist-initiated | Diagnosis, work-up and safety-netting PUBERTY INDUCTION AND REPLACEMENT IN BOYS - SPECIALIST-INITIATED 1. TESTOSTERONE OENANTHATE [1st line] Adult Lifelong replacement, where the cause is permanent: start at 50 mg intramuscularly monthly and increase every 4 to 6 months; about 200 mg fortnightly suffices for most men, reached roughly 3 years after starting. Once on adult replacement doses, a 12-weekly depot of testosterone undecanoate can be used instead - lifelong where the gonadal failure is permanent Peds This is the adolescent dose; these patients are teenagers. To start puberty in constitutional delay: "50 to 100 mg IM monthly for 3 to 6 months is sufficient to initiate pubertal development." It is a set amount, not calculated from weight, which is why no weight table is shown. Then reassess: the article says to monitor for signs of puberty - testicular enlargement in a boy - and if there are none by the end of the course, management is individualised with the family, discussing whether to repeat it or to wait. Subcutaneous injection is possible for a family giving it at home, though the article notes experience with that route is limited. Choice Alternatives named by the article: testosterone can be given orally or transdermally as well as intramuscularly, but "the IM route is most commonly used due to extensive clinical experience and predictable efficacy and safety", which is why it leads. Oral testosterone undecanoate (ANDRIOL 40 mg) is on the Egyptian register; the article states no oral dose. For a teenager whose concern is height rather than puberty, growth hormone has been used, but that is a different treatment with a different evidence base - see the caution on the referral row. Source Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/, Treatment / Management - verbatim, for permanent hypogonadism: "An example is starting replacement with testosterone enanthate or cypionate at 50 mg monthly, which can be increased every 4 to 6 months. The final adult dose varies individually, but approximately 200 mg fortnightly is sufficient for most males." For induction in constitutional delay: "Testosterone enanthate injection (or cypionate/propionate) at a dosage of 50 to 100 mg IM monthly for 3 to 6 months is sufficient to initiate pubertal development." Why Two different jobs with different regimens, and the distinction decides the course. In constitutional delay of growth and puberty the aim is only to start puberty off, and a short course does it - the article: intramuscular testosterone "is most commonly used due to extensive clinical experience and predictable efficacy and safety." In permanent gonadal failure the aim is lifelong replacement, built up slowly to an adult dose. Both are endocrinology's to start; the amounts are here because it is primary care that continues the injections and sees the boy in between. Caution Getting a 50 mg dose out of what Egypt stocks needs care. The register's usable injections are 250 mg/mL ampoules - CIDOTESTONE 250 mg, GONATESTON 250 mg/mL, TESTONON 250 mg/ml - so 50 to 100 mg means drawing a fraction of an ampoule. The old 100 mg CIDOTESTONE ampoule is marked discontinued. Testosterone cypionate is not marketed here at all. Do not use the long-acting undecanoate depot to start puberty. NEBIDO, DECAFORTIS and TESTERIOL are 750 to 1000 mg vials intended as a 12-weekly adult replacement dose - the article places undecanoate only after adult replacement levels have been reached. Starting a teenager on one is a large, irreversible dose of a drug that should be titrated. Monitor by blood level once on replacement, not by symptoms alone. The article: "Therapy can be monitored by serum testosterone levels, which should be targeted to the mid-range for age and pubertal stage." RED FLAG - Distinguish constitutional delay from permanent hypogonadism before committing to lifelong treatment, and exclude an intracranial cause first. The article's list of permanent causes that need lifelong supplementation includes congenital hypogonadotropic hypogonadism and idiopathic forms; a brain mass such as a craniopharyngioma is the diagnosis that must not be treated as a delay. Fertility is a separate treatment from puberty, and a separate conversation. The article: "Typically, human chorionic gonadotropin doses range from 500 to 3000 IU twice weekly" and "Recombinant FSH is used at doses of 75 to 225 IU 2 to 3 times weekly to achieve fertility in males with hypogonadotropic hypogonadism." It adds that clinicians must counsel carefully to set realistic expectations. Testosterone alone does not restore fertility. Egypt CIDOTESTONE 250 MG AMP. ACDIMA INTERN... 42.00 EGP PUBERTY INDUCTION IN GIRLS - SPECIALIST-INITIATED 2. ESTRADIOL VALERATE [2nd line] Adult Girls: begin at one-fourth to one-eighth of the adult replacement dose, orally or by patch, and increase gradually. Continue until breakthrough vaginal bleeding occurs or 12 to 24 months have passed, then add a progestogen to give regular monthly withdrawal bleeds. The exact starting fraction is the endocrinologist's x 12-24 months of oestrogen alone, then combined oestrogen and progestogen Peds These patients are teenagers; the dose above is the adolescent induction regimen. No milligram figure is printed for the oral route because the article states a fraction of adult replacement rather than an amount - so the actual tablet dose is set by the endocrinologist rather than by a stated number. Monitor for breast development as the sign that it is working. Source Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/, Treatment / Management - verbatim: "In girls with CDGP, 17-beta-estradiol administered orally or via a transdermal patch is the preferred therapy. Treatment is typically initiated at one-fourth to one-eighth of the adult replacement dose. A commonly used regimen involves a 25-microgram estradiol transdermal patch divided into 4 pieces and applied twice weekly for 4 to 6 months." Why The oestrogen equivalent of the testosterone row - a low dose to start breast development and the growth spurt, raised in steps rather than given at adult strength. The article on the later stage: "Estrogen is also used incrementally over time until breakthrough vaginal bleeding occurs or 12 to 24 months of treatment have passed. The recommendation is then for patients to start combination estrogen and progesterone therapy to maintain normal monthly withdrawal bleeding." The reason for the fraction is that a full adult dose too early fuses the growth plates and costs final height. Caution The patch regimen in the article cannot be reproduced exactly in Egypt. It quarters a 25 microgram patch; the register's smallest is FEM 7 50 microgram (with 75 and 100 microgram also listed), so an eighth of a 50 microgram patch would be needed to match. The oral route is the practical one here - ESTRAVODOSE estradiol valerate 1 mg and 2 mg tablets. Do not substitute a combined oral contraceptive, and do not substitute ethinylestradiol. The register lists ETHINYL OESTRADIOL 50 microgram under the name estradiol, but it is a different, far more potent oestrogen and is not what the article's regimen means by 17-beta-estradiol. The progestogen is added on a schedule, not at the start. Giving it too early blunts the breast development the treatment is for; the article's trigger for adding it is breakthrough bleeding or 12 to 24 months of oestrogen. RED FLAG - In a girl, delayed puberty with short stature raises Turner syndrome, and the article notes growth hormone is used in Turner syndrome. A karyotype is part of the work-up, and the diagnosis changes the whole plan - it is not simply a delay. Egypt ESTRAVODOSE 1 MG 28 F.C. TABS. TECHNOPHARM 33.00 EGP (1.18/unit) DIAGNOSIS, WORK-UP AND SAFETY-NETTING 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [3rd line] Adult Source No dose - the age cut-offs, the work-up and the red flags, from Delayed Puberty - StatPearls - NCBI Bookshelf (NBK544322) - https://www.ncbi.nlm.nih.gov/books/NBK544322/, Treatment / Management Why The hormone doses sit on the two rows above. They are printed because the source states them and because a card carries its treatment line rather than pointing away from it. Induction is still started and supervised by an endocrinologist - what is printed is what a GP needs in order to recognise the regimen, continue it safely between clinic visits, and know when the amount in front of them is wrong. What primary care owns is the part no prescription covers: recognising the age cut-offs, sending the first tests, and not calling it constitutional delay without looking for the causes that are not. Caution THE AGE CUT-OFFS - conventionally, puberty is called delayed at 13 years in a girl and at 14 years in a boy. In a girl that means no breast development by 13; or a gap of more than 5 years - some authors put it at 4 - between thelarche and menarche; or no periods by 16, which some experts bring down to 15. In a boy it shows as testes that have not enlarged by 14. PUBIC HAIR IS NOT PUBERTY - hair alone does not mark the start of puberty; it can come from adrenal androgens instead, which is adrenarche. What does mark it: in a girl, the breast bud - thelarche; in a boy, the testis growing, a volume of 4 mL or more, or a length above 2.5 cm. An orchidometer answers this; an impression does not. PUBERTY THAT STARTS AND THEN STOPS ALSO COUNTS - puberty can begin and then stall, progressing no further, and that arrest is itself abnormal. Where it takes longer than 4 years - other authors put the figure between 3 and 5 - to reach full puberty in a boy, or menarche in a girl, counting from the first sign, the child needs a full evaluation. THE FIRST BLOOD TESTS ARE ORDINARY ONES - LH and FSH taken in the morning, with testosterone or oestradiol, ideally on an ultra-sensitive assay, give the first clues. Alongside them, the ordinary screen: TSH and free T4; anti-tissue transglutaminase, which is looking for coeliac disease; ESR or CRP, or both, for chronic inflammation; a metabolic panel; and a full blood count. Coeliac disease and chronic inflammation present this way and are findable from a clinic. ADD THE WRIST FILM - a radiograph of the hand and the wrist on the non-dominant side gives a bone age. It helps predict the height the child will reach as an adult, and it places where the child currently sits in the sequence. THE RED FLAGS THAT CHANGE THE URGENCY - suspect a mass in the brain, a craniopharyngioma among them, and the child needs an MRI of the brain. Ask for olfactory cuts as well: in Kallmann syndrome the olfactory sulcus is missing, and the olfactory bulb is absent or underdeveloped. Ask the boy whether he can smell; headaches and visual change move this to the front of the queue. NO SINGLE TEST SETTLES IT, SO ARRANGE TO SEE THEM AGAIN - nothing on the list separates these diagnoses on its own, so the child is usually followed over months, and it is that passage of time which makes the answer clear. Booking a review in six months is a decision, not a delay. WHEN WAITING STOPS BEING REASONABLE - where constitutional delay is the likely explanation, waiting for puberty to arrive by itself is sensible up to roughly 15 to 15.5 years of age in a girl, and about 16 in a boy. Past those ages the odds of it starting spontaneously fall away steadily, and the case for treating grows. TAKE THE DISTRESS SERIOUSLY - being visibly out of step with the year group costs these teenagers: they withdraw socially, get bullied, think little of themselves, become anxious or low in mood, and struggle at school. The article treats bullying and falling school performance as part of the indication for treatment, not as a soft complaint. WHAT REASSURANCE ACTUALLY SOUNDS LIKE - in constitutional delay, tell the teenager and the parents two things. That the timing is a normal variant, not a disease. And that treating is unlikely to change the adult height he was going to reach anyway - which is often exactly what the family is most anxious about. GROWTH HORMONE IS NOT THE ANSWER TO THIS - for a teenager wanting height rather than puberty: growth hormone has never been shown to change the final adult height in constitutional delay, and the paediatric endocrine societies do not recommend it for that purpose. Saying no here is evidence-based, not obstructive. THE HORMONE DOSES ARE ON THE TWO ROWS ABOVE - they carry the induction and replacement regimens the article states, for boys and for girls. They are not started in primary care; they are printed because primary care continues them and needs to know what a correct dose looks like. Which regimen applies depends on whether the delay is constitutional or permanent, and that is the specialist's determination. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)