Boys With Delayed puberty - PowerPoint PPT Presentation

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Boys With Delayed puberty

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

  2. 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

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

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

  5. 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)

  6. Delayed Puberty Types Constitutional Hypogonadotropin hypogonadism Hypergonadotropin hypogonadism

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

  8. What do you ask him?

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

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

  11. What's important in Physical examination?

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

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

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

  15. What's your differential diagnoses?

  16. What's your investigation?

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

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

  19. imaging BA=11.5yr MRI= Normal

  20. What's your treatment ?

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

  22. But Testicular volume &Testicular length did not change

  23. , Diagnosis? Any comments?

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

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

  26. Diagnosis? .

  27. Constitutional Delayed puberty

  28. . Discussion

  29. . • 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.

  30. 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.

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

  32. CDGP

  33. . 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

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

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

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

  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. . HT deficit at onset of puberty

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

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

  41. Diagnostic approach to delayed puberty

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

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

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