Management of delayed puberty in males

Males with delayed puberty resulting from permanent hypogonadotrophic hypogonadism or a primary testicular disorder need lifelong androgen replacement therapy to induce and maintain virilisation; see Male androgen deficiency.

Males with constitutional delay or a chronic medical condition may only need temporary androgen replacement (eg until spontaneous puberty occurs or the underlying condition is managed). Clear distinction between constitutional delay and delay due to chronic illness is difficult in adolescents, and they may represent a spectrum rather than discrete causes.

A decision to start androgen replacement therapy requires specialist evaluation of the physical and psychological effects of the pubertal delay. Fertility is also a consideration in determining when to start replacement. Preliminary data show that fertility outcomes for males with hypogonadotrophic hypogonadism may be improved by early gonadotrophin therapy (human chorionic gonadotrophin [hCG] and follicle stimulating hormone [FSH]) during puberty, ideally undertaken before testosterone therapy. Referral to a specialist centre is needed for gonadotrophin therapy.

Androgen replacement therapy requires specialist guidance because:

• excessive androgen may accelerate epiphyseal maturation, leading to premature epiphyseal closure
• a full adult dose of testosterone in previously untreated males can cause priapism.

Androgen replacement therapy is given for 3 months if constitutional delay is suspected, or 6 to 12 months for other potentially reversible causes. This is followed by a break of 3 months to check for spontaneous pubertal development. A typical regimen is:

If spontaneous pubertal development has not occurred and prolonged treatment is required, the testosterone dose can be gradually increased to the adult dose at a rate that produces the desired speed of maturation. The physical and psychological effects of treatment must be monitored.