Diagnosing Pubertal Developmental Disorders. (Rare But Often Overlooked).

BALTIMORE -- If you don't particularly like evaluating the 17-year-old who has not reached menarche yet, refer her to an expert, Dr. Leo Plouffe Jr. advised.

Pubertal development disorders are so rare that "if you're not going to spend the time, you won't go broke not seeing those patients, so just refer them," Dr. Plouffe said at a reproductive endocrinology meeting sponsored by Johns Hopkins University.

Gynecologists often are the first to make a diagnosis of delayed puberty because many times it goes unrecognized by parents and even pediatricians. Still, for many gynecologists, recalling the basic physiology of puberty presents the major stumbling block.

"It wasn't the most thrilling part of our medical school days and so some of us didn't pay too much attention to it. I think the lack of a full grasp [of this] is what trips us up when it comes to working up patients with pubertal disorders," said Dr. Plouffe, medical director of women's health and reproductive medicine at Eli Lilly & Co., Indianapolis.

But if physicians do decide to manage such patients, here's what Dr. Plouffe said they need to know:

The great majority of children will progress through the very orderly and classic sequence from thelarche to adrenarche and menarche with no problems. Only about 5% of females run into trouble, developing either too early or too late. A girl who has had no sign of development by age 13 warrants an evaluation.

The key thing to remember about the sequence is that about 15% of girls will develop pubic hair before they develop breasts.