1

Puberty and the HPG axis

Puberty
The transient period between childhood and adulthood during which reproduction
function is attained.
Secondary sex characteristics develop (primary are present at birth), the adolescent
growth spurt occurs and profound psychological/physiological changes occur.
The gonads (testes/ovaries) acquire the capacity to produce mature gametes
(spermatozoa/oocytes) capable of fertilization.
Involves 2 endocrinological events: adrenarche and gonadarche
Gonads produce mature gametes:
Testes spermatozoa
Definitions:
Puberty: Puberty is a state of transition and is a collective term that encompasses all the changes that
occur in the growing individual during the transformation from a juvenile to a fertile adult.
Adrenarche: The increase in the activity of the adrenal glands just before puberty
Pubarche: appearance of pubic hair in a child during puberty
Gonadarche: the activation of the gonadal sex steroid production
Consonance: The smooth ordered progression of changes in puberty
GnRH- decapeptide synthesised and secreted by specialised neurons within the hypothalamus
GnRH pulse generator- collective group of hypothalamic neurons that discharge GnRH in
orchestrated manner
Gonadotrophs- cells in anterior pituitary that synthesise and secrete LH and FSH in response to GnRH
Gonadotrophins- LH and FSH stimulate the ovary and testis

2

Ovaries oocytes
The earliest detectable endocrine change associated with puberty is the progressive increase in the
plasma concentrations of adrenal androgens known as adrenarche. It occurs only in the great apes
and humans and spans 8-15yrs age
Adrenarche
Puberty of the adrenal androgensChange in adrenal androgen secretion
Gradual increase in adrenal androgens secretion from 6-8 18-20 years (20
fold increase peaking at ~20-25 years
The Adrenal androgens (from zona reticularis) are:
Dihydrotestosterone
Dehydroepiandrosterone (DHEA)
Dehydroepiandrosterone sulphate (DHEAS)
The secretion of androstenedione, 11-hydroxyandrostenedione and cortisol does not
change
DHEAS: from 6-8 years and 18-20 years of age there is a 20-fold increase in the
DHEAS secretion. At 20 to 25 years of age there is a peak of adrenal androgen
production (especially DHEAS) and thereafter secretion rates decline with age. This
decrease is referred to as adrenopause.
Decline thereafter = adrenopause
Mechanisms controlling adrenarche--NOT UNDERSTOOD

3

Pubarche
The appearance of pubic hair (this may be accompanied by axillary (armpit) hair
growth).
Induced by increase in adrenal androgen secretion.
Increase in adrenal androgens may be associated with comedonal (non-scarring) and
inflammatory acne due to an increase in the sebum production of pilosebaceous
units. Can result in acne if associated with infection, abnormal keratinisation or
immune influences.
Considered precocious / premature if occurs before 8 years of ages (girls) or 9 years
of age (boys).
Gonadarche
The activation of gonadal sex steroid production
Occurs several years after adrenarche.
Key effector is the gonadal steroid production
Activation of gonadal sex steroid synthesis and secretion is dependent on the release
of hypothalamic GnRH, which then acts on the pituitary to cause the release of the
gonadotrophins (LH and FSH). Gonadotrophins act on the gonads to stimulate
steroidogenesis.

Puberty depends on reactivation of GnRH release

Psychological/Emotional development during puberty
- increasing need for independence from parents
- increasing sexual awareness and interest
- development of personal sexuality
Consonance
Although the order of pubertal changes is uniform (the smooth ordered progression of
changes is termed consonance) the age of onset and both the pace and duration of
changes varies widely from one individual to another. Below, the sequence of major
changes that occur in puberty is given. This figure is adapted from a figure drawn in the
4

1970s and in this figure the average age of the onset of menarche is at about 13.5 years of
age. In Britain the average age of menarche is now about 12.5 years of age.

Tanner stages of puberty:


Recording the status of puberty
Jim Tanner and colleagues broke the development of i) pubic and axillary hair growth, ii)
breast and iii) male genitalia each into a set of 5 stages. This is referred to as Tanner stages
and these are used to describe the pubertal development of an individual.

FEMALES
MALES
ovulation
begins
breast bud
pubic hair begins
peak height spurt
menarche
pubic hair adult
breast adult
genital development begins
pubic hair begins
peak height spurt
genitalia adult
pubic hair adult
spermatogenesis
begins
8 12 16 20 years of age
5

Stages:
Female
Stage Breast development
1 Prepubertal. No breast tissue.
2 Areolar enlargement with breast bud.
3 Enlargement of breast and areola as single mound.
4 Projection of areola above breast as double mound.
5 Adult; papilla projects out of areola that is part of breast contour.
Male
Stage Genital development
1 Prepubertal.
2 Testes enlarge (4 ml); scrotum larger, reddened and skin coarser.
3 Penis enlarges, initially in length. Continued growth of testes and scrotum.
4 Penis grows in length & breadth; continued growth of testes & scrotum becomes
pigmented.
5 Testes, scrotum and penis adult size.
Both sexes
Stage Pubic hair development
1 None.
2 Few darker hairs along labia or at base of penis.
3 Curly pigmented hairs across pubes
4 Small adult configuration
5 Adult configuration with spread onto inner thighs.
6 Adult configuration with spread to linea alba.

HPG axis
The ovary is controlled by gonadotrophin release from the anterior pituitary which in turn is
stimulated by gonadotrophin releasing hormone from the hypothalamus (fig 1).
Modification of the signals occurs by nervous, steroidal and peptide input depending on the
time of the cycle.
HPG axis controls reproduction. The male and female gonadal function controlled by
feedback by:
hypothalamic and pituitary peptides and
gonadal steroids (and peptides)
6


Gonadotrophin releasing hormone (GnRH)
GnRH neurones reside in the hypothalamus, their cell bodies present in the preoptic
area (anterior part of the hypothalamus) and their nerve terminals in the ventral
hypothalamic area
The nerve terminals are in close proximity to capillary loops (the hypophyseal portal
system) which convey the blood supply to the anterior pituitary
GnRH released from the nerve terminals diffuses into the blood within the capillary
loops and passes through the portal system to act on the gonadotroph cells within
the pituitary (fig 2)
Gonadotroph cells synthesise and store the gonadotrophins, luteinising hormone
(LH) and follicle stimulating hormone (FSH)
GnRH acts on specific membrane bound receptors on the gonadotroph cells and
induces the LH and FSH synthesis and release into the circulation
GnRH is released by the hypothalamus in a pulsatile manner, approx. once every
hour
The occupation of the receptor by GnRH induces internalisation of the receptor
thereby removing the effect (figure 3)
Once GnRH levels fall the receptor is recycled to the surface in time for the next
pulse Paradoxically, GnRH agonists are used clinically to supress endogenous GnRH
release and this is due to the desensitization phenomenon (figure 4).


7

Figure 2

The gonadotrophins (LH & FSH)
The gonadotrophins are glycoproteins composed of 2 linked polypeptide chains,
designated as a and b subunits.
The a unit is the same for LH, FSH, TSH and b hCG but the b -unit is specific to each
hormone and confers the different biological activities.
Attached to these subunits are sugar or oligosaccharide structures, i.e. they are
glycosylated.
Ovarian steroids (oestradiol & progesterone)
The FSH and LH pass via the circulation to the ovaries where they act on specific
receptors to stimulate ovarian functions. These include the production of the ovarian
steroids, oestrogen (oestradiol (E
2
) is the main naturally occurring oestrogen)
testosterone and progesterone
Gonadotrophin receptors are G-coupled cell surface receptors using cAMP as the
second messenger
Oestrogen and progesterone control their own secretion by exerting a negative
feedback effect at the hypothalamic and pituitary levels thereby reducing LH and
FSH secretion
At the hypothalamus they inhibit the release of GnRH and at the pituitary level they
sensitise or desensitize the pituitary towards the action of GnRH by changing
receptor numbers, depending on the time of the cycle. Progesterone by itself has
very little feedback effect, it only synergises with oestradiol
Thus when the latter is exerting a negative feedback action, addition of progesterone
causes the oestrogen to suppress the GnRH levels further (this is the basis of the
contraceptive pill)
8

When oestrogen levels are high enough for long enough its feedback effect is altered
from a negative to a positive form.











9

Clinical application of GnRH
Discovery of the simple decapeptide structure of GnRH permitted development of
new drugs.
GnRH Synthetic: same structure as native GnRH
GnRH analogues- Single peptide replaced in the chain prevents the breakdown by
enzymes at the pituitary and receptor internalisation=Longer half-life and loss of
pulsatility
Can be used to stimulate or suppress the release of LH and FSH
Treatment with GnRH
Stimulation with native GnRH (not the analogue):
Reinstating missing hypothalamic function. i.e. induction of ovulation in women with
hypogonadotrophic hypogonadism
Always given in pulsatile fashion
Given in 1hr injections from automated pump
Use until cycle is established and conception occurs and placental and fetal
hormones take over
GnRH analogues
Inhibition of stimulation of gonad by removing LH and FSH by loss of
pulsatility
Never used for stimulation, always inhibition
ie, testicular cancer which is dependent on testosterone for growth
Uterine fibroids prior to surgery (oestrogen dependent)
Prevention of premature ovulation in IVF

GnRH analogues
Old versions tended to be agonist ie bind to and activate the receptor
Stimulate massive release for day or so until gonadotrophins in gonadotrophs
are depleted
Newer versions are antagonist
Bind to and block receptor without activation


10

LH/FSH/hCG
Peptide hormones with common a sub-unit and specific b sub-unit
.b sub-unit confers specificity of action
Sub-units are glycosylated
LH and FSH always released in pulses in normal reproductive function
Reason for pulses unclear as not needed for growth of follicle or spermatogenesis
ie., daily injection is OK
Pulses lost in unfit to reproduce conditions, but level falls also i.e. correct release is
dependent on extra-hypothalamic and extra-pituitary signals




Gonadotrophins are day/night sensitive
During puberty first rise in secretion is during sleep
11

Coincides with GH rise
Sleep-related rise persists in adulthood
Lost in weight-loss related amenorrhoea
Delayed puberty in children with sleep disorders
Travellers amenorrhoea due to jet lag
Gonadotrophin receptors
Gonadotrophins act via G-protein linked receptors-
2 distinct receptors but both use cAMP as second messenger
How does the cell know which hormone it is?
FSH low cAMP, LH high cAMP
Testis
FSH receptors on Sertoli cellsmake AMH etc
FSH and LH receptors on Leydig cells..make testosterone
Ovary
FSH receptors only on granulosa cells..make oestrogen
LH receptors always on theca cells and on differentiated granulosa cells and corpus luteum
General rule of LH and FSH
LH usually stimulates androgen production
FSH always stimulates oestrogen production
Androgen, oestrogen and progesterone control LH and FSH release by negative and
positive feedback on the hypothalamus and pituitary
Steroids
Oestrogens
12

Oestradiol 17b, but also oestrone
Progesterone.is just that.
Synthetic progesterones are known as progestagens
Androgens
Androstendione, testosterone, dihydrotestosterone


Puberty continued..
13

GnRH & HPG Axis








GnRH is synthesised & secreted by GnRH
neurones in the hypothalamus

stimulate pituitary to produce
gonadotrophins (LH & FSH)

stimulate gonads

Produce steroids that negatively/positively
feedback onto hypothalamus-pituitary
14

GnRH and Puberty:
GnRH neurones are neurosecretory cells have the capacity to synthesize and secrete
GnRH thereby stimulating the pituitary and gonads in utero and for the first 6 to 24
months of age post-natal.
At 16 gestational week activation of HPG axis. Pulsatile GnRH secretion in fetus and
1-2 years post natally. Declines until 9-10 years
GnRH neurones are restrained sometime during the post-natal period for the next
10 years. The mechanism for this is unknown.
Once the restraining mechanism has been removed the hypothalamus begins to
release GnRH in pulses. Each pulse elicits a pulse of gonadotrophin from the
pituitary gland. Initially the gonadal steroid output is low because:
i. The frequency of the gonadotrophin pulses is low and
ii. The hypothalamus is still very sensitive to the negative feedback effect of the
steroids.
Eventually an adult pattern of gonadal steroid secretion is reached when the
hypothalamus becomes less sensitive to the gonadal steroids and the frequency of
the pulses increases.
At puberty a gradual rise in pulsatile release











Activation model of
gonadotrophin axis in boys
Brain & Cognition (2010)
72:66-75
15









Changes in the pattern of
LH secretion occurring
during pubertal
development
LH pulsatility matches GnRH pulsatility
16

What stimulates the onset of puberty?
The timing of puberty is not a just a function of chronological age. However, the factors that
regulate and modulate the timing are not clearly defined. There are significant ethnic
differences between the timing of the onset of puberty. For example, in one US study 27%
of African-American girls compared to 7% white-American girls showed some secondary
sexual characteristics at 7 years of age. Based on monozygotic and dizygotic twin studies it
has been estimated that between 50 to 80% of the variance in the timing of pubertal onset
may be genetically controlled.

Clear that it is maturational event within the CNS
Inherent (genetic) maturation of 1000-3000 GnRH synthesising neurones - little
evidence in primates
Environmental factors photoperiod/seasonal
Body fat/nutrition
Leptin
Other gut hormones
Kisspeptin

Melatonin
Melatonin is synthesized in the absence of light by the pineal gland. At puberty, melatonin
secretion is reduced relative to increasing body mass and it has been postulated that this
reduces the inhibitory effect that melatonin has on GnRH neurone activity.

Melatonin is linked to the bodys circadian rhythm which is driven by the suprachiasmatic
nucleus. It provides a representation of the length of the night hence as the days shorten
and nights lengthen in autumn get an increase in the melatonin peak, which is detected in
the hypothalamus resulting in a decrease in GnRH secretion. This is a significant effect in
animals with seasonal breeding but not in humans who breed all year round. But what
about at puberty? Not much evidence.






17

Summary:
Pineal gland
Sleep hormone (produced only at night)
Anti-gonadotrophic
Fall in levels before puberty = start of puberty (related to body size?)


Average plasma concentrations of melatonin in plasma (black), saliva (blue) and a metabolite of
melatonin, 6-sulphatoxymelatonin (aMT6s), in urine (red).

Nutrition & body fat
Link between fat metabolism & reproduction
Secular trend to earlier age at menarche in girls from W.Europe & USA
average age of menarche onset (UK) is 12.5yrs
Malnutrition/Anorexia nervosa / intensive physical training
Reduced response to GnRH,
gonadotrophin levels
Amenorrhea
Restored when nourished / exercise stopped
18

Frisch et al.: body fat hypothesis
Certain % fat/body weight is required to maintain female reproductive ability
(22%)


Changes in age at menarche, 1840 to 1978, illustrating the advance in the age at menarche in
Western Europe and the United States since 1840 and the slowing of this trend since about
1965. (Modified from Tanner M, Eveleth PB. Variability between populations in growth and
development at puberty. In Berenberg SR, ed. Puberty, Biologic and Psychosocial Components.
Leiden: HE Stenfert Kroese, 1975:256-273.)
The body weight hypothesis: when children reach a critical body weight puberty begins. It
has been shown that body fat content is a better predictor of the onset of puberty than
body weight. Nutritional status affects puberty: under nutrition and strenuous activity can
delay the onset of puberty and chronic under nutrition in adults can return the reproductive
axis to the prepubertal state.
19





20




21

Leptin- can it trigger puberty?
Rise in leptin occurs ~ 2 years prior to puberty (increased GnRH pulsatility)
In starvation (low leptin) decreased activity of HPG axis
Obesity increases leptin and earlier puberty occurs
A permissive role for leptin not the driver?
No evidence of leptin receptors on GnRH neurones
In starvation (high ghrelin) decreased activity of the HPG axis
Ghrelin decreases as puberty proceeds
Low levels of leptin and high levels ghrelin decreased LH
Study:
1950s: ob/ob mouse
Hyperphagic
Obese
Hyperglycaemic
Insulin resistant
Infertile
ob/ob mouse leptin deficient
1994: leptin (ob) gene cloned
Expressed in adipocytes
Appetite suppression: tells brain it is in a fed state
Stimulates energy expenditure
Influence on reproductive system
Ob/ob mice & humans have low LH & infertile
Leptin administration in ob/ob mice restores fertility
Leptin receptors found extensively in hypothalamus
Women with exercise/anorexia-induced amenorrhea, leptin LH



22

Kisspeptin
A new neurohormone discovered
1996-2001: Novel gene discovered - a malignant melanoma metastis suppressor
gene kisspeptin/metastatin Kiss1 named after Hersheys Chocolate Kisses
(connection Pennsylvania)
Kisspeptin neurones found in arcuate & AVPV nuclei with projections to GnRH
neurones
The receptor for Kiss1 is G-protein coupled receptor, GPR54 found on GnRH
neurones
2003: Several members of 2 large consanguinous families hypogonadotrophic
hypogonadism all carrying homozygous mutation for GPR54. Caused LOSS of
GnRH

Kisspeptin: a new role?
Original observations in GPR54 null mice / humans (mutations):
Abnormal development of GnRH neurones hypogonadism
Failure to enter puberty
KO mice for GPR54 or kisspeptin hypothalamic hypogonadism
Mutations in humans- hypothalamic hypogonadism
23

Activating mutations of GPR 54 precocious puberty
Phenotype (mice)
Male: small testes and epididymus, delayed spermatogenesis but
sterile;
Female: small oviducts, folliculogenesis, no progression to ovulation,
no oestrous cycles

24

Kiss1 is released in pulses that match GnRH pulses and hence cause LH release
Different LH and FSH responses to increasing doses of kisspeptin

From Roa et al., Front.Neuroendocrinol 29: 48-69 (2008)

Kisspeptin stimulates the neuroendocrine reproductive axis
Sex steroids differentially regulate the expression of Kiss1 mRNA in different nuclei within
the forebrain
25




26





27


28


29







30



31



A new question?
Originally
what awakens the GnRH system?
Now
what awakens the kisspeptin / GPR54 / GnRH circuitry?
Some old theories being revisited
The question still remains what switches on puberty an integration of central and peripheral
inputs determined both by genetics and environment/nutrition









32


Physical & physiological changes in girls during puberty
Ovaries:
- Begin to increase in size
- Follicle growth and development (including steroidogenesis) is dependent
on gonadotrophins. Irregular pulses of gonadotrophin release stimulate
follicle growth and development past the preantral stage to stages of
development where the follicles produce oestrogen. Oestrogen is
responsible for the secondary sex characteristics.
Breasts
- Start to enlarge
- Initiation of breast development = thelarche
- First physical outward indication of the commencement of puberty
- In response to oestrogen secretion.
Pubic and axillary hair
- Begins to grow
- Stimulated by both adrenal androgens and ovarian androgens
Uterus
- Starts to enlarge.
- The uterine endometrium starts to develop when the growth spurt slows
down and oestrogen levels have continued to increase. Eventually, a
menstrual cycle occurs.
Uterine tubes
- Enlarge
Vagina
- Becomes wider and longer.
- Cytology changes: squamous epithelial cells
Cervix
- Cervical mucus production begins
External genitalia
- Increased fat deposition in the mons and labia majora
Height
- Initially small amounts of oestrogen stimulate the rate of cell division in the
epiphyseal cartilages of long bones giving rise to the growth spurt.
- Eventually oestrogen levels reach a level where they initiate epiphyseal
fusion and long bone growth ceases.
Body shape
- Pelvis widens
- Increase in fat deposition
Hypothalamo-pituitary-gondal axis
- There is maturation of the positive feedback effect of steroids on
gonadotrophin release
Onset of fertility
- Menarche is not equated with the onset of fertility. The first few menstrual
cycles are usually anovulatory. During the first year after menarche it has
33

been estimated that approximately 80% of menstrual cycles are anovulatory.
Even 6 years after menarche 20% of cycles may be anovulatory. Anovulation
in the period after menarche is largely a function of the failure of the
positive feedback effect to mature. It also takes time for the cycles to
become a regular length: initially the follicular phase will be longer and the
luteal phase, if present, shorter than in the adult.

Physical & physiological changes in boys during puberty:
External genitalia
- An increase in testicular volume (>4 ml or 2.5 cm in length) is the first
physical outward sign in males that puberty has begun. FSH stimulates
spermatogenesis, resulting in an increase in the diameter of the
seminiferous tubules whilst the LH stimulates androgen production by the
Leydig cells. The androgens produced by the testes (primarily testosterone)
stimulate the development of the secondary sex characteristics.
- As puberty progresses there is a continued increase in testicular volume, the
penis lengthens and thickens and scrotal skin changes in pigmentation and
rugosity
Pubic and axillary hair
- Begins to grow
- Stimulated by both adrenal androgens and testicular androgens
Vas Deferens
- The lumen increases in diameter in mid-puberty
Seminal vesicles, prostate gland and bulbourethral (Cowpers) glands
- As circulating testosterone concentrations increase they begin to enlarge
then start to produce their respective secretions that contribute to seminal
fluid
Larynx
- Enlarges >> Adams apple, a projection lying just under the skin of the
thyroid cartilage of the larynx, becomes prominent
- Voice deepens
Facial and body hair
- Starts to grow
Height
- Androgens may also stimulate the rate of cell division in the epiphyseal
cartilages of long bones giving rise to the growth spurt but it is more likely
that the greater height achieved by males in general is due to the longer
time taken for epiphyseal fusion to occur. Androgens are aromatised to
oestrogens in the cartilages. In the absence of increasing circulating
oestrogen concentrations resulting from ovarian secretion as occurs in girls,
the action of the oestrogen synthesized in situ on epiphyseal fusion occurs
later hence long bone growth occurs for longer.
Body shape
- Increase in muscle bulk (and also muscle strength)
- Decrease in fat deposition
Onset of fertility
34

- Even before circulating testosterone concentrations are sufficient to
stimulate the development of the secondary sex characteristics and well
before testosterone is detectable by radioimmunoassay, sufficient
testosterone is able to diffuse from the Leydig cells to the Sertoli cells and
stimulate meiosis in the spermatogonia
- Spermatozoa can be found in the urine of young boys at the very beginning
of puberty so although male fertility is a function of spermatozoa number,
potentially boys are fertile at the very beginning of pubertal development

Clinical Applications
Disorders
1. Precocious puberty
2. Precocious pseudopuberty
3. Delayed puberty
Ethnic variations
Precocious puberty development of secondary sexual characteristics: breasts and pubic
hair in girls under the age of 8 or testicular enlargement in boys under the age 9 or 10.
Pubertal changes are early but in consonance.
Ratio of girls:boys presenting in clinics with precocious puberty between 10:1-5:1
Delayed puberty range so wide - considered delayed if absence of menarche by 18yr or
lack of testicular development by 14yr
Delayed puberty more common in boys, ratio about 10:1

Precocious puberty
Gonadotrophin-dependent (or central) precocious puberty - consonance
Excess GnRH secretion - idiopathic or secondary
Excess gonadotrophin secretion - pituitary tumour
Gonadotrophin-independent precocious pseudopuberty (loss of consonance)
Testotoxicosis - activating mutation of LH receptor
McCune Albright - mutation of sub-unit of G protein- hyperactivity of endocrine glands
Sex steroid secreting tumour or exogenous steroids
Primary hypothyroidism (High TSH LH/FSH receptors)


35



Precocious puberty continued
Early development of GnRH pulses (rarely associated with a CNS cause e.g. tumours)
Increased BMI
Genetic - Russell-Silver syndrome,
McCune-Albright syndrome (MAS).
Investigations
Auxology (accurate measurement of height, including body proportions, and weight)
Steroid measurements: LH, FSH, sex steroid measurements
DHEA-S (premature pubarche/adrenarche)
LH levels: LH response to 100ug GnRH (normal for stage of puberty in central
precocious puberty, suppressed in testotoxicosis)
GnRH test (peak response >6-8 IU/L suggests precocious puberty)
Head MRI of hypothalamo-pituitary area
Pelvic ultrasound (ovarian pathology: uterus and ovaries)
Pubertal staging
Bone age estimation
Adrenal steroids- high with tumours, precursors high with CAH

Treatment:
Anti-androgens
5-reductase inhibitor (T --> 5-DHT)
Aromatse inhibitor
Long-acting GnRH analogue (central precocious puberty)
Growth Hormone

Precocious pseudo-puberty
Premature adrenarche/pubarche -precocious development of pubic and/or axillary
hairs - also CAH/Cushings
Premature thelarche - precocious breast development: isolated cyclical (< 2 years)
with absence of other pubertal development, or variant (> 2 years) proceeding to
precocious puberty
Non consonance
Causes
Congenital adrenal hyperplasia
Tumours of the ovary, adrenal or testis
hCG secreting tumours
36

McCune Albright syndrome
Exogenous sex steroids
Testotoxicosis
Delayed puberty
Define: no secondary sexual maturation by 13 in girls or 14 in boys
Impaired GnRH secretion
constitutional delay affecting both growth and puberty (most common),
hypothalamic/pituitary tumours,
genetic - Kallmans Syndrome
Hypogonadism -
Congenital e.g. Turners (45XO) and Klinefelters (47XXY)
Acquired (trauma, surgery, chemotherapy etc)
Secondary Hypogonadism -
Congenital e.g. Prader-Willi syndrome
Acquired (tumours, drugs etc)

Investigating delayed puberty
Family history, dysmorphic features, anosmia
Auxology (accurate measurement of height, including body proportions, and weight)
Pubertal staging
Bone age estimation based on above
LH, FSH, sex steroid measurements
LH response to 100ug GnRH
Adrenal steroids- high with tumours, precursors high with CAH
MR scans of hypothalamo-pituitary area
Ultrasound scans of pelvis (uterus and ovaries)

Treating delayed puberty
Testosterone (males)
Oestrogens (females)
Oxandralone (synthetic steroid)