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    Delayed menarche with normal pubertal growth

    The Case

    A 14-year-old female presents for a wellness visit. On history, she is noted to not have started her menstrual cycle but on physical exam has significant breast and pubic hair development since the age of 10 years.

    Pertinent review of systems findings include that the patient has denied appetite changes and unexpected weight changes. She has no fevers, no night sweats, no headaches, no nipple discharge, no tachycardia, no palpitations, no constipation, no hair loss, no cold or heat intolerance, and no abdominal pain, nausea, vomiting, or diarrhea. She reports no cyclic pelvic or abdominal pain, vaginal bleeding, vaginal discharge, or vaginal pain; no eating disorder; and no increase in physical activity. The patient also does not exercise regularly.



    The patient does not have any significant past medical history. Her family history includes the mother, who started her menstrual cycle at age 12 years, and her sister, who started her menstrual cycle at age 10 years. The father is deceased from un known causes. The patient currently is not taking any medication.

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    Her social history includes living with her mother and older sister, and she is doing well in school at the appropriate grade level. She denies alcohol, drugs, and tobacco use. She denies sexual activity currently or in the past. She denies depression and anxiety, and has no history of mental illnesses. She is not concerned with not having a period.

    Physical exam

    The patient’s blood pressure (BP) is 147/92 mm Hg; pulse is 72 beats per minute; respiratory rate is 16 breaths per minute; and her oral temperature is 98.2°F. Her weight is 102.4 kg (225 lb 12 oz), which puts her at the 100th percentile for weight for age (see Growth Chart 1); her body mass index (BMI) is 30.91 kg/m2, which puts her at the 97th percentile for BMI (see Growth Chart 2); and her height is 1.82 m (5 ft 11.65 in), in the 100th percentile for stature for age (see Growth Chart 3).

    The patient is oriented to person, place, and time. She appears well developed and well nourished, and is noted to have elevated blood pressure. Head, eyes, nose, and throat exams are normal, as are lungs, abdominal, and cardiovascular exams. No hair loss or hirsutism are noted. Her skin is warm and dry. No acne is noted. A dark discoloration and velvety thickening of the skin is noted at the neck region consistent with acanthosis nigricans. The patient is Tanner stage IV for breast and pubic hair development.

    At this stage, a workup is initiated to rule out organic causes for delayed menarche in a teenaged girl with secondary sexual development.

    NEXT: Differential diagnosis

    Rachel S Dawson, DO, MPH, FAAP, FSAHM
    Dr Dawson is a pediatrician specializing in adolescent medicine at Baylor Scott & White Health, Killeen, Texas. She is director of the ...
    Rosa Cervantes, MSN, FNP
    Ms Cervantes is a family nurse practitioner in Fort Polk, Louisiana.


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