Which of the following is consistent with a diagnosis of delayed puberty?

Significant emotional concerns develop when puberty is delayed. By definition, if breast development has not begun by age 13, delayed puberty should be suspected. Menarche usually follows about 1 to 2 years after the beginning of breast development; if menarche is delayed beyond age 16, delayed puberty should be investigated. Appropriate laboratory tests include circulating pituitary and steroid hormone levels, karyotypic analysis, and central nervous system (CNS) imaging when indicated. An FSH value greater than 40 mIU/mL defines hypergonadotropic hypogonadism as a cause of delayed pubertal maturation. Hypergonadotropic hypogonadism is seen in girls with gonadal dysgenesis, such as occurs with Turner syndrome. Since gonadal dysgenesis is such a common cause of absent pubertal development, hypergonadotropic hypogonadism is frequently but not invariably found in these patients.