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Page 1 of 17 PubertyTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH WILLIAM B. ZIPF, MD, FAAP Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH [email protected] T: 614/840-0535 F: 614/840-0536

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Page 1: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 1 of 17

PubertyTiming is everything

BELINDA PINYERD PhD RN

Central Ohio Pediatric Endocrinology and Diabetes Services

Columbus OH

WILLIAM B ZIPF MD FAAP

Central Ohio Pediatric Endocrinology and Diabetes Services

Columbus OH

BWResearchcolumbusrrcom

T 614840-0535

F 614840-0536

Page 2 of 17

ABSTRACT

Puberty is a dynamic period of physical growth sexual maturation and psychosocial

achievement that generally begins between age 8 and 14 years The age of onset varies as a

function of gender ethnicity health status genetics nutrition and activity level Puberty is

initiated by hormonal changes triggered by the hypothalamus Children with variants of

normal pubertal developmentboth early and late pubertyare common in pediatric

practice Recognizing when variations are normal and when referral for further evaluation is

indicated is an important skill

INTRODUCTION

Puberty derived from the Latin pubertas meaning adulthood is not a de novo event but a

process leading to physical sexual and psychosocial maturation (Blondell Foster amp Dave

1999) Puberty differs from adolescence in that it is just one change (maturation of the

reproductive system) that occurs during adolescence From a biological perspective puberty

is the stage of development during which an individual first attains fertility and is capable of

reproduction Physical changes that occur during puberty include somatic growth primary

sexual organ development (gonads and genitals) and the appearance of secondary sexual

characteristics (breasts and pubic hair) This paper reviews the hormonal processes

responsible for inducing puberty clinical indicators and staging of normal puberty and

psychosocial changes that accompany the physical maturation Abnormal puberty patterns

and guidelines for assessment are also reviewed

OVERVIEW REGULATION OF PUBERTY In normal puberty hormone secretion changes dramatically Central to the process is a

section of the brain called the hypothalamus which produces a substance called gonadotropin

releasing hormone (GnRH) During childhood GnRH secretion is minimal but with the onset

of puberty secretion of GnRH is enhanced The primary function of GnRH is to regulate

the growth development and function of the testes in the male and the ovaries in the

female GnRH signals the pituitary gland to secrete luteinizing hormone (LH) and follicle-

When its time to change you have to rearrange - Peter Brady

Page 3 of 17

stimulating hormone (FSH) (also known as gonadotropins) In boys LH stimulates

testosterone production and FSH promotes sperm production In girls both LH and FSH

are necessary for ovulation (rupture of follicle and release of egg from the ovary) while FSH

stimulates development and maturation of a follicle in one the ovaries

HORMONAL CHANGES Two processes contribute to the physical manifestations of puberty gonadarche the ovary or

testes component of puberty and adrenarche the adrenal gland component of puberty These

two components may seem to occur simultaneous and be a consequence of the same

phenomena but they are separate and distinct events

Gonadarche is initiated by cells of the hypothalamus that secrete GnRH During childhood

prior to the onset of puberty the hypothalamus gonadostat is exquisitely sensitive to very

low concentrations of sex steroids (androgens and estrogens) As a result GnRH secretion is

suppressed preventing LH and follicle-stimulating hormone FSH release from the pituitary

At the end of childhood the hypothalamus is released from the suppressive effects of the

sex steroids resulting in increased GnRH release and increased release of LH and FSH In

boys LH stimulates testosterone production and FSH supports sperm maturation In girls

FSH and LH stimulate ovary production of estrogen progesterone and testosterone all

necessary for normal menstruation (Lee 2003)

Adrenarche can occur separate from and without other signs of sexual development The

physical signs of adrenarche include the development of adult body odor increase in

testicular size and early changes in body growth axillary hair growth and development of

pubic hair (pubarche) Biochemically adrenarche actually begins earlier then these signs

Studies have shown that in both boys and girls at approximately six years there is an increase

production of adrenal hormones by the adrenal gland The stimulus of adrenarche has not

yet been determined but it is separate from the onset of pituitary secretion of LH and FSH

(Lalwani Reindollar amp Davis 2003)

While adrenarche begins biochemically in boys and girls at the same time pubarche (onset of

sexual hair development) occurs 6 to 12 months later in boys than girls In females the signs

Page 4 of 17

of adrenarche occur approximately six to 12 months after the onset of gonadarche

Physically it is observed that shortly after the onset of the first signs of breast development

(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen

secretion For some girls this sequence is reversed Recently there is greater attention being

given to this component of puberty because abnormalities in the timing of adrenarche have

been shown to be associated with irregular menstrual cycles obesity insulin resistance and

increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche

cannot be distinguished from the signs of gonadarche However the presence of pubarche

without a change in testicular size is usually a sign that gonadarche has not yet begun

STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast

development adrenarche menarche) on average requiring a period of 45 years (range 156

years) with girls beginning puberty earlier than boys In fact most information available

about the timing of puberty is for girls as breast development and onset of menstruation

(menarche) are more overt and recordable than changes in penis and testicle size in boys

Several factors in addition to gender and ethnicity impact the timing of puberty including

genetics dietary intake and energy expenditure Genetic factors play an important role as

illustrated by the similar age of menarche in members of an ethnic population and in

mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal

versus vegetable) amount of dietary fat and total calories has also been related to onset of

puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both

sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg

anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the

onset of puberty (Warren amp Vu 2003)

What specifically triggers the onset is still debated The attainment of a particular proportion

of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant

2002) Interest in this theory has intensified recently as a result of delayed puberty noted in

athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried

2001)

Page 5 of 17

Females

The first visible sign of sexual maturation is the appearance of breast buds generally

around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally

complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first

sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair

growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the

next three years the pubic hair becomes darker curlier and coarser and spread to cover a

larger area Hair also develops under the arms on the arms and legs and to a slight degree

on the face

The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually

occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually

anovulatory which is associated with irregular and often painful periods After

approximately one to two years the menstrual cycles become ovulatory and more regular

(Zacharias Rand amp Wurtman 1976

Males

For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is

followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum

begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens

and widens taking several years to reach full size Sperm production coincides with testicular

and penile growth generally occurring at age 13514 years Facial hair appears about three

years after the onset of pubic hair growth first in the mustache area above the upper lip and

later at the sides of the face and on the chin The density and distribution of hair growth

varies considerably among adult men and is correlated more with genetic factors than with

hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately

two-thirds of males some time during puberty Onset may coincide with the onset of puberty

but primarily begins at ages 1314 before testosterone levels have reached adult levels Most

commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)

Page 6 of 17

OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt

During puberty females and males experience a growth velocity greater than at any postnatal

age since infancy The pubertal growth spurt in girls is usually observed along with the first

signs of puberty (breast development and pubic hair) Peak growth occurs when breast

development is between Tanner stages 2 and 3 Because girls reach peak height velocity

about 13 years before menarche there is limited growth potential after menarche most girls

grow only about 25 cm in height after menarche although there is a variation from 1 to as

much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in

males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly

rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31

cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth

(Abbassi 1998)

In both males and females the ages at menarche and peak height velocity are not good

predictors of adult height because the duration of pubertal growth is the more important

determinant of final height Nonetheless extremely early onset of puberty can diminish

ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp

Juranger 1991) can increase stature

Acne

Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of

gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe

acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs

at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with

advancement through puberty However acne vulgaris can be the first notable sign of

puberty in a girl preceding public hair and breast development

Mood and depression

During puberty young girls frequently exhibit a negative self-image Prepubertal boys and

girls demonstrate an equal frequency of depression although there is a more frequent

occurrence in girls at stage 3 This change in the prevalence of depression appears more

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 2: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 2 of 17

ABSTRACT

Puberty is a dynamic period of physical growth sexual maturation and psychosocial

achievement that generally begins between age 8 and 14 years The age of onset varies as a

function of gender ethnicity health status genetics nutrition and activity level Puberty is

initiated by hormonal changes triggered by the hypothalamus Children with variants of

normal pubertal developmentboth early and late pubertyare common in pediatric

practice Recognizing when variations are normal and when referral for further evaluation is

indicated is an important skill

INTRODUCTION

Puberty derived from the Latin pubertas meaning adulthood is not a de novo event but a

process leading to physical sexual and psychosocial maturation (Blondell Foster amp Dave

1999) Puberty differs from adolescence in that it is just one change (maturation of the

reproductive system) that occurs during adolescence From a biological perspective puberty

is the stage of development during which an individual first attains fertility and is capable of

reproduction Physical changes that occur during puberty include somatic growth primary

sexual organ development (gonads and genitals) and the appearance of secondary sexual

characteristics (breasts and pubic hair) This paper reviews the hormonal processes

responsible for inducing puberty clinical indicators and staging of normal puberty and

psychosocial changes that accompany the physical maturation Abnormal puberty patterns

and guidelines for assessment are also reviewed

OVERVIEW REGULATION OF PUBERTY In normal puberty hormone secretion changes dramatically Central to the process is a

section of the brain called the hypothalamus which produces a substance called gonadotropin

releasing hormone (GnRH) During childhood GnRH secretion is minimal but with the onset

of puberty secretion of GnRH is enhanced The primary function of GnRH is to regulate

the growth development and function of the testes in the male and the ovaries in the

female GnRH signals the pituitary gland to secrete luteinizing hormone (LH) and follicle-

When its time to change you have to rearrange - Peter Brady

Page 3 of 17

stimulating hormone (FSH) (also known as gonadotropins) In boys LH stimulates

testosterone production and FSH promotes sperm production In girls both LH and FSH

are necessary for ovulation (rupture of follicle and release of egg from the ovary) while FSH

stimulates development and maturation of a follicle in one the ovaries

HORMONAL CHANGES Two processes contribute to the physical manifestations of puberty gonadarche the ovary or

testes component of puberty and adrenarche the adrenal gland component of puberty These

two components may seem to occur simultaneous and be a consequence of the same

phenomena but they are separate and distinct events

Gonadarche is initiated by cells of the hypothalamus that secrete GnRH During childhood

prior to the onset of puberty the hypothalamus gonadostat is exquisitely sensitive to very

low concentrations of sex steroids (androgens and estrogens) As a result GnRH secretion is

suppressed preventing LH and follicle-stimulating hormone FSH release from the pituitary

At the end of childhood the hypothalamus is released from the suppressive effects of the

sex steroids resulting in increased GnRH release and increased release of LH and FSH In

boys LH stimulates testosterone production and FSH supports sperm maturation In girls

FSH and LH stimulate ovary production of estrogen progesterone and testosterone all

necessary for normal menstruation (Lee 2003)

Adrenarche can occur separate from and without other signs of sexual development The

physical signs of adrenarche include the development of adult body odor increase in

testicular size and early changes in body growth axillary hair growth and development of

pubic hair (pubarche) Biochemically adrenarche actually begins earlier then these signs

Studies have shown that in both boys and girls at approximately six years there is an increase

production of adrenal hormones by the adrenal gland The stimulus of adrenarche has not

yet been determined but it is separate from the onset of pituitary secretion of LH and FSH

(Lalwani Reindollar amp Davis 2003)

While adrenarche begins biochemically in boys and girls at the same time pubarche (onset of

sexual hair development) occurs 6 to 12 months later in boys than girls In females the signs

Page 4 of 17

of adrenarche occur approximately six to 12 months after the onset of gonadarche

Physically it is observed that shortly after the onset of the first signs of breast development

(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen

secretion For some girls this sequence is reversed Recently there is greater attention being

given to this component of puberty because abnormalities in the timing of adrenarche have

been shown to be associated with irregular menstrual cycles obesity insulin resistance and

increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche

cannot be distinguished from the signs of gonadarche However the presence of pubarche

without a change in testicular size is usually a sign that gonadarche has not yet begun

STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast

development adrenarche menarche) on average requiring a period of 45 years (range 156

years) with girls beginning puberty earlier than boys In fact most information available

about the timing of puberty is for girls as breast development and onset of menstruation

(menarche) are more overt and recordable than changes in penis and testicle size in boys

Several factors in addition to gender and ethnicity impact the timing of puberty including

genetics dietary intake and energy expenditure Genetic factors play an important role as

illustrated by the similar age of menarche in members of an ethnic population and in

mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal

versus vegetable) amount of dietary fat and total calories has also been related to onset of

puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both

sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg

anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the

onset of puberty (Warren amp Vu 2003)

What specifically triggers the onset is still debated The attainment of a particular proportion

of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant

2002) Interest in this theory has intensified recently as a result of delayed puberty noted in

athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried

2001)

Page 5 of 17

Females

The first visible sign of sexual maturation is the appearance of breast buds generally

around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally

complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first

sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair

growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the

next three years the pubic hair becomes darker curlier and coarser and spread to cover a

larger area Hair also develops under the arms on the arms and legs and to a slight degree

on the face

The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually

occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually

anovulatory which is associated with irregular and often painful periods After

approximately one to two years the menstrual cycles become ovulatory and more regular

(Zacharias Rand amp Wurtman 1976

Males

For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is

followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum

begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens

and widens taking several years to reach full size Sperm production coincides with testicular

and penile growth generally occurring at age 13514 years Facial hair appears about three

years after the onset of pubic hair growth first in the mustache area above the upper lip and

later at the sides of the face and on the chin The density and distribution of hair growth

varies considerably among adult men and is correlated more with genetic factors than with

hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately

two-thirds of males some time during puberty Onset may coincide with the onset of puberty

but primarily begins at ages 1314 before testosterone levels have reached adult levels Most

commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)

Page 6 of 17

OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt

During puberty females and males experience a growth velocity greater than at any postnatal

age since infancy The pubertal growth spurt in girls is usually observed along with the first

signs of puberty (breast development and pubic hair) Peak growth occurs when breast

development is between Tanner stages 2 and 3 Because girls reach peak height velocity

about 13 years before menarche there is limited growth potential after menarche most girls

grow only about 25 cm in height after menarche although there is a variation from 1 to as

much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in

males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly

rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31

cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth

(Abbassi 1998)

In both males and females the ages at menarche and peak height velocity are not good

predictors of adult height because the duration of pubertal growth is the more important

determinant of final height Nonetheless extremely early onset of puberty can diminish

ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp

Juranger 1991) can increase stature

Acne

Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of

gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe

acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs

at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with

advancement through puberty However acne vulgaris can be the first notable sign of

puberty in a girl preceding public hair and breast development

Mood and depression

During puberty young girls frequently exhibit a negative self-image Prepubertal boys and

girls demonstrate an equal frequency of depression although there is a more frequent

occurrence in girls at stage 3 This change in the prevalence of depression appears more

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 3: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 3 of 17

stimulating hormone (FSH) (also known as gonadotropins) In boys LH stimulates

testosterone production and FSH promotes sperm production In girls both LH and FSH

are necessary for ovulation (rupture of follicle and release of egg from the ovary) while FSH

stimulates development and maturation of a follicle in one the ovaries

HORMONAL CHANGES Two processes contribute to the physical manifestations of puberty gonadarche the ovary or

testes component of puberty and adrenarche the adrenal gland component of puberty These

two components may seem to occur simultaneous and be a consequence of the same

phenomena but they are separate and distinct events

Gonadarche is initiated by cells of the hypothalamus that secrete GnRH During childhood

prior to the onset of puberty the hypothalamus gonadostat is exquisitely sensitive to very

low concentrations of sex steroids (androgens and estrogens) As a result GnRH secretion is

suppressed preventing LH and follicle-stimulating hormone FSH release from the pituitary

At the end of childhood the hypothalamus is released from the suppressive effects of the

sex steroids resulting in increased GnRH release and increased release of LH and FSH In

boys LH stimulates testosterone production and FSH supports sperm maturation In girls

FSH and LH stimulate ovary production of estrogen progesterone and testosterone all

necessary for normal menstruation (Lee 2003)

Adrenarche can occur separate from and without other signs of sexual development The

physical signs of adrenarche include the development of adult body odor increase in

testicular size and early changes in body growth axillary hair growth and development of

pubic hair (pubarche) Biochemically adrenarche actually begins earlier then these signs

Studies have shown that in both boys and girls at approximately six years there is an increase

production of adrenal hormones by the adrenal gland The stimulus of adrenarche has not

yet been determined but it is separate from the onset of pituitary secretion of LH and FSH

(Lalwani Reindollar amp Davis 2003)

While adrenarche begins biochemically in boys and girls at the same time pubarche (onset of

sexual hair development) occurs 6 to 12 months later in boys than girls In females the signs

Page 4 of 17

of adrenarche occur approximately six to 12 months after the onset of gonadarche

Physically it is observed that shortly after the onset of the first signs of breast development

(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen

secretion For some girls this sequence is reversed Recently there is greater attention being

given to this component of puberty because abnormalities in the timing of adrenarche have

been shown to be associated with irregular menstrual cycles obesity insulin resistance and

increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche

cannot be distinguished from the signs of gonadarche However the presence of pubarche

without a change in testicular size is usually a sign that gonadarche has not yet begun

STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast

development adrenarche menarche) on average requiring a period of 45 years (range 156

years) with girls beginning puberty earlier than boys In fact most information available

about the timing of puberty is for girls as breast development and onset of menstruation

(menarche) are more overt and recordable than changes in penis and testicle size in boys

Several factors in addition to gender and ethnicity impact the timing of puberty including

genetics dietary intake and energy expenditure Genetic factors play an important role as

illustrated by the similar age of menarche in members of an ethnic population and in

mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal

versus vegetable) amount of dietary fat and total calories has also been related to onset of

puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both

sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg

anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the

onset of puberty (Warren amp Vu 2003)

What specifically triggers the onset is still debated The attainment of a particular proportion

of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant

2002) Interest in this theory has intensified recently as a result of delayed puberty noted in

athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried

2001)

Page 5 of 17

Females

The first visible sign of sexual maturation is the appearance of breast buds generally

around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally

complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first

sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair

growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the

next three years the pubic hair becomes darker curlier and coarser and spread to cover a

larger area Hair also develops under the arms on the arms and legs and to a slight degree

on the face

The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually

occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually

anovulatory which is associated with irregular and often painful periods After

approximately one to two years the menstrual cycles become ovulatory and more regular

(Zacharias Rand amp Wurtman 1976

Males

For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is

followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum

begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens

and widens taking several years to reach full size Sperm production coincides with testicular

and penile growth generally occurring at age 13514 years Facial hair appears about three

years after the onset of pubic hair growth first in the mustache area above the upper lip and

later at the sides of the face and on the chin The density and distribution of hair growth

varies considerably among adult men and is correlated more with genetic factors than with

hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately

two-thirds of males some time during puberty Onset may coincide with the onset of puberty

but primarily begins at ages 1314 before testosterone levels have reached adult levels Most

commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)

Page 6 of 17

OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt

During puberty females and males experience a growth velocity greater than at any postnatal

age since infancy The pubertal growth spurt in girls is usually observed along with the first

signs of puberty (breast development and pubic hair) Peak growth occurs when breast

development is between Tanner stages 2 and 3 Because girls reach peak height velocity

about 13 years before menarche there is limited growth potential after menarche most girls

grow only about 25 cm in height after menarche although there is a variation from 1 to as

much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in

males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly

rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31

cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth

(Abbassi 1998)

In both males and females the ages at menarche and peak height velocity are not good

predictors of adult height because the duration of pubertal growth is the more important

determinant of final height Nonetheless extremely early onset of puberty can diminish

ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp

Juranger 1991) can increase stature

Acne

Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of

gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe

acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs

at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with

advancement through puberty However acne vulgaris can be the first notable sign of

puberty in a girl preceding public hair and breast development

Mood and depression

During puberty young girls frequently exhibit a negative self-image Prepubertal boys and

girls demonstrate an equal frequency of depression although there is a more frequent

occurrence in girls at stage 3 This change in the prevalence of depression appears more

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 4: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 4 of 17

of adrenarche occur approximately six to 12 months after the onset of gonadarche

Physically it is observed that shortly after the onset of the first signs of breast development

(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen

secretion For some girls this sequence is reversed Recently there is greater attention being

given to this component of puberty because abnormalities in the timing of adrenarche have

been shown to be associated with irregular menstrual cycles obesity insulin resistance and

increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche

cannot be distinguished from the signs of gonadarche However the presence of pubarche

without a change in testicular size is usually a sign that gonadarche has not yet begun

STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast

development adrenarche menarche) on average requiring a period of 45 years (range 156

years) with girls beginning puberty earlier than boys In fact most information available

about the timing of puberty is for girls as breast development and onset of menstruation

(menarche) are more overt and recordable than changes in penis and testicle size in boys

Several factors in addition to gender and ethnicity impact the timing of puberty including

genetics dietary intake and energy expenditure Genetic factors play an important role as

illustrated by the similar age of menarche in members of an ethnic population and in

mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal

versus vegetable) amount of dietary fat and total calories has also been related to onset of

puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both

sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg

anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the

onset of puberty (Warren amp Vu 2003)

What specifically triggers the onset is still debated The attainment of a particular proportion

of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant

2002) Interest in this theory has intensified recently as a result of delayed puberty noted in

athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried

2001)

Page 5 of 17

Females

The first visible sign of sexual maturation is the appearance of breast buds generally

around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally

complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first

sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair

growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the

next three years the pubic hair becomes darker curlier and coarser and spread to cover a

larger area Hair also develops under the arms on the arms and legs and to a slight degree

on the face

The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually

occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually

anovulatory which is associated with irregular and often painful periods After

approximately one to two years the menstrual cycles become ovulatory and more regular

(Zacharias Rand amp Wurtman 1976

Males

For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is

followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum

begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens

and widens taking several years to reach full size Sperm production coincides with testicular

and penile growth generally occurring at age 13514 years Facial hair appears about three

years after the onset of pubic hair growth first in the mustache area above the upper lip and

later at the sides of the face and on the chin The density and distribution of hair growth

varies considerably among adult men and is correlated more with genetic factors than with

hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately

two-thirds of males some time during puberty Onset may coincide with the onset of puberty

but primarily begins at ages 1314 before testosterone levels have reached adult levels Most

commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)

Page 6 of 17

OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt

During puberty females and males experience a growth velocity greater than at any postnatal

age since infancy The pubertal growth spurt in girls is usually observed along with the first

signs of puberty (breast development and pubic hair) Peak growth occurs when breast

development is between Tanner stages 2 and 3 Because girls reach peak height velocity

about 13 years before menarche there is limited growth potential after menarche most girls

grow only about 25 cm in height after menarche although there is a variation from 1 to as

much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in

males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly

rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31

cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth

(Abbassi 1998)

In both males and females the ages at menarche and peak height velocity are not good

predictors of adult height because the duration of pubertal growth is the more important

determinant of final height Nonetheless extremely early onset of puberty can diminish

ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp

Juranger 1991) can increase stature

Acne

Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of

gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe

acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs

at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with

advancement through puberty However acne vulgaris can be the first notable sign of

puberty in a girl preceding public hair and breast development

Mood and depression

During puberty young girls frequently exhibit a negative self-image Prepubertal boys and

girls demonstrate an equal frequency of depression although there is a more frequent

occurrence in girls at stage 3 This change in the prevalence of depression appears more

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 5: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 5 of 17

Females

The first visible sign of sexual maturation is the appearance of breast buds generally

around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally

complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first

sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair

growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the

next three years the pubic hair becomes darker curlier and coarser and spread to cover a

larger area Hair also develops under the arms on the arms and legs and to a slight degree

on the face

The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually

occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually

anovulatory which is associated with irregular and often painful periods After

approximately one to two years the menstrual cycles become ovulatory and more regular

(Zacharias Rand amp Wurtman 1976

Males

For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is

followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum

begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens

and widens taking several years to reach full size Sperm production coincides with testicular

and penile growth generally occurring at age 13514 years Facial hair appears about three

years after the onset of pubic hair growth first in the mustache area above the upper lip and

later at the sides of the face and on the chin The density and distribution of hair growth

varies considerably among adult men and is correlated more with genetic factors than with

hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately

two-thirds of males some time during puberty Onset may coincide with the onset of puberty

but primarily begins at ages 1314 before testosterone levels have reached adult levels Most

commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)

Page 6 of 17

OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt

During puberty females and males experience a growth velocity greater than at any postnatal

age since infancy The pubertal growth spurt in girls is usually observed along with the first

signs of puberty (breast development and pubic hair) Peak growth occurs when breast

development is between Tanner stages 2 and 3 Because girls reach peak height velocity

about 13 years before menarche there is limited growth potential after menarche most girls

grow only about 25 cm in height after menarche although there is a variation from 1 to as

much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in

males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly

rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31

cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth

(Abbassi 1998)

In both males and females the ages at menarche and peak height velocity are not good

predictors of adult height because the duration of pubertal growth is the more important

determinant of final height Nonetheless extremely early onset of puberty can diminish

ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp

Juranger 1991) can increase stature

Acne

Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of

gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe

acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs

at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with

advancement through puberty However acne vulgaris can be the first notable sign of

puberty in a girl preceding public hair and breast development

Mood and depression

During puberty young girls frequently exhibit a negative self-image Prepubertal boys and

girls demonstrate an equal frequency of depression although there is a more frequent

occurrence in girls at stage 3 This change in the prevalence of depression appears more

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 6: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 6 of 17

OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt

During puberty females and males experience a growth velocity greater than at any postnatal

age since infancy The pubertal growth spurt in girls is usually observed along with the first

signs of puberty (breast development and pubic hair) Peak growth occurs when breast

development is between Tanner stages 2 and 3 Because girls reach peak height velocity

about 13 years before menarche there is limited growth potential after menarche most girls

grow only about 25 cm in height after menarche although there is a variation from 1 to as

much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in

males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly

rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31

cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth

(Abbassi 1998)

In both males and females the ages at menarche and peak height velocity are not good

predictors of adult height because the duration of pubertal growth is the more important

determinant of final height Nonetheless extremely early onset of puberty can diminish

ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp

Juranger 1991) can increase stature

Acne

Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of

gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe

acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs

at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with

advancement through puberty However acne vulgaris can be the first notable sign of

puberty in a girl preceding public hair and breast development

Mood and depression

During puberty young girls frequently exhibit a negative self-image Prepubertal boys and

girls demonstrate an equal frequency of depression although there is a more frequent

occurrence in girls at stage 3 This change in the prevalence of depression appears more

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 7: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 7 of 17

related to serum sex steroid concentrations than to LH or FSH values or the physical

changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide

increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-

to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually

committed suicide during puberty had the onset of their depression in childhood or early

puberty even though the act of suicide occurred later in puberty (Rao et al 1993)

Body image

An important aspect of puberty is the development of body image Body image is a persons

inner conception of hisher physical appearance As obvious from the previous discussion

adolescence is a time of great physical and social change Adolescents are critical and

embarrassed about their bodies during puberty either because they are maturing too early

too late or they are not developing according to societals standards of attractiveness

Adolescent girls appear to be particularly vulnerable to developing a negative body image

especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis

1999) Adolescents with severe body image distortions are vulnerable to developing

psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)

Psychosocial changes

Puberty includes a profound social change from the sheltered single-classroom environment

of elementary school to the multiple classrooms and teachers of middle school (Mayer amp

Carter 2003) There is exposure to new peers often with different life experiences and

behavior patterns Risk-taking behaviors often increase including sexual precocity and

alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child

entering puberty develops maturing abstract thought and decision-making processes Other

psychological and psychosocial changes that occur during this time include the ability to

absorb the perspectives or viewpoints of others the development of personal and sexual

identity the establishment of a system of values and increasing autonomy from family

(Remschmidt 1994)

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 8: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 8 of 17

ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years

recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the

threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was

defined as pubic hair developing in girls younger than 8 years old and boys younger than 9

years However the results of a large cross-sectional study (Herman-Giddens Slora amp

Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous

studies have documented with pubic hair development appearing in white girls as young as 7

years (between 711 years) and in African American girls as young as 6 years (between 611

years) The timing of puberty is significant from a clinical standpoint given the observation

that early-maturing girls and late-maturing boys show more evidence of adjustment

problems than other adolescents (Graber et al 1997) However the definition of early

puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys

(Saenger 2003)

Early

The majority of children who show signs of puberty at a young age have no discernable

underlying pathology particularly if they meet other criteria (see Table 1) Some physicians

order an x-ray to check that the skeletal age of the child is no more than 25 standard

deviations (typically about 2 years) above the chronological age For boys younger than 9

years of age who have penile enlargement scrotal thinning and accelerated growth a formal

evaluation is warranted

TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY

Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly

Source Nakamoto 2000

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 9: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 9 of 17

When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is

designated central or true precocious puberty (CPP) In a minority of patients CPP

arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-

cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS

lesions seem to predispose males and females equally to early central puberty that is the sex

ratio among patients with neurogenic CPP approximates unity However among children

with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex

difference with the female to male ratio approaching 101 in most series (Palmert amp

Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with

behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)

reported more withdrawal social problems aggression somatic complaints and depression

in children with premature adrenarche as compared to children with on-time adrenarche

Precocious puberty also places a child at risk for not achieving hisher genetic height

potential The rapid maturation of the growth plate (due to sex steroid exposure) will often

result in temporary acceleration of linear growth but the accompanying early closure of

growth plates results in early cessation of growth and ultimately shorter than would be

expected adult height (Lee 1999)

Delayed

Delayed puberty describes the clinical condition in which the physical manifestations of

puberty start late (usually gt +25 SD later than the mean) In the United States puberty is

considered to be delayed if sexual maturation has not become apparent by age 14 years in

boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche

by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these

criteria approximately 25 of healthy adolescents will be identified as having pubertal delay

(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying

pathology but instead represents an extreme end of normal puberty referred to as

constitutional delay of growth and maturation When puberty does begin it is entirely

normal However delayed puberty generally warrants referral to a pediatric endocrinologist

to rule out possible genetic hypothalamic pituitary gonodal or system conditions that

could be present

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 10: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 10 of 17

PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is

the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969

1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and

breast (female)genitalia (males) development

In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is

characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast

buds become larger and pubic hair growth continues but it is mostly in the center and does

not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of

pubic hair underarm hair growth and the breasts take on a mound form The first

menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached

Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and

type forming the classical upside-down triangle shape common to women Rough estimates

based upon the size and shape of the breasts (see Figure 1) along with the amount and type

of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp

Tanner 1969)

In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)

In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the

same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in

the pubic area testicular enlargement and scrotum growth thinning and reddening During

stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is

characterized by more pubic hair darkening of the scrotum and increased growth of the

penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his

pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the

testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-

hood) The Prader orchidometer which consists of a series of increasingly larger oval beads

is the standard by which the practitioner makes a determination of the patients testicular

size (Styne 2002)

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 11: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 11 of 17

When a child presents with abnormal puberty the goal of the initial assessment is to

distinguish benign constitutional causes from pathologic causes The history should focus on

the childs previous growth and development including the timing and sequence of the

physical milestones of puberty A history of medical or surgical treatment may provide clues

to an underlying pathologic condition The family history may reveal information about a

familial pattern of delayed or early puberty as well as information about genetic disease A

physical examination should focus on evaluation of the genitalia and determination of the

stage of pubertal development A detailed growth chart is used to estimate annual growth

rate (centimeters per year) and to determine if a growth spurt has occurred When the history

andor evaluation of the child with early or delayed pubertal development suggest a

pathological cause referral to a pediatric endocrinologist is warranted

CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for

pediatric practitioners Parents and adolescents often experience anxiety when puberty is not

occurring as expected even when it occurs within the range of normal The pediatric

practitioner can allay much of that anxiety with counseling regarding the natural and normal

variation of this process A clear understanding of pubertal milestones also promotes

appropriate interventions for delayed or advanced puberty when the practitioner and parents

are in agreement that intervention is in the best interest of the child Recently changes in the

timing of puberty as compared to previously published standards now make the

understanding of this complex process even more important The observation that more

children are showing signs of puberty earlier places pressure upon the practitioner to

differentiate the child with early but otherwise normal puberty from the child with early

onset puberty as a consequence of a pathologic process Even with normal but early-onset

puberty close observation of the temporal process is needed to adequately predict if the

abnormal timing will impact final adult height Referral to a specialist in pediatric

endocrinology is indicated for patients who present with signs of early or delayed puberty

Health care for adolescents should include systematic monitoring of pubertal development

and concerns in order to aggressively educate preadolescents to negotiate this period

smoothly and to avoid high-risk behaviors that could have negative health and social

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 12: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 12 of 17

sequelae during adolescence and adulthood Interventions with parents of children who

present with abnormal puberty include providing anticipatory guidance supporting parent

communication strategies and providing support and information resources (Doswell amp

Vandestienne 1996 Williams 1995) Finally with the observation that precocious

adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity

insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated

with the metabolic syndrome are particularly relevant when the child presents with signs of

early puberty

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 13: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 13 of 17

TABLE 2 TANNER STAGES OF FEMALE PUBERTY

FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION

From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION

STAGE BREAST PUBIC HAIR

1

Preadolescent

Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)

2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged

There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia

3 Further enlargement of breast mound increased palpable glandular tissue

Hair is darker coarser more curled and spreads to the pubic junction

4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast

Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs

5

Adult

Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident

Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 14: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 14 of 17

TABLE 3 TANNER STAGES OF MALE PUBERTY

STAGE GENITAL STAGE PUBIC HAIR STAGE

1

Preadolescent

Testes scrotum and penis are about the same size and proportion as those in early childhood

Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair

2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin

There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis

3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum

Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes

4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin

Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs

5

Adult

Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached

Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 15: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 15 of 17

REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 16: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 16 of 17

Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker

Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303

Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23

Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
Page 17: PubertyŠTiming is everything! - Semantic Scholar · PubertyŠTiming is everything! BELINDA PINYERD, PhD, RN Central Ohio Pediatric Endocrinology and Diabetes Services Columbus, OH

Page 17 of 17

Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18

  • STAGING AND TIMING
    • Females
    • Males
      • OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
        • Body image
        • An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
        • Psychosocial changes
          • ABNORMAL PUBERTY
            • Early
            • Delayed
              • CLINICAL IMPLICATIONS
                • Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10