Puberty

&
Tanner Staging
Price Ward, M.D.
A 13-year-old boy presents for a routine health supervision visit. He is very
concerned about a lump on his chest that appears to be increasing in size.
You have not seen him in 2 years, and your last note indicates that the results
of his examination were normal. He appears well, has normal vital signs, and
has a body mass index of 25. He is very embarrassed and reluctantly allows
you to examine him. You find a slightly tender, rubbery mass under his right
areola that measures approximately 2 cm in diameter. The remainder of his
examination, including a genital examination, is unremarkable. He is at sexual
maturity rating 2/3.

• Of the following, the MOST appropriate next step in this boy’s

management is to

• A. discuss normal development

• B. obtain an endocrinology consult
• C. obtain ultrasonography of the mass
• D. refer him to a plastic surgeon for excision of the mass
• E. suggest that treatment for the mass is weight loss
• The boy in the vignette presents with gynecomastia as evidenced by the
presence of a firm rubbery mass under the nipple-areolar complex. In
males, during early puberty, the ratio of estrogen to testosterone is
increased, and up to 70% of males in sexual maturity rating (SMR) stage 2
of pubertal development (testicular volume of 5-10 mL) have some breast
enlargement on examination that may be tender as a result of edema and
inflammation. Although initially unilateral, the other breast enlarges in up
to 75% of cases. In most males, such breast tissue is no longer palpable
after 18 months (1–3 years) because puberty progresses and androgen
concentrations increase. Therefore, discussing normal developmental
changes and reassuring this adolescent is all that is required at this time.
If the mass does not regress after 2 years or by the end of pubertal
development, especially if it causes emotional concerns, referral to a
plastic surgeon may be considered.
PREP Pearls
• Reassurance and follow-up to ensure regression of male
breast enlargement in early puberty is usually sufficient.
• Male breast enlargement in early puberty is most often
caused by physiologic hormonal changes.
• A comprehensive history and physical examination are
usually the extent of the evaluation required for male breast
enlargement in early puberty.
 Goals of this talk:

Understand normal puberty so

that you can appreciate abnormal
Appropriately identify the Tanner
Stage/SMR of your patients
 Common Concerns of Puberty
Starting too late or too early
Unequal development of
breasts
Breast tissue in boys
Acne, dandruff, body odor
AM I NORMAL???
 Typical Ages of Puberty Events
• Start of Puberty
– Boys: 11-12
– Girls: 10-11
• Length of Puberty
– Boys: 3-4 years
– Girls: 4-6 years
 Growth Spurt
• Boys (~ 14 yrs): • Girls (~12 yrs):
– Peak Growth Velocity – Peak Growth Velocity =
= SMR 4 = 10 cm/yr SMR 3 (1 year prior to
menarche) = 8-9 cm/yr
– 99% growth by bone
age 17
– Only grow about 7.5 cm
total after menarche
– 99% growth by bone
age 15
 Order of Changes
• Boys • Girls
Breast buds appear =
– 1st: Growth of testicles – 1 : thelarche
st

– Pubic hair appears – Pubic hair appears =

– Growth of penis, adrenarche
scrotum – Growth spurt
– Axillary hair – Axillary hair
– First ejaculations – Breasts mature
– Growth spurt – Periods begin= menarche
– Facial Hair – Adult height
– Adult height
 Precocious & Delayed Puberty
• Boys: • Girls:
– Precocious = Onset – Precocious = Onset
of puberty before of puberty before
age 9 age 8
– Delayed = Onset of – Delayed =
puberty after age 14 • NO evidence of
puberty by age 14
Staging Puberty Development

i.e. Tanner Stages

or
Sexual Maturity Rating
 Tanner Staging- Girls
• Breast Development: • Pubic Hair:
1: prepubertal 1: prepubertal: no hair
2: breast bud, areola widens 2: sparse long hair over labia
3: continued enlargement of majora
areola and breast, no 3: daker, coarser, curlier hair
separation of contours sparsely over mons pubis
4: areola and papilla 4: abundant, coarse adult-
separate from contour of type hair to mons pubis
breast, secondary mound 5: adult-type/quality hair
5: mature female breast spreads to medial thighs
 Tanner Staging- Boys
• Genitalia: • Pubic Hair:
1: prepubertal 1: prepubertal
2: testes and scrotum begin 2: sparse long hair at/lateral
to enlarge to base of penis
3: Penis lengthens, scrotum 3: hair darkens, coarser,
further enlarges curlier at/lateral to base of
4: Further growth of testes penis
and scrotum. Increasing 4: abundant coarse adult-
pigmentation of scrotum, type hair over pubis
width/length of penis 5: adult-type/quality hair
5: Adult size/shape spreads to medial thigh
14 YEARS OLD

SMR 2,3 and 4

Breast Stage 1 SMR 3

SMR 4
Sexual Maturity
Rating 2
Breast Stage 5
 Pubic Hair Stage 3
Pubic Hair Stage 1

Pubic Hair Stage 2

Pubic Hair Stage 5

Pubic Hair Stage 4
A 14-year-old girl presents for her annual health supervision
visit. She has no complaints, and her review of systems
reveals no findings of note. However, her mother is concerned
that her daughter has not yet had menarche. The girl’s height
is at the 5th percentile and her weight is at the 25th percentile.
On physical examination, she has Sexual Maturity Rating
(SMR) 1 breast development and SMR 3 pubic hair.
Examination of the external genitalia reveals a patent vagina
and pink mucosae.
Of the following, the BEST next step in evaluation of this
patient is to:

A: measure serum estradiol

B: obtain a karyotype
C: perform a bone age radiograph
D: Reassure the family and see them again in 1 year
E: re-examine in 6 months
The girl described in the vignette has no breast buds (SMR 1) and pink vaginal
mucosa, both of which indicate no estrogenization. In addition, she is relatively
short, with a height at the 5th percentile. These findings should raise suspicion
for Turner syndrome, which requires karyotyping for diagnosis. Measuring
serum estradiol is unnecessary because her physical examination findings
indicate that the serum estradiol value will be prepubertal. A bone age
radiograph would be useful in documenting her skeletal maturity, but it is not the
most important next step in evaluating this girl. The lack of evidence of puberty
at 14 years of age argues against reassuring the family and re-examining the
girl in 6 months or 1 year, which could delay the diagnosis and appropriate
therapy.
An 8-year-old boy has been referred to you because of concerns regarding his pubertal
development.  His mother reports that during the last 6 months he has developed pubic
hair, axillary hair, and body odor. She also has noted that he seems to be getting taller.
His past medical history is otherwise unremarkable. On physical examination, you note
an adult body odor and sexual maturity rating 2 pubic hair and axillary hair. His penis
appears prepubertal, and his testicles are 2 cm in length. Laboratory testing reveals the
following results:
• Luteinizing hormone and follicle-stimulating hormone levels, undetectable
• Testosterone level, 4 ng/dL (0.14 nmol/L); reference range, 2.5 to 10 ng/dL (0.07-
0.35 nmol/L)
• Dehydroepiandrosterone sulfate, 167 μg/dL (4.51 μmol/L); reference range, 13-115
μg/dL (0.35-3.10 μmol/L)
• 17-hydroxyprogesterone levels, 72 ng/dL; reference range, 15-90 ng/dL
Of the following, the MOST likely explanation for this boy’s pubic hair development is:

A. androgen-producing adrenal tumor

B. central precocious puberty
C. exposure to exogenous testosterone
D. late-onset congenital adrenal hyperplasia
E. premature adrenarche
Normal pubertal development is due to increased gonadotropin levels that lead to increased
production of sex hormones by the gonads. The boy described in the vignette has pubic hair
development, axillary hair, and adult body odor but does not have testicular enlargement.

Because the first sign of true pubertal progression is enlargement of the testicles, the most likely
explanation for this boy’s development of pubic and axillary hair and body odor is premature
adrenarche due to the activation of adrenal androgens (eg, dehydroepiandrosterone and
dehydroepiandrosterone sulfate). The sulfated form is more practically used in diagnosing
conditions because its levels are more stable than nonsulfated dehydroepiandrosterone.  Although
adrenarche and pubarche (maturation of the gonads) often occur concurrently, the 2 entities are in
fact separate and can occur independently. Cases like the one in the vignette are often worrisome
to parents and physicians and require a thorough understanding of physiology to differentiate
normal processes from pathologic ones.

The differential diagnosis of precocious puberty can generally be divided into 2 categories: (1)
central true precocious puberty and (2) peripheral pseudoprecocious puberty. In boys, the lack of
testicular enlargement removes central precocious puberty from the differential diagnosis and
focuses efforts on eliminating other potentially pathologic causes (eg, premature adrenarche,
testotoxicosis, exogenous androgen exposure, adrenal tumors, and congenital adrenal
hyperplasia).

Exposure to exogenous testosterone and androgen-producing tumors could cause pubic hair
development and increased body odor without testicular maturation but would also likely be
associated with penile growth and a rapid progression of symptoms. Congenital adrenal hyperplasia
should also be part of the differential diagnosis but is unlikely in this boy because the screening 17-
hydroxyprogesterone level is within the normal range.