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Pediatric Reproductive Endocrinolgy
Table 1: Significant Racial Differences in Puberty from PROS Study Table 3a: Tanner Staging—Breast Development in Girls
Black Girls White Girls Stage I
Mean age of onset of any development 8.11 years 9.71 years Pre-adolescent. Elevation of papilla only.
Mean age of menarche 12.11 years 2.88 years Stage II
Breast development at 7 years 15.44% 4.97% Breast bud stage. Elevation of breast and
Breast development at 8 years 37.76% 10.50% papilla as small mound. Enlargement of
Pubic hair growth at 7 years 17.65% 2.75% areola diameter.
Pubic hair growth at 8 years 34.27% 7.67% Stage III
PROS = Pediatric Research in Office Settings (study by the AAP).
Further enlargement and elevation of
breast and areola with no separation of
Table 2: Sequence of Pubertal Development in Females
• Increase in growth velocity—usually the first event, but can overlap with breast
Projection of aerola and papilla to form
budding; evident by rapid change in shoe size.
a secondary mound above the level of
• Adrenarche—development of body odor and skin changes; overlaps with increase in
growth velocity and thelarche.
•Thelarche (or breast buds)—occurs within 1 year of the growth spurt.
Mature stage. Projection of papilla only
caused by recession of the areola to the V
• Pubarche—occurs within 6 months of breast budding; the two may overlap.
•Peak height velocity—occurs within 1 to 2 years of breast budding, usually at Tanner
general contour of the breast.
• Axillary hair growth—usually occurs 1 to 2 years after pubarche.
• Physiologic leukorrhea (estrogen-stimulated clear, milky vaginal discharge)—occurs 6 or
Table 3b: Tanner Staging—Pubic Hair of Both Sexes
more months before menarche.
• Menarche—occurs within 2 years of breast budding in the majority; usually occurs
Stage I IIIIII
within 1 year after peak height velocity, at Tanner stage 3–4.
Preadolescent. The vellus over the pubes is not
• Ovulation—can begin episodically at any time around menarche; regular ovulation can
further developed than that over the
occur within 6 months of menarche and as late as 5 years after menarche, but the
abdominal wall; that is, no pubic hair.
majority of cycles are ovulatory within 5 years of menarche.
Sparse growth of long, slightly pigmented downy
hair, straight or curled, chiefly along the labia.
Precocious puberty is, in general, consistent with onset of segments or all of
Considerably darker, coarser, and more curled.
the above-mentioned pubertal milestones beginning at six years of age.
The hair spreads sparsely over the junction of the pubes.
Precocity is divided into GnRH-dependent and GnRH-independent classes.
With the exception of premature thelarche, which is addressed below, it is
Hair now adult in type, but area covered is still considerably smaller than in the adult. No
associated with advanced bone age that, if untreated, results in short
spread to the medial surface of the thighs.
stature. Table 4 provides details of the classification.
Adult in quantity and type with distribution of the horizontal (or classically ‘feminine’)
The most common form of precocious puberty is idiopathic, in which central—
pattern. Spread to medial surface of thighs, but not up line alfa or elsewhere above the base
i.e. gonadotropin-dependent—premature maturation of the HPO axis occurs.
of the inverse triangle (spread up line alfa occurs late and is stage VIA).
A less common etiology is that of central nervous system (CNS) neoplasms—
Figures adapted from Marchall WA, Tanner JM, Variations in patterns of pubertal changes in girls, Arch Dis Child,
1969;44:291. Reprinted from Ross GT, Vande Wiele RL, Frantz AG, The normal ovary. In: Williams RH (ed.),
hypothalamic hamartomas, which are benign tumors that release GnRH and
Textbook of Endocrinology, 6th edn, Philadelphia: W.B. Saunters, 1981, p362.
thus stimulate ovarian function. This problem is more common in males than
in females and can be detected via magnetic resonance imaging (MRI). closure. Isolated segments of precocious puberty may occur, such as
precocious thelarche, which is often a reflection of increased ovarian
Gonadotropin-independent precocious puberty is often manifest as hormone production. Suppression of such hormone output frequently results
McCune-Albright Syndrome. There is a triad of cutaneous hyper- in regression of breast development. Similarly, precocious pubarche can
pigmentation (café au lait spots), polyostotic fibrous dysplasia, and isosexual occur and requires assessment for the underlying etiology and appropriate
Isolated premature thelarche may occur and, when present, treatment. Premature adrenarche is associated with pubic hair, axillary hair,
usually occurs at two to three years of age. Bone age remains normal and or both before eight years of age. The etiology remains an area of debate,
the problem is self-limited. The incidence of isolated precocious thelarche is but is thought to be associated with increased androgens from the adrenal
gland zona reticularis.
It is more common in Asian or Afro-American girls.
Long-term sequelae include progression to full-blown precocity.
Management depends on the underlying cause of the precocity. In general,
a key principle in the management of precocious puberty is to delay Delayed Puberty
premature closure of the epiphyseal plates and thus overall short stature. Delayed puberty is equated with lack of breast development by chronologic
Currently, goandotropin-releasing hormone agonists (GnRHag) are the age 13 or primary amenorrhea with the presence of secondary sex
primary mode of treatment to suppress the HPO axis and prevent epiphyseal characteristics by 15 years of age. Table 5 provides information regarding the
54 US OBSTETRICS AND GYNECOLOGY 2007
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