Adolescent Medicine

Pubescence is a dynamic process that takes two and a half to five years to complete. The word pubescence is used, instead of puberty, because pubescence implies that it is an extended process. Puberty is a process. Also, remember that individuals may start the growth spurt early. Two young men, fourteen years of age, they have different growth patterns. And the implications of that are terrific among the adolescents themselves. The nice thing that we can do for smaller adolescent, is that we can assure him that when he comes back for the 10 year reunion, that he is probably going to be taller than the guy that started developing early.
As far as physical development, the first sign of pubescence in males is usually testicular enlargement. It usually starts around 11½ years of age. The first sign of pubescence in females is breast bud development with the usual onset is somewhere between eight and 14 years of age.
Another important concept from the growth and development standpoint is the sequence of secondary sexual characteristics. In males, that sequence is the following: testicular growth, pubarche, penile growth, and finally peak height velocity. From the graph over here, you can see that for females, peak height velocity occurs much earlier, about two years earlier than males. Remember too, that menarche usually occurs around two years after thelarche, or the onset of breast bud development, and it usually is a sexual maturity rating of 4 for females. Girls height rarely increases more than a couple of inches after menarche.Tanner staging. This is the breast staging with stage 1, the top two pictures, lateral and AP being Tanner stage 1, which is really just childlike. No palpable glands. Tanner stage 2 with a breast lump right under the breast bud directly below the areola. Tanner stage 3 being when the breast extends beyond the areola and is palpable beyond the areola. Stage 4 is when we get the typical mound on mound configuration. The first mound is actually the gland of the breast itself and the second mound is where the areola and the nipple form one complex that becomes the second mound on top of the first mound. And finally, stage 5, or the mature breast of the female where the puffiness of the areola goes away and the areola becomes contiguous with the skin of the rest of the breast with a protuberant nipple.
Another common finding in most of your practices and certainly in the adolescent medicine world is that we see a lot of gynecomastia in males. It is very common. Some estimates say that at least 25% of males have gynecomastia to some extent or another. And certainly it can also be represented in the female population as simple breast asymmetry and there will be a huge disparity between one breast and the other, which from a psychological standpoint can be traumatizing to the adolescent female. We may need to refer those girls either for reduction or augmentation of one of the breasts.
Gynecomastia in males can certainly change a lot of habits, including whether they decide to dress a certain way. One of the common things is that the guy wears a very tight T-shirt with lots of layers over to totally disguise the prominence of the breast. The other thing we hear is that physical activity changes. That they stop going swimming. If the P.E. at school requires that they take a shower with everybody, they avoid P.E. at all costs. Go to the showers as everyone else is getting dressed which makes them late to class and therefore they're constantly tardy. Gynecomastia in males will resolve within a year or two. Most of the time you don't need to do anything but give a little reassurance. Rarely, we will send someone over for plastic surgery. When they are Tanner stage 4 or sexual maturity rating of 4 and preferably even 5, but it depends again upon how psychologically traumatizing the gynecomastia has Pubic area. Prepubertal or stage 1 is basically no hair. These are two pictures of stage 2. I think if you look closely you can see a little bit of hair here and a little more here. Stage 3 is when the dense hair is in very circumscribed limits and moving on to 4, where basically the mons area is filled out with dense, curly hair, and then 5 where the hair extends onto the thighs or upwards toward the umbilicus.
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