Puberty

Puberty refers to the process of physical changes by which a child's body becomes an adult body capable of reproduction. Growth accelerates in the first half of puberty and reaches completion by the end. Body differences between boys and girls before puberty are almost entirely restricted to the genitalia. During puberty, major differences of size, shape, composition, and function develop in many body structures and systems. The most obvious of these are referred to as secondary sexual characteristics. In a strict sense, the term puberty (and this article) refer to the bodily changes of sexual maturation rather than the psychosocial and cultural aspects of adolescent development.

Puberty as a physical process

Physical changes of puberty in girls

Breast development

The first physical sign of puberty in girls is usually a firm, tender lump under the center of the areola(e) of one or both breasts, occurring on average at about 10.5 years. This is referred to as thelarche. By the widely used Tanner staging of puberty, this is stage 2 of breast development (stage 1 is a flat, prepubertal breast). Within 6-12 months, the swelling has clearly begun in both sides, softened, and can be felt and seen extending beyond the edges of the areolae. This is stage 3 of breast development. By another 12 months (stage 4), the breasts are approaching mature size and shape, with areolae and papillae forming a secondary mound. In most young women, this mound disappears into the contour of the mature breast (stage 5), although there is so much variation in sizes and shapes of adult breasts that distinguishing advanced stages is of little clinical value.

Related Topics:
Areola(e) - Breast - Thelarche - Tanner staging - Papilla

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Pubic hair in girls

Pubic hair is often the second unequivocal change of puberty. It is referred to as pubarche and the pubic hairs are usually visible first along the labia. The first few hairs are described as Tanner stage 2. Stage 3 is usually reached within another 6–12 months, when the hairs are too numerous to count and appear on the mons as well. By stage 4, the pubic hairs densely fill the "pubic triangle." Stage 5 refers to spread of pubic hair to the thighs and sometimes upward towards the umbilicus. In about 15% of girls, the earliest pubic hair appears before breast development begins.

Related Topics:
Pubic hair - Pubarche - Labia - Mons - Thigh - Umbilicus

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Vagina, uterus, ovaries

The mucosal surface of the vagina also changes in response to increasing levels of estrogen, becoming thicker and a duller pink in color (in contrast to the brighter red of the prepubertal vaginal mucosa). Whitish secretions (physiologic leukorrhea) are a normal effect of estrogen as well. In the next 2 years following thelarche, the uterus and ovaries increase in size. The ovaries usually contain small cysts visible by ultrasound.

Related Topics:
Mucosal surface - Vagina - Estrogen - Leukorrhea - Uterus - Ovaries - Cyst - Ultrasound

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Menstruation and fertility

The first menstrual bleeding is referred to as menarche. The average age of menarche is about 12.7 years, usually about 2 years after thelarche. Menses (menstrual periods) are not always regular and monthly in the first 1–2 years after menarche. Ovulation is necessary for fertility, and may or may not accompany the earliest menses. By 2 years after menarche, over 90% of girls are experiencing very regular, predictable menses accompanied by ovulation. Continued irregularity after 2 years from menarche usually predicts prolonged irregularity and anovulation. The word nubility has been proposed academically to designate achievement of fertility.

Related Topics:
Menstrual bleeding - Menarche - Ovulation - Fertility

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Pelvic shape, fat distribution, and body composition

During this period, also in response to rising levels of estrogen, the lower half of the pelvis widens (providing a larger birth canal). Fat tissue increases to a greater percentage of the body composition than in males, especially in the typical female distribution of breasts, hips, and thighs. This produces the typical female body shape.

Related Topics:
Pelvis - Birth canal

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Body and facial hair in girls

In the months and years following the appearance of pubic hair, other areas of skin which respond to androgens develop heavier hair in roughly the following sequence: underarm (axillary) hair, perianal hair, upper lip hair, sideburn (preauricular) hair, and periareolar hair. Arm and leg hair becomes heavier more gradually over 10 years or more. Although in Western culture, hair in some of these areas is unwanted, it rarely indicates a hormone imbalance unless it occurs elsewhere as well (such as under the chin and in the midline of the chest).

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Height growth in girls

The estrogen-induced pubertal growth spurt in girls begins at the same time the earliest breast changes begin, or even a few months before, making it one of the earliest manifestations of puberty in girls. Growth of the legs and feet accelerates first, so that many girls have longer legs in proportion to their torso in the first year of puberty. The rate of growth tends to reach a peak velocity (as much as 7.5-10 cm or 3-4 inches per year) midway between thelarche and menarche and is already declining by the time menarche occurs. In the 2 years following menarche most girls grow about 5 cm (2 inches) before growth ceases at maximal adult height. This last growth primarily involves the spine rather than the limbs.

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Body odor, skin changes, and acne

Rising levels of androgens can change the fatty acid composition of perspiration, resulting in a more "adult" body odor. This often precedes thelarche and pubarche by 1 or more years. Another androgen effect is increased secretion of oil (sebum) from the skin. This change increases the susceptibility to acne, a characteristic affliction of puberty greatly variable in its severity.

Related Topics:
Androgen - Fatty acid - Perspiration - Body odor - Sebum - Acne

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Physical changes of puberty in boys

Testicular size, function, and fertility

In boys, testicular enlargement is the first physical manifestation of puberty (and is termed gonadarche). Testes in prepubertal boys change little in size from about 1 year of age to the onset of puberty, averaging about 2–3 cc in volume and about 1.5-2 cm in length. Testicular size continues to increase throughout puberty, reaching maximal adult size about 6 years later. While 18-20 cc is reportedly an average adult size, there is wide variation in the normal population.

Related Topics:
Gonadarche - Testes - 2–3 cc - 1.5-2 cm - 18-20 cc

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The testes have two primary functions: to produce hormones and to produce sperm. The Leydig cells produce testosterone (as described below), which in turn produces most of the changes of male puberty. However, most of the increasing bulk of testicular tissue is spermatogenic tissue (primarily Sertoli and interstitial cells). The development of sperm production and fertility in males is not as well documented. Sperm can be detected in the morning urine of most boys after the first year of pubertal changes (and occasionally earlier).

Related Topics:
Hormone - Sperm - Leydig cell - Testosterone - Sertoli - Interstitial cell - Fertility

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Genitalia

A boy's penis grows little from the fourth year of life until puberty. Average prepubertal penile length is 6 cm. The prepubertal genitalia are described as Tanner stage 1. Within months after growth of the testes begins, rising levels of testosterone promote growth of the penis and scrotum. This earliest discernible beginning of pubertal growth of the genitalia is referred to as stage 2. The penis continues to grow until about 18 years of age, reaching an average adult size of about 12-14 cm.

Related Topics:
Penis - 6 cm - Scrotum - Adult size - 12-14 cm

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Although erections and orgasm occur in prepubertal boys, they become much more common during puberty, accompanied by a markedly increased libido. Ejaculation becomes possible early in puberty; prior to this boys may experience dry orgasms. Emission of seminal fluid may occur due to masturbation or spontaneously during sleep (commonly termed a wet dream, and more clinically called a nocturnal emission). The ability to ejaculate is a fairly early event in puberty compared to the other characteristics. However, in parallel to the irregularity of the first few periods of a girl, for the first one or two years after a boy's first ejaculation, his seminal fluid may contain few active sperm.

Related Topics:
Erection - Orgasm - Libido - Ejaculation - Dry orgasm - Nocturnal emission

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Pubic hair in boys

Pubic hair often appears in a boy shortly after the genitalia begin to grow. As in girls, the first appearance of pubic hair is termed pubarche and the pubic hairs are usually first visible at the dorsal (abdominal) base of the penis. The first few hairs are described as Tanner stage 2. Stage 3 is usually reached within another 6–12 months, when the hairs are too numerous to count. By stage 4, the pubic hairs densely fill the "pubic triangle." Stage 5 refers to spread of pubic hair to the thighs and upward towards the umbilicus.

Related Topics:
Pubic hair - Thigh - Umbilicus

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Body and facial hair in boys

In the months and years following the appearance of pubic hair, other areas of skin which respond to androgens develop heavier hair in roughly the following sequence: underarm (axillary) hair, perianal hair, upper lip hair, sideburn (preauricular) hair, periareolar hair, and the rest of the beard area. Arm, leg, and back hair become heavier more gradually. There is a large range in amount of body hair among adult men, and significant differences in timing and quantity of hair growth among different ethnic groups.

Related Topics:
Hair - Underarm - Perianal hair - Upper lip hair - Sideburn - Periareolar - Beard

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Voice change

Under the influence of androgens, the voice box, or larynx, grows in both genders. This growth is far more prominent in boys, causing the male voice to drop, rather abruptly, about one octave, probably because the larger vocal folds have a lower fundamental frequency. Occasionally, this is accompanied by cracking and breaking sounds in the early stages. Most of the voice change happens during stage 4 of male puberty around the time of peak growth. However, it usually precedes the development of significant facial hair by several months to years.

Related Topics:
Voice box - Larynx - Octave - Vocal folds - Fundamental frequency

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Height growth in boys

Compared to girls' early growth spurt, growth accelerates more slowly in boys and lasts longer, resulting in a taller adult stature among males than females (on average about 10 cm or 4 inches). The difference is attributed to the much greater potency of estradiol compared to testosterone in promoting bone growth, maturation, and epiphyseal closure. In boys, growth begins to accelerate about 9 months after the first signs of testicular enlargement and the peak year of the growth spurt occurs about 2 years after the onset of puberty, reaching a peak velocity of about 8.5–12 cm or 3.5–5 inches per year. The feet and hands experience their growth spurt first, followed by the limbs, and finally ending in the trunk. Epiphyseal closure and adult height are reached more slowly, at an average age of about 17.5 years. As in girls, this last growth primarily involves the spine rather than the limbs.

Related Topics:
Growth - 10 cm - Estradiol - Epiphyseal - Spine

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Male musculature and body shape

By the end of puberty, adult men have heavier bones and nearly twice as much skeletal muscle. Some of the bone growth (e.g., shoulder width and jaw) is disproportionately greater, resulting in noticeably different male and female skeletal shapes. The average adult male has about 150% of the lean body mass of an average female, and about 50% of the body fat.

Related Topics:
Bone - Muscle

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This muscle develops mainly during the later stages of puberty, and muscle growth can continue even after a male is biologically adult. The peak of the so-called "strength spurt," the rate of muscle growth, is attained about one year after a male experiences his peak growth rate.

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Body odor, skin changes, acne

Rising levels of androgens can change the fatty acid composition of perspiration, resulting in a more "adult" body odor. As in girls, another androgen effect is increased secretion of oil (sebum) from the skin and the resultant variable amounts of acne.

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Breast development in boys: pubertal gynecomastia

Estradiol is produced from testosterone in male puberty as well as female, and male breasts often respond to the rising estradiol levels. This is termed gynecomastia. In most boys, the breast development is minimal, similar to what would be termed a "breast bud" in a girl, but in many boys, breast growth is substantial. It usually occurs after puberty is underway, may increase for a year or two, and usually diminishes by the end of puberty. It is increased by extra adipose tissue if the boy is overweight.

Related Topics:
Estradiol - Breast - Gynecomastia - Overweight

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Although this is a normal part of male puberty for perhaps half of boys, breast development is usually as unwelcome as upper lip hair in girls, and can be removed surgically if the boy's distress is substantial.

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Variations of normal puberty

Typical puberty is described above, but many children vary with respect to timing of onset, tempo, steadiness of continuation, and sequence of events.

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Timing of onset

Puberty is a process with a gradual onset beginning with changes of neuronal function in the hypothalamus, resulting in rising hormonal signals between brain and gonads, proceeding to gonadal growth and production of sex steroids, which in turn induce changes in responsive parts of the body. The definition of onset, therefore, depends on the perspective (e.g., hormonal versus physical) and purpose (establishing population normal standards, clinical care of early or late children, or a variety of other social purposes). The most commonly used definition of onset for both social and medical purposes is the appearance of the first physical changes described in this section of this article, but the reader should understand that they are a result of preliminary neural, hormonal, and gonadal function changes that are usually impossible or impractical to detect.

Related Topics:
Hypothalamus - Hormonal - Brain - Gonad - Sex steroid

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The age at which puberty begins can vary widely between individuals. Timing of onset is affected by genetic factors, body mass and nutritional state, and general health. Timing may also be affected by environmental factors (exogenous hormones and environmental substances with hormone-like effects) and there is even weak evidence that life experiences may play a role as well. Ethnic/racial differences have been recognized for centuries, although many of them may be attributable to confounding environmental and socioeconomic factors (such as weight).

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Average age for first signs of breast development in girls is about 10.5 years. Average age for first signs of testicular enlargement in boys is 11.5 years. See Tables below for approximate average ages and ranges for other milestones of physical development of North American children.

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Duration of puberty (time from onset to completion) varies less between children than does the age of onset. Duration of puberty in girls from onset of breast development to cessation of growth is roughly 5 years. Duration of puberty in boys from first testicular enlargement to cessation of growth is about 6 years.

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Table 1 provides 3rd, 50th, and 97th percentiles for attainment of selected stages by American girls as reported in 1985. In these tables, B, PH, and G refer to the Tanner stages of physical puberty: B is breast, PH is pubic hair, and G is genitalia (penis and testes). B1, PH1, and G1 are the prepubertal stages of each of these, while B2, PH2, and G2 are the earliest signs of puberty. B5, PH5, and G5 are adult stages at the end of puberty. The Tanner stage article contains links to fuller explanations of the specific stages. All three tables below express ages as years and months (y and m).

Related Topics:
Percentile - Tanner stage

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Table 1: Ages of attainment of pubertal stages of American girls

3rd %ile 50th %ile 97th %ile

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B2 8y 10m 10y 11m 13y 0m

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B3 9y 10m 11y 11m 14y 0m

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B4 10y 6m 12y 11m 15y 5m

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PH2 9y 0m 11y 3m 13y 6m

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PH3 9y 8m 11y 11m 14y 3m

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PH4 10y 5m 12y 7m 14y 11m

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Menarche 10y 10m 12y 9m 14y 7m

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Peak height velocity 9y 0m 11y 6m 14y 0m

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However, a later survey from a group of American primary pediatric practices reported both a slightly earlier average onset, greater range, and more importantly, a significant difference between white and African-American girls at some stages (Table 2).

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Table 2: Recent survey on American girls by race

White girls 3rd %ile 50th %ile 97th %ile

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B2 6y 5m 10y 0m 13y 7m

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B3 8y 7m 11y 4m 14y 1m

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B4 10y 4m 12y 9m 15y 3m

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B5 11y 4m 14y 6m 17y 9m

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PH2 7y 2m 10y 5m 13y 8m

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PH3 8y 8m 11y 5m 14y 2m

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PH4 10y 5m 12y 7m 14y 9m

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PH5 12y 5m 14y 7m 16y 8m

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Menarche 10y 6m 12y 10m 15y 3m

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Peak height velocity 10y 12y 2m 14y

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African-American 3rd %ile 50th %ile 97th %ile

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B2 5y 0m 8y 11m 12y 10m

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B3 7y 7m 10y 2m 12y 11m

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PH2 4y 9m 8y 9m 12y 9m

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PH3 7y 6m 10y 3m 13y 0m

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Menarche 9y 10m 12y 2m 14y 6m

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Table 3: Ages of attaining stages of puberty for American boys

3rd % 50th % 97th%

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PH2 9y 11m 12y 0m 14y 1m

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PH3 11y3m 13y 1m 14y 11m

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PH4 12y 0m 13y 10m 15y 9m

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G2 9y 3m 11y 6m 13y 9m

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G3 10y 2m 12y 4m 14y 8m

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G4 11y 3m 13y 3m 15y 5m

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Testicular size

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4 cc or 2.5 cm 9y 6m 11y 6m 13y 6m

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6 cc or 3 cm 10y 2m

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12 cc or 3.6 cm 11y 6m 14y 0m 16y 6m

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15 cc or 3.8 cm 16y 6m

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Peak height velocity 11y 13y 6m 15y 8m

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Variations of tempo and progression

Tempo is the speed at which the process of pubertal changes progresses from beginning to end. The duration of puberty generally varies less than timing of onset, and approximates 4 years for girls and 6 for boys (from first physical changes to attainment of adult height). Nevertheless, some healthy children can proceed through puberty at a faster or slower tempo than most.

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An interruption of progression of puberty is usually, but not always, due to abnormal causes such as malnutrition or anorexia nervosa. Perhaps the most common apparently healthy variation is apparent interruption for a couple of years just after attainment of an early sign of initiation. For instance, some girls may seem to develop stage 2 breast buds at 6 or 7 years of age with no other signs of puberty, and nothing may happen for 2 or 3 years. Physicians refer to this as "unsustained puberty."

Related Topics:
Malnutrition - Anorexia nervosa

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Variations of sequence

The sequence of events of pubertal development can occasionally vary. For example, in about 15% of boys and girls, pubarche (the first pubic hairs) can precede, respectively, gonadarche and thelarche by a few months. Rarely, menarche can occur before other signs of puberty in a few girls. These variations deserve medical evaluation because they can occasionally signal a disease.

Related Topics:
Pubarche - Gonadarche - Thelarche - Menarche

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Conclusion of puberty

In a general sense, the conclusion of puberty is reproductive maturity. Criteria for defining the conclusion may differ for different purposes: attainment of the ability to reproduce, achievement of maximal adult height, maximal gonadal size, or adult sex hormone levels. Maximal adult height is achieved at an average age of 14.5 years for American girls and 17.5 years for American boys. Potential fertility (sometimes termed nubility) usually precedes completion of growth by 1-2 years in girls and 3-4 years in boys. Stage 5 in the tables above typically represents maximal gonadal growth and attainment of adult hormone levels.

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