2025 – PAGE 60 – ADOLESCENT MEDICINE

NORMAL PUBERTY PEARLS

Here are some great pearls and shortcuts about normal puberty.

• Girls have adult-looking breasts in SMR 3 and 5.
• SMR 4 = mound on mound breasts
• SMR 2 to 5 usually lasts about 3 to 5 years in total duration for both sexes.
• MENARCHEusually occurs in SMR 3 or SMR 4 OR, within 2–3 YEARS of the onset of puberty.
• MENSES/HEIGHT: At the onset of menses, girls are probably within 1–2 inches (2.5–5 cm) of their adult height. Why do I say that? Because they’re probably in SMR 4 (which occurs after the peak height velocity).
• VAGINAL BLEEDING: Bloody vaginal discharge while in SMR 2 shouldn’t happen. Consider a foreign body (e.g., toilet paper) in your differential.

HEIGHT

For the test, pre-pubertal basal rate for height in both boys and girls is 5–6 cm/year. The peak is 10 cm/yr. Early puberty results in shorter adult height.

GROWTH SPURTS

Elevated alkaline phosphatase can be normal during growth spurts. Hematocrit increases alongside growth spurts.

THELARCHE, ADRENARCHE THEN MENARCHE

(THELARCHE) Breast development → (ADRENARCHE) Hair development → (MENARCHE) Menses

PEARLS AND MNEMONICS: “Girls are TAMer than boys.” “Boys like to TAP Her!”

• Girls are “TAMer” = Thelarche, then Adrenarche, then Menarche = Breast development → Hair development → Menses. Thelarche = first sign of puberty – stage 2. Adrenarche is the same thing as Pubarche. Breasts: Look most natural at SMR 1, 3, and 5. TAM = “Breasts are higher than Pubic hair which is higher than a Vagina.”
• Boys = “TAP Her” = Testicular enlargement, then Adrenarche, then Phallus/Penile enlargement, THEN Height velocity peaks. Keep in mind that while testicular enlargement is ALWAYS the first sign of puberty in males, sometimes Phallus/Penile enlargement can occur before Adrenarche.

ESTROGEN

Estrogen causes the development of breasts + change in vaginal color + labial prominence.

MNEMONIC: “Breast-rogen”

ANDROGENS

Androgens cause pubic hair development.

PEARL: If you’re presented with an adolescent “girl” with breasts but NO pubic hair, guess what? She’s NOT A GIRL! Think ANDROGEN INSENSITIVITY (aka TESTICULAR FEMINIZATION) in someone carrying XY chromosomes.

PEARL: If presented with an adolescent female with a history of pubic hair development, but no history of preceding breast development, the patient likely has LOW ESTROGEN. If the child has pubic hair, virilization, and advanced skeletal maturation, the patient likely has ANDROGEN EXCESS.

PEARL: If an adolescent presents with isolated PREMATURE ADRENARCHE (pubic hair with no breasts or no increase in testicular size), get bone age films! If the bone age films are within 1–2 years of the chronologic age, it’s OKAY TO OBSERVE. If not, the patient will need an Endocrinologist to intervene.

PEARL: Short “girl” with no breasts (or just buds), absent or scant pubic hair, no menses → TURNER’S SYNDROME → Get a karyotype.

PEARL: Always question whether or not the girl in your question is truly a normal XX girl without any hormonal issues/deficiencies.