Last updated: November 9, 2023

Summarytoggle arrow icon

Puberty refers to the phase of development between childhood and adulthood in which complete functional maturation of the reproductive glands and external genitalia occurs. The other processes that characterize this transitional phase are the development of secondary sex characteristics, growth spurts, and psychosocial changes. The stages of development during puberty are classified according to the Tanner stages. Although there is considerable variation between individuals, puberty begins on average at the age of 11 in girls and 13 in boys. When puberty begins abnormally early it is referred to as precocious puberty and is classified into two main types: peripheral precocious puberty, which is independent of gonadotropin-releasing hormone secretion; and central precocious puberty, which involves the hypothalamo-hypophyseal axis. At the other end of the disease spectrum, puberty may be delayed or absent. This delay can be constitutional (most common), secondary to underlying conditions, or due to hypogonadism.

Normal pubertytoggle arrow icon


  • A phase of development between childhood and complete, functional maturation of the reproductive glands and external genitalia (adulthood)

Phases of pubertal changes

The age of pubertal onset may vary, but the order of changes that occur in each person is consistent.


Influential factors

  • General health (nutritional state, bodyweight) [1]
  • Genetics
  • Social environment (e.g., family stress)


  • Normal age of onset: 8–13 years (average 11 years)
  • Normal order of changes: adrenarche gonadarche thelarche (age of onset 8–11 years) growth spurt (age of onset 11.5–16.5 years) pubarche (mean age of onset 12 years) → menarche (age of onset 10–16 years, mean age: 13 years) [2]


  • Normal age of onset: 9–14 years (average 13 years)
  • Normal order of changes: adrenarche gonadarche; (age of onset 9–14 years) → pubarche (mean age of onset 13.5 years) growth spurt (mean age of onset 13.5 years)→ androgenic hair growth

The first visible sign of puberty in males is testicular enlargement, while in females it is breast development.

Physical changes during pubertytoggle arrow icon

Tanner stages

  • A sexual maturity rating (SMR) scale used to assess the development of secondary sexual characteristics (e.g., breast, genital, pubic hair development) in both males and females
Tanner Stages Breast development (girls)
  • Prepubertal appearance and size
  • Occasional elevation of the nipple
Genital development (boys)
  • Testicular volume of 4 mL
  • Larger scrotum
  • Penile growth has not begun
  • Scrotal skin darkens in color and texture
  • Continued enlargement of the testes and scrotum
  • Penile growth begins
  • Testicular volume of 12 mL
  • Scrotum growth
  • Penile growth continues: longer and wider penis
  • Development of penis glans
Pubic hair development (boys and girls)
  • Sparse, lightly pigmented hair (straight or curled) on the labia/base of the penis
  • Adult pubic hair that does not extend to the inner thighs
  • Adult pubic hair that extends to the inner thighs with horizontal upper border

Other morphological changes during puberty [3][4][5]

  • Breast development (boys)
    • Occurs approximately within 18 months of pubertal onset in males
    • Usually during Tanner stage 3
    • Lasts for ∼ 6–18 months
    • Gynecomastia is diagnosed in a pubertal male when the palpable subareolar gland and ductal tissue is ≥ 2 cm (see “Pubertal gynecomastia”).
  • Growth spurt
    • Linear growth during adolescence is approx. 5 cm/year from 4 years of age to puberty
    • Varies between the sexes, generally occurs between ages 13–15 years (in girls, it can begin two years earlier).
    • Includes ↑ growth in trunk and limbs
    • Assessed using growth velocity charts
    • It generally lasts ∼ 2 years, girls complete it at age 15 and boys at age 17.
  • Bone growth
  • Bodyweight and composition during adolescence
    • Boys: initial ↓ body fat (early puberty) → ↑ lean body mass (late puberty)
    • Girls: gradual increase in body fat
    • Affected by nutritional status
  • Dermatological changes [6]
  • Myopia: due to axial growth of the eye
  • Other physical changes associated with menarche: anemia

Psychosocial and cognitive changes during pubertytoggle arrow icon

Adolescence is a time of not only pubertal physical change but also cognitive, psychological, and social development that may or may not be associated with reaching sexual maturity.

Stage of adolescence [7][8]

Age Physical development Cognitive development Psychosocial development Sexuality and relationships
Early adolescence
  • 10–14 years
  • Cognitive development: growing intellectual interests, concrete thinking, limited capacity for abstract thinking, little interest in the future
  • Preoccupation with self-esteem and body image
  • Mood swings
  • Struggles with rules and desire for independence vs. dependence
Middle adolescence
  • 15–16 years
  • Physical growth continues for boys but slows down for girls
  • Growing interest in the future (e.g., long-term goals)
  • Enhanced moral reasoning
  • Expanding capacity for abstract thinking and problem solving
  • Exploration of identity and lifestyles
  • Experimentation with hobbies, interests, and risks (e.g., cigarette smoking, recreational drug use, sex)
  • Increased drive to become independent, questioning of authority
  • Strong orientation to peer groups that can influence behavior and preferences
  • Self-exploration of sexual interests and relationships
Late adolescence (early adulthood)
  • ≥ 17 years
  • Physical maturity (end of physical puberty changes)
  • Capacity for abstract and rational thought continues to develop
  • Longterm planning and goal-setting
  • Firmer sense of identity and independence
  • Development of stable, intimate relationships

Precocious pubertytoggle arrow icon

Definition [9]

Epidemiology [3][10]

  • Incidence: 1:5,000 to 1:10,000 children
  • Ten times more common in girls than boys.


Central precocious puberty [3][9][11]




Clinical features


  • Laboratory tests
  • Imaging
    • X-ray of the nondominant hand and wrist: allows comparison between skeletal maturation and chronological age
      • Assess and confirm accelerated bone growth.
      • Bone age is within 1 year of a child's age: Puberty likely has not started.
      • Bone age is > 2 years of the child's age: Puberty has been present for a year or longer.
    • MRI/CT of the brain with contrast: when LH is confirmed
      • Perform in girls ≤ 6 years of age, all boys, and children with neurologic symptoms.
      • Rule out intracranial causative pathology.


  • GnRH agonist (e.g., leuprolide, buserelin, goserelin): to prevent premature fusion of growth plates
    • Close monitoring of therapy
    • Follow-up is recommended every 4–6 months to assess progression.
  • Manage underlying cause.

Peripheral precocious puberty [3][9][11][12]



Clinical features



Central precocious puberty has a central cause (e.g., hypothalamic lesions) and high GnRH levels, while peripheral precocious puberty has a peripheral cause (e.g., germ cell tumors), without elevated GnRH levels.

Benign pubertal variants [11]

Description Clinical features Diagnosis
Premature adrenarche [13]
  • Precocious pubarche: onset of pubic and/or axillary hair growth < 8 years in girls and < 9 years in boys
  • Adult-type body odor
  • Seborrhea, acne
  • Other secondary sexual characteristics are absent.
  • Growth rate is linear and height for age is normal or increased.
Idiopathic premature pubarche
Benign precocious thelarche
Benign precocious menarche/vaginal bleeding

Obesity-related precocious sexual development [16][17][18]

McCune-Albright syndrometoggle arrow icon

Definition [19]


  • Accounts for 5% of cases of precocious puberty (more common in females) [20]
  • Affects 1 in 100,000 to 1 in 1,000,000 individuals in the general population [20]
  • Peak incidence: early childhood


Pathophysiology [21]

Clinical features [19]

Diagnostics [19][22]


Differential diagnosis


  • The condition is lethal when the mutation affects all cells (i.e., occurs before fertilization), but survivable in patients affected by mosaicism.

The 3 P's of McCune-Albright syndrome are Polyostotic fibrous dysplasia, Pigmentation (café-au-lait spots), and Precocious puberty.

Delayed onset of pubertytoggle arrow icon

Definition [23][24]

Etiology [25]

Clinical features

Diagnosis [25]

Treatment [25]

Referencestoggle arrow icon

  1. Blondell RD, Foster MB, Dave KC. Disorders of puberty. Am Fam Physician. 1999; 60 (1): p.209-218.
  2. Patricia B. Reagan, Pamela J. Salsberry, Muriel Z. Fang, William P. Gardner, Kathleen Pajer. African-American/white differences in the age of menarche: Accounting for the difference. Soc Sci Med. 2012; 75 (7): p.1263-1270.doi: 10.1016/j.socscimed.2012.05.018 . | Open in Read by QxMD
  3. Klein et al.. Disorders of Puberty: An Approach to Diagnosis and Management. American Family Physician. 2017; Volume 96 (Number 9).
  4. Krabbe S, Christiansen C, Rodbro P, Transbol I. Effect of puberty on rates of bone growth and mineralisation: with observations in male delayed puberty.. Arch Dis Child. 1979; 54 (12): p.950-953.doi: 10.1136/adc.54.12.950 . | Open in Read by QxMD
  5. Saggese G, Baroncelli GI, Bertelloni S. Puberty and bone development. Best Practice & Research Clinical Endocrinology & Metabolism. 2002; 16 (1): p.53-64.doi: 10.1053/beem.2001.0180 . | Open in Read by QxMD
  6. Bergler-Czop B, Brzezińska-Wcisło L. Dermatological problems of the puberty. Postepy Dermatol Alergol. 2013; 30 (3): p.178–187.doi: 10.5114/pdia.2013.35621 . | Open in Read by QxMD
  7. Kaplowitz P, Bloch C. Evaluation and Referral of Children With Signs of Early Puberty. Pediatrics. 2015; 137 (1): p.e20153732.doi: 10.1542/peds.2015-3732 . | Open in Read by QxMD
  8. Partsch C-J. Pathogenesis and epidemiology of precocious puberty. Effects of exogenous oestrogens. Hum Reprod Update. 2001; 7 (3): p.292-302.doi: 10.1093/humupd/7.3.292 . | Open in Read by QxMD
  9. Tirumuru SS, Arya P, Latthe P, Kirk J. Understanding precocious puberty in girls. The Obstetrician & Gynaecologist. 2012; 14 (2): p.121-129.doi: 10.1111/j.1744-4667.2012.00094.x . | Open in Read by QxMD
  10. Rivera-Arkoncel MLC, Pacquing-Songco D, Lantion-Ang FL. Virilising ovarian tumour in a woman with an adrenal nodule. Case Reports. 2010; 2010 (dec13 1): p.bcr0720103139-bcr0720103139.doi: 10.1136/bcr.07.2010.3139 . | Open in Read by QxMD
  11. Oberfield SE, Sopher AB, Gerken AT. Approach to the girl with early onset of pubic hair.. J Clin Endocrinol Metab. 2011; 96 (6): p.1610-22.doi: 10.1210/jc.2011-0225 . | Open in Read by QxMD
  12. Rosenfield RL. Normal and Premature Adrenarche. Endocr Rev. 2021; 42 (6): p.783-814.doi: 10.1210/endrev/bnab009 . | Open in Read by QxMD
  13. Rosenfield RL. Normal and almost normal precocious variations in pubertal development premature pubarche and premature thelarche revisited.. Horm Res. 1994; 41 Suppl 2: p.7-13.doi: 10.1159/000183950 . | Open in Read by QxMD
  14. Solorzano CMB, McCartney CR. Obesity and the pubertal transition in girls and boys . Reproduction. 2010; 140 (3): p.399-410.doi: 10.1530/REP-10-0119 . | Open in Read by QxMD
  15. Soliman A, De Sanctis V, Elalaily R, Bedair S. Advances in pubertal growth and factors influencing it: Can we increase pubertal growth?. Indian J Endocrinol Metab. 2014; 18 (7): p.53-62.doi: 10.4103/2230-8210.145075 . | Open in Read by QxMD
  16. Childhood Obesity: Implications in Pubertal Process. Updated: January 1, 2015. Accessed: August 4, 2017.
  17. Delayed Puberty. Updated: February 1, 2017. Accessed: August 4, 2017.
  18. Delayed Puberty. Updated: February 2, 2012. Accessed: August 4, 2017.
  19. Rosen DS, Foster C. Delayed Puberty. Pediatrics in Review. 2001; 22 (9): p.309-315.doi: 10.1542/pir.22-9-309 . | Open in Read by QxMD
  20. Association of Maternal & Child Health Programs. Adolescent Development. Association of Maternal & Child Health Programs. 2020.
  21. Christie D, Viner R. Adolescent development. BMJ. 2005; 330 (7486): p.301-304.doi: 10.1136/bmj.330.7486.301 . | Open in Read by QxMD
  22. Holbrook, Brady. McCune Albright Syndrome. StatPearls. 2020.
  23. McCune Albright Syndrome. Updated: January 1, 2017. Accessed: September 7, 2020.
  24. Dumitrescu CE, Collins MT. McCune-Albright syndrome. Orphanet J Rare Dis. 2008; 3 (1).doi: 10.1186/1750-1172-3-12 . | Open in Read by QxMD
  25. ller L, Wood NH, Khammissa RA, Lemmer J, Raubenheimer EJ. The nature of fibrous dysplasia. Head Face Med. 2009; 5: p.22.doi: 10.1186/1746-160X-5-22 . | Open in Read by QxMD
  26. Tang C, Zafar Gondal A, Damian M. Delayed Puberty. StatPearls. 2020.

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