Previous article
Vaginitis: Diagnosis and Treatment
Nov 2025
Next article
Acute Low Back Pain: Diagnosis and Management

Disorders of Puberty: Common Questions and Answers

Emily E. Brown, MD
Corey D. Fogleman, MD

American Family Physician. 2025;112(5):513-521C.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Clinicians often need to differentiate between benign, self-limited variations of pubertal development and more serious underlying causes. Precocious puberty should be considered when thelarche occurs in female patients before 8 years of age or when testicular enlargement occurs in male patients before 9 years of age. Delayed puberty should be considered in female patients who lack breast development by 13 years of age or do not experience menarche by age 15 and in male patients who lack testicular growth by age 14. Assessment should focus on clinical and family history, growth, and pubertal examination to rule out benign pubertal variations. Further laboratory and radiographic workup may include early morning testing of luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone (thyrotropin), total testosterone (in male patients), and estradiol (in female patients), as well as left-hand bone age radiography. Neuroimaging with contrast-enhanced magnetic resonance imaging of the brain should be obtained in all patients with central precocious puberty who have neurologic signs or symptoms; are female and younger than 6 years; or are male and younger than 9 years. Specialist evaluation by pediatric endocrinology is often indicated when examination results are not consistent with a benign variation of puberty.

EMILY E. BROWN, MD, AAHIVS, is an associate director of the Lancaster General Hospital Family Medicine Residency Program, Lancaster, Pennsylvania.

COREY D. FOGLEMAN, MD, FAAFP, is a deputy director of the Lancaster General Hospital Family Medicine Residency Program.

Address correspondence to Emily E. Brown, MD, at emily.brown@pennmedicine.upenn.edu.

Author disclosure: No relevant financial relationships.

  1. 1.Klein DA, Emerick JE, Sylvester JE, et al. Disorders of puberty: an approach to diagnosis and management. Am Fam Physician. 2017;96(9):590-599.
  2. 2.Bakhtiani P, Geffner M. Early puberty. Pediatr Rev. 2022;43(9):483-492.
  3. 3.Bakhtiani P, Geffner M. Delayed puberty. Pediatr Rev. 2022;43(8):426-435.
  4. 4.Eckert-Lind C, Busch AS, Petersen JH, et al. Worldwide secular trends in age at pubertal onset assessed by breast development among girls: a systematic review and meta-analysis. JAMA Pediatr. 2020;174(4):e195881.
  5. 5.Bradley SH, Lawrence N, Steele C, et al. Precocious puberty. BMJ. 2020;368:l6597.
  6. 6.Carel JC, Léger J. Clinical practice. Precocious puberty. N Engl J Med. 2008;358(22):2366-2377.
  7. 7.Bordini B, Rosenfield RL. Normal pubertal development: part I: the endocrine basis of puberty. Pediatr Rev. 2011;32(6):223-229.
  8. 8.Kaplowitz P, Bloch C; Section on Endocrinology, American Academy of Pediatrics. Evaluation and referral of children with signs of early puberty. Pediatrics. 2016;137(1):e20153732.
  9. 9.Chen LK, Wang G, Bennett WL, et al. Trajectory of body mass index from ages 2 to 7 years and age at peak height velocity in boys and girls. J Pediatr. 2021;230:221-229.e5.
  10. 10.Rosenfield RL, Lipton RB, Drum ML. Thelarche, pubarche, and menarche attainment in children with normal and elevated body mass index. Pediatrics. 2009;123(1):84-88.
  11. 11.Herman-Giddens ME, Steffes J, Harris D, et al. Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics. 2012;130(5):e1058-e1068.
  12. 12.Osinubi AA, Lewis-de Los Angeles CP, Poitevien P, et al. Are Black girls exhibiting puberty earlier? Examining implications of race-based guidelines. Pediatrics. 2022;150(2):e2021055595.
  13. 13.Nella AA, Kaplowitz PB, Ramnitz MS, et al. Benign vaginal bleeding in 24 prepubertal patients: clinical, biochemical and imaging features. J Pediatr Endocrinol Metab. 2014;27(9–10):821-825.
  14. 14.Brosens I, Benagiano G. Clinical significance of neonatal menstruation. Eur J Obstet Gynecol Reprod Biol. 2016;196:57-59.
  15. 15.Rohayem J, Alexander EC, Heger S, et al. Mini-puberty, physiological and disordered: consequences, and potential for therapeutic replacement. Endocr Rev. 2024;45(4):460-492.
  16. 16.Renault CH, Aksglaede L, Wøjdemann D, et al. Minipuberty of human infancy - a window of opportunity to evaluate hypogonadism and differences of sex development? Ann Pediatr Endocrinol Metab. 2020;25(2):84-91.
  17. 17.American Academy of Pediatrics Section on Endocrinology. Choosing wisely: five things physicians and patients should question. Updated 2022. Accessed February 23, 2025. https://downloads.aap.org/AAP/PDF/Choosing%20Wisely/CWEndocrinology.pdf
  18. 18.Kaplowitz PB, Mehra R. Clinical characteristics of children referred for signs of early puberty before age 3. J Pediatr Endocrinol Metab. 2015;28(9–10):1139-1144.
  19. 19.Kulshreshtha B, Arpita A, Rajesh PT, et al. Adolescent gynecomastia is associated with a high incidence of obesity, dysglycemia, and family background of diabetes mellitus. Indian J Endocrinol Metab. 2017;21(1):160-164.
  20. 20.Nebesio TD, Eugster EA. Pubic hair of infancy: endocrinopathy or enigma? Pediatrics. 2006;117(3):951-954.
  21. 21.Soriano-Guillén L, Corripio R, Labarta JI, et al. Central precocious puberty in children living in Spain: incidence, prevalence, and influence of adoption and immigration. J Clin Endocrinol Metab. 2010;95(9):4305-4313.
  22. 22.Haddad NG, Eugster EA. Peripheral precocious puberty including congenital adrenal hyperplasia: causes, consequences, management and outcomes. Best Pract Res Clin Endocrinol Metab. 2019;33(3):101273.
  23. 23.Kemper KJ, Romm AJ, Gardiner P. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. 2007;356(24):2541-2542.
  24. 24.Rohani F, Salehpur S, Saffari F. Etiology of precocious puberty, 10 years study in Endocrine Reserch Centre (Firouzgar), Tehran. Iran J Reprod Med. 2012;10(1):1-6.
  25. 25.Qudsiya Z, Gupta V. Peripheral precocious puberty.StatPearls Updated July 10, 2023. Accessed August 27, 2025. https://www.ncbi.nlm.nih.gov/books/NBK560588/
  26. 26.Skeletal Development of the Hand and Wrist: A Radiographic Atlas and Digital Bone Age Companion. Gaskin CM.Skeletal Development of the Hand and Wrist: A Radiographic Atlas and Digital Bone Age Companion Oxford University Press; 2011.
  27. 27.Burns J, Policeni B, Bykowski J, et al.; Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® Neuroendocrine Imaging. J Am Coll Radiol. 2019;16(5S):S161-S173.
  28. 28.Fink DA, Nelson LM, Pyeritz R, et al. Fragile X associated primary ovarian insufficiency (FXPOI): case report and literature review. Front Genet. 2018;9:529.
  29. 29.Blondell RD, Foster MB, Dave KC. Disorders of puberty. Am Fam Physician. 1999;60(1):209-218.
Previous article
Vaginitis: Diagnosis and Treatment
Nov 2025
Next article
Acute Low Back Pain: Diagnosis and Management

Current issue

May 2026

May 2026

Copyright © 2026 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissions for copyright questions and/or permission requests.