Do you assess Tanner stages as part of a physical exam?

Tanner Staging Assessment in Physical Examination

Yes, Tanner staging should be assessed as part of the physical examination in specific clinical contexts, particularly for monitoring pubertal development in at-risk populations and evaluating growth and development in children starting at age 10 years.

When Tanner Staging is Recommended

In Cancer Survivors

• For prepubertal and peripubertal cancer survivors at risk for premature ovarian insufficiency, monitoring of growth and pubertal development and progression through Tanner staging is strongly recommended at least annually 1
• Surveillance frequency should increase as clinically indicated based on growth and pubertal progress as measured by physical examination 1
• For prepubertal females age ≥11 years who fail to initiate or progress through puberty, laboratory evaluation should be performed 1
• Endocrinology consultation is strongly recommended for prepubertal females with no signs of puberty by age 13 years or primary amenorrhea by age 16 years despite other pubertal signs 1

In Children on Tyrosine Kinase Inhibitors

• Tanner staging should be performed every 6 months until Tanner stage 5 is reached in children with chronic myeloid leukemia receiving TKI therapy 1
• Early referral for endocrine evaluation is recommended for delayed puberty, with consideration of sex hormone levels 1

In General Pediatric Practice

• The Endocrine Society recommends boys undergo Tanner staging evaluation starting at age 10 years to establish a baseline for monitoring pubertal progression 2
• Annual monitoring of Tanner staging beginning at age 10 years helps identify delayed puberty if progression does not occur as expected 2
• Assessment of pubertal stage should be performed according to Tanner stages in patients older than 10 years of age 2

Clinical Context for Assessment

Precocious Puberty Surveillance

• Yearly height, height velocity, weight, and Tanner stage evaluations are recommended for survivors at risk of precocious puberty (particularly those who received cranial irradiation ≥18 Gy) 1
• Tanner stage 2 breast development before age 8 years in girls warrants endocrine referral 1
• The first physical sign of male puberty is testicular enlargement (measured via orchidometer), not pubic hair development 2

Delayed Puberty Evaluation

• Documenting Tanner staging for pubic hair and testicular volume is crucial in evaluating delayed puberty 3
• Absence of both axillary and pubic hair suggests pre-pubertal status (Tanner stage 1) 3
• Referral to pediatric endocrinology is recommended for persistently abnormal hormone levels, confirmed hypogonadism, or lack of progression 3

Important Clinical Considerations

Examination Technique

• Physical examination by a trained clinician remains the gold standard for Tanner staging 4
• Assessment should include evaluation of pubic hair distribution and breast development in females or genital development in males 4
• In girls, breast development (thelarche) is the first physical sign of puberty activation, not pubic or axillary hair (adrenarche) 1

Self-Assessment Limitations

• While self-assessment questionnaires show moderate to good agreement with physician examination (kappa 0.48-0.74), they should be used cautiously 5, 6
• Self-assessment is less reliable in early and mid-pubertal stages (Tanner stage 3), with only 46.9% accuracy in one study 6
• Obese children tend to overestimate their pubertal development compared to non-obese peers 7
• Self-assessment may be appropriate for large epidemiological studies where direct examination is not feasible, but not as a substitute for clinical evaluation 6, 8

Common Pitfalls to Avoid

• Do not confuse adrenarche (pubic/axillary hair) with true pubertal activation in girls—look for breast development 1
• Remember that menstrual cycles do not reliably indicate fertility in cancer survivors, as gonadotoxic therapy can cause premature ovarian failure despite regular menses 1
• Pubertal timing varies by race and ethnicity, so consider population-specific norms 1