Female Sexual Maturity Rating

Information has been excerpted from VisualDx clinical decision support system as a public health service. Additional information, including symptoms, diagnostic pearls, differential diagnosis, best tests, and management pearls, is available in VisualDx.


Tanner staging, also known as sexual maturity rating, is a uniformly accepted scale to describe the onset and progression of pubertal changes. Girls are rated on a 1-5 scale based on their breast development and pubic hair growth. In females, the normal onset of puberty ranges from ages 8 to 13 years.

Breast staging as well as other physical markers of puberty (eg, height velocity) are more reliable than pubic hair staging for assessing pubertal development since the adrenal axis matures independently.

Look For

Breast development:

  • Stage I – No glandular breast tissue palpable. Only the papilla is elevated over the chest wall, as seen in childhood.
  • Stage II – Breast bud palpable under the areola. Thelarche is the first pubertal sign in females. There is elevation of the breasts and papilla as small “breast buds” and increased diameter of the areola.
  • Stage III – Breast tissue palpable outside areola; no areolar development. The breasts and areola continue to enlarge, without separation of contour.
  • Stage IV – Areola elevated above the contour of the breast, forming a “double scoop” appearance, ie, secondary mounds. There is further development of the breast tissue.
  • Stage V – Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development (may extend slightly above the contour of the breast), and nipple protrusion. Mature female breasts.

Hair development:

  • Stage I – No sexual hair. Vellus hair appears similar to that over the abdominal wall.
  • Stage II – Downy hair. There is a sparse distribution of long, dark, downy hair that is straight or slightly wavy, found mainly along the labia.
  • Stage III – Scant terminal hair. The hair is significantly darker, courser, and curlier. The hair has spread over the junction of the pubis.
  • Stage IV – Terminal hair that fills the entire triangle overlying the pubic region. The hair is as course as adult hair, but the distribution is less than that seen in an adult female.
  • Stage V – Terminal hair that extends beyond the inguinal crease onto the thigh. The hair is of adult distribution and type. The area of coverage appears as an inverse triangle with spread to the medial surface of the thighs.

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