Papilla (nipple) development during female puberty

JOURNAL OF ADOLESCENT HEALTH CARE 2:217-220, 1982

Papilla (Nipple) Development During Female Puberty REUBEN D. R O H N , M.D.

The purpose of this study was to compare breast papilla (nipple) development to the established criteria of secondary sexual maturation. One hundred and sixty-eight girls (100 black and 68 white) ranging in age from 2 - 2 1 years had their papilla diameter measured and their Tanner stage assessed. Minimal nipple development occurred from stages P H 1 - P H 3 (2.91-4.08 m m ) a n d B 1 - B 3 (2.75-3.96 m m ) or premenstrually (3.61 m m ) . Significant growth occurred beyond stages P H 3 , B3 ( P H 4 - - 7 . 2 2 m m , P H 5 - - 9 . 3 6 m m , B 4 m 7 . 7 4 m m , B 5 - - 9 . 4 7 m m ) and near or after menarche(7.82 mm for girls 0m2 years post-menarche, 9.23 m m for gifts 2m4 years post-menarche and 9.65 m m for girls more than four years after menarche). A more objective definition for breast stages B4 and B5, based on nipple diameter, may now be feasible, thus enhancing the precision with which physiologic events occurring toward the close of puberty can be studied. KEY WORDS: Papilla Nipple development

Sexual maturity rating Tanner staging Puberty The evolution of sexual development scales began early in this century as a result of the increased interest in the study of the physiology of puberty. Despite the development of objective measures for some secondary characteristics, such as the orchidometer with its graded models for testicular size (1), very little attention has been paid to development of objective devices or techniques for determining breast maturation characteristics. One such attempt has been to measure areola size (2, 3), but

From the Department of Pediatmcs, Eastern Virginia Medical School, Chzldren's Hospital of the King's Daughters, 800 West Olney Road, Norfolk, Virginia 23507. Manuscript accepted July 8, 1981.

papilla or nipple measurment has received little or no attention. The purpose of this study was to determine the characteristics of nipple development in the female and to compare that development to the Tanner criteria for breast and pubic hair stages and the age of menarche. Since some ambiguity has existed between breast stages 4 and 5 (4), an objective measurement such as nipple size might allow discrimination between the two stages.

Subjects and Methods A total of 168 girls served as the subjects (100 Black and 68 White). These girls were seen in the various clinics of the Children's Hospital and at the Norfolk Detention Home. Breast and pubic hair stage were determined by the Tanner criteria (4) by one observer, and the recalled age of menarche was recorded for each subject. The girls ranged in age from 2-21 years. After breast palpation, the greatest diameter of the erect nipple plateau was measured using a steel rule graduated in millimeters (65 subjects) or a plastic template (103 subjects) with graduated circular cut-outs (Fig 1). A Student's t test showed no statistically significant difference between papilla measurements obtained in 26 girls by both techniques. Thus the measurements of all 168 girls were combined. All measurements were made by the same observer and both papillae were measured. The smaller of the two measurements was used in the analysis. As noted by Masters and Johnson, cold, tactile, or psychic stimulation may lead to areolar engorgement which may mimic the areolar mounding of breast stage 4 (5). Changes in the diameter of the base of the nipple may occur as well (5). To circumvent these problems, breast staging was assessed prior to breast palpation and only the plateau portion of the erect nipple was measured. The nipple

© Society for Adolescent Medicine, 1982 Published by Elsevier Science Publishing Co, Inc., 52 Vanderbilt Ave., New York, NY 10017

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JOURNAL OF ADOLESCENT HEALTH CARE Vol. 2, No. 3

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measurement before and after breast palpation in twenty girls showed no significant difference (P >

0.20). Papilla diameter was compared to breast stage (B), pubic hair stage (PH), and menstrual age (M). All girls were placed into one of four arbitrary menstrual age groupings for data analysis: (a) Group M1, all premenstrual girls; (b) Group M2, those menstruating less than two years; (c) Group M3, those menstruating two years but less than four years, and (d) Group M4, those menstruating for more than four years. The data were analyzed by multiple regression analysis and a two-way analysis of variance. Subsequently, one-way analysis of variance with post hoc t tests by the procedure of Scheffe (6) was then applied to assess for significant differences between sex stages or menstrual age groups.

Results

Multiple regression analysis revealed that nipple size was significantly correlated to the variables of breast stage, pubic hair stage, and menstrual age (r = 0.8664, r = 0.8445, r = 0.8406 respectively). No significant correlations were noted for the variables of race or health status (r = -0.0061, f = -0.2724). The latter variable was determined because girls with various endocrine or chronic disorders were included in the study along with normal girls. The results of the analysis of variance was statistically significant for breast and pubic hair stages and menstrual age grouping (F = 180.3, F = 134.0, F = 191.0, respectively, with P < 0.00001 in each

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case). Post h o c t test results indicated significant differences in nipple diameter among breast stages B1, B3, B4, and B5. Stage B2 fell between, but not statistically different from either stages B1 or B3 (Fig. 2). Significant nipple diameter increment was found among stages PH1, PH4, and PH5. Stages PH1, PH2, and PH3 were not statistically different from each other (Fig. 3). By menstrual age grouping, papilla diameter showed significant increase among stages M1, M2, and M3. There was an insignificant difference in diameter between stages M3 and M4 (Fig. 4). Discussion

The first description of breast development staging was reported by Stratz in 1909 (7). He described four stages of breast development (7). These stages were used in studies by Pryor (8) and by Greulich et al., in the 1930s (9). Reynolds and Wines added a fifth stage in their longitudinal studies of girls during the 1940s (10). This stage is the current Tanner stage B3: elevation of both the breast and areola with no distinct separation of their contours (10). The five-stage descriptions are most commonly used today. In the studies by Reynolds and Wines (10) and by Tanner (4), there is significant ambiguity between stages B4 and B5. In the former study, eight of thirty-two girls lacked a secondary areola m o u n d (10). Another seven of thirty-two had only slight Tanner stage B4 development (10). Tanner's experience was similar (4). He also reported that for many girls the areola m o u n d stage often persisted into adulthood (4). The findings of Masters and Johnson, concerning the effects of sexual excitation of the h u m a n female breast, suggests further potential pitfalls in differentiating B4 from B5 (5). Only two studies have examined areola devel-

March 1982

NIPPLE DEVELOPMENT

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opment during puberty. Garn in 1952 measured the maximum diameter of the left areola in frontal somatotype photographs (2). He found areola diameter enlargement to be an early sign of puberty in girls (2). This enlargement continued from stage B2 to B5, but proceeded faster in the earlier stages (2). Roche and colleagues, in the semilongitudinal study in 1971, compared areola development to chronologic age, pubic hair stage, age of peak height velocity, age of menarche, and subcutaneous fat thickness (3). Although they found increasing areola size with pubertal progression, it was concluded that areola size was not significantly related to any of the factors

studied (3). This lack of a correlation, they concluded, indicated that genetic factors were the primary determinants of areola size. To my knowledge, no one has studied breast papilla diameter during puberty. This cross-sectional study found minimal nipple development premenstrually or from Tanner stages PH1 to PH3 or B1 to B3. Although in the latter instance there was a statistically significant increment from B1 to B3, there is some degree of overlap of individual measurements in the two stages (Fig. 2). The greatest growth in papilla diameter occurred after stages B3 or PH3 or near menarche (Figs. 2-4). There is virtually no

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Figure 3. Nipple size compared to Tanner pubic

hair stages. Differences are statistically significant for stages PHI, PH4, and PH5 (P < 0.05)

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JOURNAL OF ADOLESCENT HEALTH CARE Vol. 2, No. 3

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Menstrual Age Group overlap among individual measurements of stages B3 and B4, PH3 and PH4 or of groups M1 and M2. There was also a statistically significant incremental gradation between stages B4 and B5, PH4 and PH5, and groups M2 and M3 (Figs. 2-4), even though there is some overlap in each case. A newer, more objective definition for stages B4 and B5 based on the papilla diameter may n o w be feasible. On the basis of these data, designation of a specific nipple measurement to those stages may be premature. Nevertheless, a greater number of observations may statistically narrow the scatter. Longitudinal studies should be of further help in confirming these findings and in assigning specific measurements of nipple size to the currently used Tanner breast stages. I would like to thank Gerry Philips and Mary Gleason for their help in running the computer programs for the data. I especially thank Ron Jordan, Ph.D., for his time and his expert assistance in the handling of the statistical analyses.

References 1. Prader A: Testicular size: Assessment and clinical importance. Triangle 7:240-243, 1966 2. Garn SM: Changes in areolar size during the steroid growth phase. Child Develop 23:55-60, 1952 3. Roche AF, French NY, Daville GH: Areo]ar size during pubescence. Human Biol 43:210-223, 1971 4. Tanner JM: Growth at Adolescence. 2nd ed., Oxford; Blackwell Scientific Publications, 1962 5. Masters WH, Johnson VE: Human Sexual Response. Boston: Little Brown & Co., 1966 6. Scheffe HA: The Analysis of Variance. New York: Wiley, 1959 7. Stratz CH: Der Korper des Kindes und seine Pflege. Stuttgart, Ferdinand Enke, 1909 8. Pryor HB: Certain physical and physiological aspects of adolescent development. J Pediat 8:52-62, 1936 9. Greulich WW, Day HG, Lachman SE, et al.: A handbook of methods for the study of adolescent children. Monographs of the Society for Research in Child Develop Vol. III #2, Serial #15, Washington, D.C., 1938 10. Reynolds EL, Wines JV: Individual differences in physical changes associated with adolescence in girls. Am J Dis Children 75:329-350, 1948