Papilla (nipple) development in puberty

J O U R N A L OF A D O L E S C E N T H E A L T H CARE 1985;6:429-432

Papilla (Nipple) Development in Puberty The Adolescent Mate REUBEN D. R O H N / M . D .

Papilla (nipple) development was studied in 230 males (119 black, 111 white) aged 3-29 years to compare this development to the established criteria for sexual maturation. Comparison was also made with a previous study of female nipple development to determine whether or when any differences between male and female nipple development occurred. Our male subjects were further assessed to determine if nipple size differed in the presence or absence of gynecomastia. Significant nipple development occurred between pubic hair stages PH1 (diameter 2.8 ram), PH4 (4.4 mm), and PH5 (5.4 mm). Similarly, there was significan t incremental growth between genital stages G1 (3.0 mm), G3 (4.6 ram), and G5 (5.5 mm). Nipple development was similar in both sexes through stage PH3, but significantly diverged at stage PH4 (p K 0.000001) because of a marked increase in female nipple diameter. Boys with gynecomastia had a significantly larger nipple size than boys who had none (p K 0.001). Differences in nipple diameter between the sexes and between boys with and without gynecomastia probably result from differences i n estrogen levels, Perhaps in the future, it will be possible on the basis of nipple diam e ter to predict which adolescent boys will have persistent gynecomastia. KEY WORDS:

Papilla development, male Sexual maturation Gynecomastia A recent study of papilla (nipple) development in the adolescent female showed a significant growth of the

From the Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, Virginia. Address reprint requests to: Reuben D. Rohn, M.D., Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, 800 West Olney Road, Norfolk, VA 23507. Manuscript accepted December3, 1984.

papilla after breast (B) stage 3 and pubic hair (PH) stage 3, and near or after menarche (1). In addition, definite distinction could be made between stages B4 and B5 based upon nipple size (1), whereas previously there was significant ambiguity between stages B4 and B5 (2,3). Male nipple development during puberty has not been systematically studied. By inspection it appears that nipple development is different between the adult male and female, but it is usually difficult to perceive any difference in nipple size between prepubertal boys and girls. Some boys develop gynecomastia during puberty while others do not. Does papilla size differ in males with and without gynecomastia? The purpose of this study was threefold: 1) to assess papilla development in boys and compare it to established criteria of sexual maturation (Tanner staging); 2) to compare male pubertal nipple development with female development; and 3) to compare nipple development in boys with and without gynecomastia.

Methods A total of 230 boys (119 black, 111 white) ranging in age from 3 to 29 years seen in various clinics of the Children's Hospital of the King's Daughters or at the Norfolk Detention Home served as the subjects. Pubic hair and genital (G) ratings were staged by one observer using the Tanner criteria. The presence or absence of gynecomastia was determined by breast palpation. After palpation, the greatest diameter of the erect nipple plateau was measured using a plastic template with circular cutouts graduated in millimeters (Figure 1). All measurements were made on both sides by the same observer. The smaller of the two measurements was used in the analysis.

© Society for Adolescent Medicine, 1985 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017

429 0197-0070/85/$3.30

430

ROHN

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 6, No. 6

Figure 1. Plastic template (graduated in millimeters) used to measure

nipple size.

For comparison, a total of 390 girls ranging in age from I to 22 years (229 black, 161 white), of whom 168 were previously reported (1), were evaluated in the same setting outlined above. Tanner staging for B and PH plus menstrual age grouping (M) and nipple diameter were determined as previously described (1). The data for both sexes were analyzed by multiple regression analysis. Subsequently, a one-way analysis of variance with post hoc t-tests by the procedure of Scheffe was applied to assess for significant difference s between Tanner stages for each sex and for the girl's menstrual age group (4).

Results Multiple regression analysis revealed that nipple size was significantly correlated with the boy's PH G

stages (r = 0.7499, r = 0.6988, respectively). No significant correlations were noted for race or health status (r = 0.0915, r = - 0.1618, respectively). Health status was determined because subjects with chronic disorders were included in the study group. The results of the analysis of variance were statistically significant for PH and G stages ff = 73.9 and f = 58.0, respectively, p < 0.00001 in each case). Post hoc tltest results on the boys showed significant differences in nipple diameter between PH1, PH4, and PH5 stages. Stage PH2 was no different from PH1, and stage PH3 fell between stages PH2 and PH4 but was not statistically different from stage PH2 (Figure 2, Table 1). Significant nipple diameter increment was also found between stages G1, G3, and G5 (G2 was not different from G1), Stage G4 fell between but was not statistically different from stages G3 or G5 (Table 1). Boys with gynecomastia had significantly larger nipple diameters than boys without gynecomastia (Table 2). Judged by Tanner stage, significance was reached only at stage PH5.

iT--Mean ± S.D. Girls -I-Mean ~ S.D. Boys 12

n=171

._10 E

n=47

m8 N .~. 6 4

n=83 ~-~ n~93 1

n=34 ~ n=23 2

Figure 2. Nipple diameter compared to PH stage for both sexes.

n=55 ~_ n=60 n=29 n=25

3 Pubic Hair Stage

4

5

November 1985

MALE PAPILLA DEVELOPMENT

431

Table 1. Nipple Diameter (mm) and Pubertal Development Male PH stage

Nipple diameter

1 (n 2 (n 3 (n 4 (n 5 (n

2.8 3.2 4.0 4.4 5.4

= 93) = 23) =-25) = 29) = 60)

Nipple diameter

G stage

(0.8)a (0.6) (0.9) (1.0) (1.2)

1 (n 2 (n 3 (n 4 (n 5 (n

= = = = =

104) 33) 29) 22) 42)

3.0 3.5 4.6 4.8 5.5

(0.9) (0.8) (1.1) (1.1) (i.2)

Female PH stage 1 (n =

2 (n 3 (n 4 (n 5 (n

= = = =

83) 34) 55) 47) 171)

Nipple diameter 3.0 3.3 4.1 7.1 9.7

B stage

(1.0)

1 (n =

(0.9) (1.5) (1.8) (1.6)

2 (n 3 (n 4 (n 5 (n

= = = =

87) 39) 45) 76) 143)

Nipple diameter 2.9 (0.8) 3.3 (0.9) 4.1 (1.3) 7.7 (1.6) 9.9 (1.4)

M group M1 (n = MIA (n = MIB (n = MIC (n = M2 (n = M3 (n = M4 (n =

193) 79) 83) 31) 52) 74) 71)

Nipple diameter 3.7 (1.5) 3.0 (0.9) 3.7 (1.5) 5.1 (1.7) 8.3 (1.5) 9.8 (1.5) 10.0 (1.4)

Abbreviations: M1 = all prepubertal girls; MIA = premenarcheal girls < 8 years old; MIB = premenarcheal girls 8 to < 12 years old; MIC = premenarcheal girls > 12 years old; M2 = girls 0 to < 2 years postmenarche; M3 = girls 2 to < 4 years postmenarche; M4 = girls > 4 years postmenarche. aNumbe.r in parentheses is the standard deviation.

For t h e girls, the m u l t i p l e r e g r e s s i o n a n a l y s i s indicated t h a t n i p p l e size w a s significantly c o r r e l a t e d to B a n d P H stages a n d M age (r = 0.8924, r = 0.8663, a n d r = 0.8393, respectively). T h e a n a l y s i s of variance w a s significant for the s a m e t h r e e variables (f = 549.1, f = 401.0, a n d f = 503.9, r e s p e c t i v e l y , p < 0.00001 for each). T h e results of t h e p o s t h o c t-tests w e r e the s a m e for the 390 girls as for the original 186 (1). Significant n i p p l e i n c r e m e n t o c c u r r e d b e t w e e n Table 2. Comparison of Nipple Size in Adolescent Males With and Without Gynecomastia PH stage

Gynecomastia

Nipple size (mm)

A. 3 B. 3 C. 4 D. 4 E. 5 F. 5 G. Allb H. All

Present (n = 8) Absen t (n = 17) Present (n = 8) Absent (n = 21) Present (n = 14) Absent (n = 46) Present (n = 31) Absent (n = 132)

4.0 (0.9)a 4.0 (0.8) 4.8 (0.7) 4.2 (1.0) 6.1 (1.1)c 5.2 (1.2) 5.0 (1.3)d 3.9 (1.2)

aNumber in parentheses is the standard deviation. bCompares boys 10-17 years old. cSignificant difference E versus F: p < 0.03. dSignificant difference G versus H: p < 0.001.

stages B1, B3, B4, a n d B5 as well as P H 1 , P H 3 , P H 4 , a n d P H 5 a n d b e t w e e n m e n s t r u a l g r o u p s M1, M2, a n d M3 (Figure 2 a n d Table 1). A d i v i s i o n of M1 into three s u b u n i t s b a s e d o n age w a s significantly different. T h e r e w a s a significant d i v e r g e n c e in n i p p l e d i a m eter b e t w e e n sexes after stage PH3. Before stage PH3, n i p p l e d i a m e t e r w a s the s a m e in b o t h sexes. By stage PH4, n i p p l e d i a m e t e r a l m o s t d o u b l e d in females (p < 0.000001) (Figure 2, Table 1). M o r e o v e r , o n l y e l e v e n b o y s h a d a n i p p l e d i a m e t e r of 7 m m or greater, a n d n o n e s h o w e d a d i a m e t e r g r e a t e r t h a n 8 mm.

Discussion This cross-sectional s t u d y f o u n d t h a t n i p p l e d i a m e ter in b o y s p r o g r e s s e d significantly f r o m s t a g e s PH1 to P H 4 a n d P H 4 to P H 5 as well as f r o m s t a g e s G1 to G3 a n d G3 to G5. I n c o m p a r i s o n to girls, t h e r e w a s a lesser increase of n i p p l e size b e y o n d PH3. It is k n o w n t h a t e s t r o g e n a n d p o s s i b l y p r o g e s t e r o n e are r e s p o n s i b l e for f e m a l e b r e a s t d e v e l o p m e n t a n d nipple m a t u r a t i o n (5,6). T h u s , t h e sex difference in nipple d i a m e t e r at stage P H 4 m a y reflect the significant c h a n g e i n s e c r e t i o n of either h o r m o n e . T h e large in-

432

ROHN

cremental increase in nipple size between premenarcheal and early menarcheal girls gives further credence to this hypothesis because at this stage a significant change in hormonal secretion has been shown to occur (8). Boys with gynecomastia had significantly larger nipples than boys without. It is reported that boys who have gynecomastia have an increased estrogen to testosterone ratio (7). Thus, estrogen may be the source for their larger nipple diameters. The fact that the boys with gynecomastia at stage PH5 had the largest nipple size of any other male group is of further interest as gynecomastia usually resolves by late puberty (9). Thus, this difference in nipple size may be clinically useful if it proves possible in a longitudinal study to distinguish between those boys whose gynecomastia will resolve and those whose gynecomastia will persist and possibly require surgery for resolution. Further studies are needed to determine whether nipple diameter is dependent upon estrogen or progesterone levels Or secretory patterns. Sexua! maturation staging by nipple size appears feasible for the female adolescent. As previously concluded, nipple diameter appear s to better differentiate stages B4 and B5 in girls (1). In teenage boys, sexual maturation staging by nipple size does not

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 6, No. 6

appear to be feasible, despite the statistical significance , because the incremental gradations are small. I would like to thank Jerry Phillips, Mary Gleason, and Claudia Wade for their he!p with the computer programs for data analysis, and Susan Bedegrew for her clerical assistance. A special thanks goes to Ronald Jordan, Ph.D for his assistance and suggestions in the statistical analyses.

References 1. Rohn RD. Papilla (Nipple) development during female puberty. J Adol Health Care 1982;3:217-20. 2. Tanner JM. Growth at adolescence, 2nd edition. Oxford, Blackwell Scientific Publications, 1962, p. 37. 3. Reynolds EL, Wines JV. Individual differences and physical changes associated with adolescence in girls. Am J Dis Children 1948;75:329-50. 4. Scheffe HA. The analysis of variance. New York, Wiley, 1959. 5. Emerson K, Wilson JD" Diseases of the breast and of milk formation. In: isselbacher KJ, Adams RD, Braunwald E et al., eds. Harrison's princiPals of internal medicine, 9th edition. New York, McGraw Hill Book Co., !980, pp. 1787-94. 6. Tyson JE, Zacur HA. Diagnosis and treatment of abnormal lactation. Clin Obste t Gynecol 1975;18:65-93. 7. Lee PA. The relationship of concentration of serum hormones to pubertal gynecomasfia. J pediatr 1975;86:212-15. 8. Winter JSD, Faiman C, Reyes FI. Normal and abnormal pubertal development. Clin Obstet Gynecol 1978;21:67-86. 9. Nydick M, Bustos J, Dale JH, et al. Gynecomastia in adolescent boys. JAMA 1961;178:449-54.