Determine Tanner stage for pubertal suppression eligibility
STEP 1 — Gather Information
Obtain the patient's sex assigned at birth and perform a focused physical examination: for individuals assigned female, assess breast development using Tanner stages; for individuals assigned male, assess testicular volume and penile size using Tanner stages. Record the highest breast or genital Tanner stage observed.
STEP 2 — Rule In / Rule Out
Determine whether the observed Tanner stage is G2/B2 or higher. If yes, rule in that puberty has begun; if the stage remains at 1 (prepubertal), rule out puberty onset.
STEP 3 — Classify or Stratify
Classify the patient as eligible for consideration of pubertal suppression if Tanner stage is G2/B2 or higher (≥2); classify as not eligible if Tanner stage is 1.
STEP 4 — Decide
If eligible (≥2), refer the patient to a multidisciplinary team for shared decision‑making regarding initiation of gonadotropin‑releasing hormone agonist suppression; if not eligible (stage 1), schedule a follow‑up assessment in 3 to 6 months to re‑evaluate Tanner progression.
Clinical Guardrails / Mimics / Pitfalls
Do not confuse adrenarche (pubic/axillary hair) with gonadarche; avoid relying solely on patient‑reported changes; be aware that obesity can mimic breast tissue in assigned females; do not delay assessment based on age alone; consider obtaining LH/FSH or ultrasensitive estradiol/testosterone if physical findings are ambiguous.
Concrete Clinical Example
A 12‑year‑old assigned female presents with breast budding (Tanner stage 2) and no pubic hair. The clinician records Tanner stage G2, rules in puberty onset, classifies as eligible, and refers to the multidisciplinary team for discussion of GnRH agonist suppression.
Source: Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons, Endocrine Society, 2017, doi:10.1210/jc.2017-01658