Puberty -- "Am I Normal" 

One of the biggest concerns girls going through puberty have is "am I normal?" Parents can help their daughters go through these changes and develop a positive body image. It is important to know what constitutes normal development and when a visit to a physician to discuss puberty is warranted.

The average age of menarche (first menstrual period) in the United States is12.8. Menarche is preceded by a growth spurt, breast development and growth of pubic and underarm hair. Breast development generally starts around age 10 but may occur at earlier ages, it generally precedes menarche by about 2 years. During the first 2-3 years after menarche menstrual cycles tend to be irregular. Most cycles are between 21-45 days in the first 3 years although occasionally shorter or longer cycles may be noted. By the third year after menarche most cycles are 21-34 days long but the cycle length is not firmly established until the age of 19-20. In general menstrual bleeding lasts 2-7 days. It is difficult to quantify "normal" blood loss but most teens and adults report changing sanitary pads or tampons 3-6 times a day.

Girls who are anticipating the start of their menses have very concrete concerns; what to do if their period starts at school, at a friends house, or when they are wearing white pants. Assure that they are aware of protection available and even have the appropriate supplies ahead of time. Practice what they could say to the school nurse or friend. Make sure they know that almost all women would be honored to help them deal with their first period and it is nothing to be embarrassed about. Girls who are given a positive outlook on their period are less likely to have problems with painful periods later on in life.

To help girls understand their cycles and that they are "normal" have them chart their periods on a calendar. Sometimes girls are concerned they have 2 periods in a month charting can help them see that there is a normal length between cycles (e.g. a period that starts at the beginning of the month and another one at the end). Some girls need instruction on appropriate types of protection. Pads come in all sizes and shapes. A deodorant pad is not necessary. Many girls can use tampons; however they may need instruction in how to use them and should be encouraged to use a tampon of low absorbency.

If girls (or their mothers) are concerned that they may be having abnormal cycles then a discussion with a physician is warranted. Reassure girls that a pelvic exam is usually not necessary at the first visit. Girls should be evaluated if menarche doesn’t occur before age 15, breast development does not occur by age 13 or menses are absent for more than 2 months. Extremely heavy or painful menses should be discussed with a physicin as should extremely irregular periods 2-3 years after menarche. Polycystic ovarian syndrome (PCOS) is the most common cause of severe menstrual irregularities in teenagers. This is characterized by completely irregular cycles with months in between menses along with signs of excessive androgen production such as abnormal hair growth, severe acne and obesity. Teenagers may remove unwanted hair around their nipples, abdomen and face so careful (and sensitive) questioning may be needed to find these signs. Early management of this syndrome can help adolescents avoid or minimize the impact of excessive hair growth, severe acne and obesity.

Lack of menstrual periods can be a sign of pregnancy and a sensitive pregnancy test is always part of an evaluation of amenorrhea in adolescents. Teenagers may be unwilling or unable (especially if involved in an abusive relationship) to honestly discuss sexual activity with parents or physicians. Amenorrhea may also be a sign of an underlying eating disorder such as anorexia or bulimia. Intensive exercise may also be a cause of a lack of menstrual periods or even delayed puberty.

It is likely easier for parents to talk to their children about the physical changes that occur during puberty than the social aspects such as sexuality, relationships, peer-pressure and body image. Parents must communicate freely with their children about these issues and take advantage of any "teachable moment". There are many resources available for parents from health care professionals (just ask!), to books and internet sites. I have links to several useful sites for adolescents and their parents on my website.