Precocious Puberty

Girls feel unprepared for puberty, new study finds

Precocious Puberty | Johns Hopkins Medicine

Girls from low-income families in the U.S. are unprepared for puberty and have largely negative experiences of this transition, according to researchers at Columbia University's Mailman School of Public Health and the Johns Hopkins Bloomberg School of Public Health.

Their latest paper on the puberty experiences of African-American, Caucasian, and Hispanic girls living mostly in urban areas of the Northeastern U.S. shows that the majority of low-income girls feel they lack the information and readiness to cope with the onset of menstruation.

The research is one of the first comprehensive systematic reviews of the literature on puberty experiences of low-income girls in the U.S.

The findings are published online in the Journal of Adolescent Health.

“Puberty is the cornerstone of reproductive development,” said Marni Sommer, DrPH, MSN, RN, associate professor of Sociomedical Sciences at the Mailman School of Public Health.

“Therefore, the transition through puberty is a critical period of development that provides an important opportunity to build a healthy foundation for sexual and reproductive health.

Given the importance of this transition, the research is striking in its lack of quantity and quality to date.”

The investigators used Qualitative Research guidelines to review the data from peer-reviewed articles with a qualitative study design published between 2000 and 2014. They used a quality assessment form as a further check of the data.

The age of breast development and menarche has declined steadily in the U.S. during the last 25 years, with 48 percent of African-American girls experiencing signs of physical development by age 8.

“This trend may mean that increasing numbers of African-American girls are not receiving adequately timed puberty education¬, leaving them uninformed and ill-prepared for this transition,” said Ann Herbert, doctoral candidate at the Bloomberg School of Public Health.

Although many of the girls reported being exposed to puberty topics from at least one source — mothers, sisters, or teachers — most felt that the information was inaccurate, insufficient, or provided too late.

Girls also reported being disappointed in the information they received from mothers; meanwhile many mothers said they were unable to fully address their daughters' needs.

Mothers were uncertain about the right time to initiate conversations, uncomfortable with the topic, and uninformed about the physiology of menstruation. The timing of puberty also influenced girls' puberty experiences.

The researchers noted that despite a strong focus on adolescent sexual health outcomes, such as sexually transmitted infections and teen pregnancy, clinicians and public health practitioners in the U.S.

have yet to capitalize on the issues of puberty onset and menstruation as a window of opportunity to improve adolescent sexual and reproductive health. In addition, the current body of research leaves out many topics entirely.

“For example, missing are the voices of adolescents with non-conforming gender role and sexual orientation,” Herbert said.

Earlier research showed that irrespective of race, higher-income girls had more knowledge about puberty, were more prepared for menarche, and had more positive attitudes about menstruation, strongly suggesting socioeconomic disparities related to preparation for puberty.

“Findings from the current review suggest that low-income girls today expressed a sentiment similar to girls studied in the 1980s and 1990s — a feeling that they were largely unprepared for puberty and menarche,” noted Herbert.

“Our review makes it clear that there is a need for new more robust interventions to support and provide information about puberty for low-income girls, something we are considering for the coming years,” said Sommer.

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Materials provided by Columbia University's Mailman School of Public Health. Note: Content may be edited for style and length.


Puberty-Suppressing Drugs For Transgender Teens

Precocious Puberty | Johns Hopkins Medicine

But policymakers have been slower to catch on.

Currently, only Massachusetts, Oregon, California, Vermont, and the District of Columbia cover any sort of transgender care through their Medicaid plans, while only Colorado, Oregon, Connecticut, California, Vermont, Washington, Illinois, Maryland and the District of Columbia prohibit private insurers from refusing to cover them. Oregon remains the only state to offer puberty-suppressing medications for adolescents on its Medicaid plan.

“Oregon is leaps and bounds ahead of other states in making these steps,” says Kara Connelly, a pediatric endocrinologist at Oregon Health & Science University's Doernbecher Children's Hospital.

The treatment involves taking gonadotropin-releasing hormone analogs, which were originally used to treat precocious puberty in children, she says. It can be taken as a monthly injection or as implant.

But either way, it's not cheap: The drugs can cost up to a $1,000 a month.

Oregon's decision to offer them through its Medicaid program, Connelly says, will improve access for low-income kids who couldn’t otherwise afford them.

The move came as a surprise to many within the transgender-activism community, says Jenn Burleton, the executive director of TransActive Gender Center, a small Portland-based nonprofit that provides advocacy and referral services for gender-dysphoric youth.

Burleton says that when her organization first heard that the state was looking at adding transgender care to its Medicaid program, she and a group of doctors that work with TransActive contacted the Oregon Health Authority and asked to testify before a committee that evaluates proposed additions.

“We honestly weren't very optimistic it would be covered because we weren't sure that the conversation about transgender adolescents had entered the zeitgeist enough,” she says.

But in December 2012, the Oregon Health Evidence Review Commission, which prioritizes Medicaid spending, approved the subcommittee’s recommendation that puberty-suppressing drugs be covered by Healthy Kids Oregon, the state's Medicaid program for minors.

According to Karynn Fish, spokesperson for the Oregon Health Authority, children 18 and younger make up about 45 percent of the 935,026 Oregonians receiving coverage through Medicaid. The agency does not have numbers on how many transgender youths are covered, but according to Fish, the number is ly very small.

To get the treatment, young people will meet with a counselor for mental-health evaluation, which is now also covered by Healthy Kids Oregon.

Once they've been diagnosed with gender dysphoria, they will meet with an endocrinologist to find out where they are in their hormonal development and when they can begin taking the drugs.

The added coverage also includes follow-up treatment and related care.

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Premature Thelarche

Precocious Puberty | Johns Hopkins Medicine

Thelarche means “the beginning of breast development.” Therefore, if a girl begins to show breast enlargement at an early age (anywhere from birth to six years), it is called “premature thelarche.”

Technically, most cases of early breast enlargement are harmless, and do not progress significantly. They are not the beginning of (continued) breast development.

They also are not usually associated with the development of the other physical signs of puberty, e.g., acne, pubic hair, periods, or rapid growth.

Therefore, a better term for this condition is infantile, or early, “gynecomastia,” which only signifies that one or both breasts are enlarged.


What causes premature thelarche?

Studies of girls with early breast enlargement have not shown elevated blood levels of estrogen or any other abnormality.

Occasionally, an ovarian cyst (or cysts) may be seen on a pelvic ultrasound, but this condition also may occur in girls without breast enlargement; therefore, it is not clear if the cyst(s) are secreting enough estrogen to cause the breast enlargement. Some physicians believe that the girls are just temporarily more sensitive to their normal blood levels of estrogen.


Who gets premature thelarche?

There is not one identifiable group of girls who develops early breast enlargement. However, it is a concern if a male infant or a young boy shows breast enlargement.


How does premature thelarche cause disease?

Premature thelarche is not a disease; instead, it is a normal finding in some young girls or female infants. If there are other signs of puberty, then a physician should evaluate the child for the causes of early puberty.


What are the common findings?

The common finding is the enlargement of one or both breasts. In simple premature thelarche, there are no other signs of pubertal development, and the child is growing at a normal-not an increased-rate.


How is premature thelarche diagnosed?

Most commonly, premature thelarche is diagnosed in a female infant or a girl up to three years of age. Occasionally, a girl from three to six years of age will show an enlargement of one or both breasts.

However, after age six, the beginning of breast development is actually the beginning of puberty; however, it is a very slow form of development.

In addition, girls with early breast development usually do not have early periods.

Typically, the girl has no other signs of puberty, and is growing at a normal, pre-pubertal growth rate, i.e., about two inches a year.

Laboratory studies are not usually helpful, since they show low (pre-pubertal) concentrations of estrogen or other hormones that stimulate pubertal development.

An x-ray of the hand shows a picture that is normal for the girl's age, and not that of an older girl.


How is premature thelarche treated?

Treatment for early breast development is not necessary; however, the physician and the parents may want to monitor any changes in the girl's breast size.


What are the complications?

Usually, there are no complications associated with early breast development. Since there is a very small chance that the girl is actually starting puberty, it is recommended that both the physician and the parents monitor her.


How is premature thelarche prevented?

Premature Thelarche cannot be prevented. Parents should be sensitive to their children's concerns and encourage communication so as to alleviate anxiety or fears.



Kappy MS, Ganong CS. Advances in the treatment of precocious puberty. Adv Pediatr 1994;41:223-61.

About the Author

Dr. Kappy is a professor of pediatrics at the University of Colorado Health Sciences Center and the Chief of the Pediatric Endocrinology Department at The Children's Hospital in Denver, Colorado.

He was a recipient of the Johns Hopkins University Distinguished Alumnus Award in 1996. His research interest include the treatment of precocious puberty and the effects of growth hormone in growth hormone-deficient individuals.

Copyright 2012 Michael S. Kappy, M.D., Ph.D., All Rights Reserved


Puberty: Stages and first signs

Precocious Puberty | Johns Hopkins Medicine

Everyone goes through puberty slightly differently, but there are puberty stages that usually happen at certain ages in a young person’s development.

In this article, we look at the stages of puberty for males and females, and the ways that parents and caregivers can help to support kids through this time.

Share on PinterestPeople’s experience of puberty varies.

Females start puberty sooner than males. Puberty in females most often begins between the ages of 8 and 13 years. The process may continue until they are 14 years old, although this can be later.

The first stage of puberty includes prepuberty changes. These are changes that start to happen in the body but are not yet visible.

One of the first physical changes females will notice during puberty is their breasts starting to grow.

The initial stage of growth is breast buds. Slight swelling appears under the nipple, and the area of skin around the nipple, known as the areola, will start to get bigger.

The breasts will then slowly start to grow during puberty. Females may experience some tenderness or itchiness as the breasts begin to change. It is usual for each breast to grow at slightly different rates, which will often even out over time.

Females will also start to notice more hair growing in places such as their legs and arms. At around 12 years old, on average, females will begin to see hair growth under the arms.

Pubic hair will start growing along the labia and will gradually become thicker, curlier, and cover a larger area of the vulva. In the final stages of puberty, pubic hair may grow around the top of the thighs.

Females will usually begin their period roughly 2 years after their breasts have started to grow. They might get their first period anywhere between 10 and 16.5 years old. It is also normal for females to have white vaginal discharge.

Females will also grow taller in puberty, with a gradual height increase each year. In the first stages of puberty, females may grow 5–6 centimeters (cm) in a year. In the following stages of puberty, this can increase to 7–8 cm per year. Females will usually stop growing around 16 years of age.

Females may also increase in weight and have more body fat around the upper arms, thighs, and back. Hips tend to become wider, while the waist narrows.

At 17–18 years old, breasts are usually fully developed. Breasts can continue to grow up until the early 20s, though.

One of the first changes in males during puberty is the scrotum enlarging and becoming darker. Once the scrotum and testes begin growing, the penis also starts to grow.

Males will start growing pubic hair at the base of the penis, which will then gradually cover a larger area around the genitals. As pubic hair grows, it becomes darker and coarser.

In the later stages of puberty, pubic hair may spread to the thighs and stomach. Males will also have hair growth under their arms, legs, and usually on their face and chest.

In the first stages of puberty, males may grow in height by about 5–6 cm. In later stages of puberty, this can increase to 7–8 cm and then 10 cm per year. Males will usually stop growing around 17 years old.

Height changes can happen in growth spurts, where teenagers may grow very quickly over several months. A period of slower growth may then follow. Males also become more muscular during puberty.

Hormonal changes during puberty can sometimes cause slight breast swelling in males. Breast swelling is a common and temporary stage of male puberty.

As the voice begins to deepen, males may find their voice “breaks.” This means the voice may go through a period of switching between sounding deep and high before it becomes permanently deeper.

Males may start having erections as the body begins to produce sperm. Males may also have ejaculations while they sleep, which people may refer to as “wet dreams.”

Some people may experience puberty later or earlier than usual. This can sometimes be a sign of an underlying medical condition, so people should see their doctor.

If people experience puberty early, a doctor may refer to this as precocious puberty.

In females, early puberty is the appearance of puberty signs and symptoms before the age of 8, such as:

  • ovulation and menstruation
  • underarm and pubic hair
  • breast development

For males, early puberty is the appearance of puberty signs and symptoms before the age of 9, such as:

  • a deepening voice
  • pubic and underarm hair
  • enlarged testicles and penis
  • facial hair
  • acne
  • sperm production

Early puberty may be a result of an underlying medical condition. Some causes of early puberty include:

  • an issue with the central nervous system
  • genetic syndrome
  • a family history of the condition
  • tumors or growths affecting either the ovaries, brain, pituitary gland, or adrenal glands
  • early release of puberty hormones with no known cause

Delayed puberty means there are no physical signs of puberty in females by the age of 13 or males by 14 years old.

Symptoms of delayed puberty in females include:

  • more than 4 years between the first signs of breast growth and their first period
  • no breast development by age 13 years
  • no menstruation by 14 to 16 years old

Symptoms of delayed puberty in males include:

  • no testicle enlargement by 14 years of age
  • longer than 4 years to reach the adult genital development stage
  • no pubic hair by age 15 years

If people have signs of delayed puberty, they may want to see their doctor. Causes of delayed puberty can include:

  • a family history of delayed puberty
  • chromosomal or genetic disorders
  • chronic illness
  • tumors affecting the pituitary gland or hypothalamus, a part of the brain that affects hormones

Kids go through many physical and emotional changes during puberty and may experience:

  • mood swings
  • depression
  • anxiety
  • low self-esteem
  • self-consciousness
  • aggression
  • body image issues

Both males and females may develop acne during puberty. This is because of their body changes and increases in hormone production. These developments can create excess oil, which contributes to the start of acne. Washing the face daily with a cleanser may help to keep acne under control.

During puberty, people also start to sweat more. Daily hygiene is essential and may help prevent body odor. Young people may want to start using deodorant.

Sometimes, certain body parts, such as hands, feet, arms, and legs, will grow more quickly than the rest of the body. This may cause temporary clumsiness and a slight lack of coordination.

Parents and caregivers may want to discuss these issues with their teenagers to ease any embarrassment or anxiety they may feel about their changing bodies.

Teenagers may start experiencing romantic or sexual feelings for people of the opposite or same sex. Some teenagers may also feel uncomfortable about their assigned gender.

Talking through these issues with teenagers and giving them plenty of support can help them address any anxiety or confusing emotions they may be experiencing through puberty.

Advice from Planned Parenthood, which discusses how to talk through puberty with teenagers, may be helpful.

Although everyone will experience puberty slightly differently, particular physical changes occur that signal puberty. If people experience puberty symptoms a lot later or earlier than the standard stages, it may indicate an underlying medical condition, and people should see their doctor.

Some individuals may feel anxious or embarrassed about the changes to their bodies during puberty. Parents and caregivers may find that discussing the stages of puberty with their preteen or teenager might help to ease their worries.