Dr Danie Schneider
Obstetrician and Gynaecologist, Somerset West

Puberty and beyond

What is puberty?

Puberty is another word for the developmental changes a girl’s body goes through during the preteen and teen years. The biggest changes during puberty are that a girl’s body grows taller in a short period of time (called the “growth spurt “) and that her body changes to become more like that of an adult woman’s body. It now becomes possible for her to fall pregnant.


What causes puberty?

Puberty is caused by hormones secreted by the brain and ovaries. Estrogen produced by the ovaries is the cause of many of the changes that occur in a girl’s body during puberty.


What are the stages of puberty?

Girls usually start puberty between the ages of 9 – 12 years, but the exact time your child starts puberty depends on different factors, such as genetics, diet and weight.

In many girls, the first sign of puberty is breast development, hair growth in the genital area (pubic hair), under the arms and on the legs. In some girls, pubic hair is the first sign of puberty. Monthly periods usually start within 2 years after the breasts or pubic hair start developing.


What is early puberty?

Puberty is early in girls if it starts before the age of 8. It is important to understand that puberty can start early without there being any underlying medical problem. Some girls therefor just start puberty earlier than others and in these cases no intervention is indicated.  Other causes could be abnormally high levels of hormones produced by the brain or ovaries.  Treatment depends on the underlying cause of the early puberty, your child’s age and on how fast her body is changing.


When is puberty late?

Breast development is usually the first sign of puberty in a girl and this should have happened by age 12.  It is important to understand that late puberty does not mean your daughter has a medical problem. Some children just start puberty late and this often runs in families. Remember that girls can also start puberty late if they are too thin, don’t eat enough or exercise excessively. As a general rule menstrual bleeding that has not started by age 15 needs evaluation.


What should we expect from the first periods?

It is important to discuss these changes of her body with your daughter, before her first period. Let her know what the changes are and what to expect.

When a girl first starts getting her period, she might not get one every month and it is normal for a period to skip a month, or occur twice in 1 month. This usually settles over time as her body matures. Some girls develop premenstrual symptoms and feel bloated or have mood changes right before they get their period. Some girls also have a clear or white vaginal discharge at times and this is also normal.

Research has shown that by one year after menarche (first period), 65 percent of girls have regular menstrual cycles (with 10 or more periods per year).  Most irregular bleeding will therefor settle on its own.

It is important to understand that girls who have their first period (menarche) later than average, usually settle more slowly into a regular menstrual pattern. In these  girls It is important to understand that when the menarche occurs after the age of 13, only about 50%  will ovulate regularly within the next 5 years and irregular bleeding is therefore common in this group ( 14- 19 years).


What is abnormal uterine bleeding?

Abnormal uterine bleeding (AUB) refers to excessive, prolonged and/or irregular uterine (endometrial) bleeding. Remember that girls, who have their first period (menarche) later than the average, usually settle more slowly into a regular menstrual pattern. In this group irregular ovulation due to an immature control centre in the brain is the most common underlying reason and accounts for about 80% of cases. This type of abnormal bleeding pattern usually settles over time as the body matures.


When and why should abnormal bleeding be investigated?

Menstrual bleeding lasting longer than 7 days is regarded as excessive.  It is important to understand that research has shown that neither patients nor doctors can accurately estimate the volume of blood loss during a period.  It is therefore important to use clinical parameters to judge blood loss in your daughter. Heavy bleeding is often defined by its influence on daily activities (e.g. it wakes someone from sleep or the need to change sanitary protection at night), soaks a pad or tampon more than every 2 hours or interferes with social, emotional or physical quality of life. The passing of blood clots bigger than 2,5 cm is also an indication of heavier loss.

Many girls have irregular bleeding during the first few months after their first period. This usually resolves without treatment.  If irregular bleeding persist beyond this time or if the bleeding is heavy (as defined above), further evaluation is indicated.

Many girls are prone to anaemia due to the combination of menstrual bleeding and low iron intake through their diet.  Low iron can cause excessive tiredness, lack of concentration and cause vulnerability to infections and therefore needs prevention and further treatment.

A bleeding tendency is also a common cause of excessive, regular menstrual bleeding in adolescents. This can be diagnosed with appropriate tests and treated effectively with the right medication. Evaluation to rule out a bleeding tendency is therefore indicated if heavy bleeding is associated with easy bruising or if there is a family history of a bleeding disorder.


How should we approach the first periods?

It is important to explain to your daughter what is happening to her body. Point out your daughters’ strengths rather than focus on her body changes. Be sensitive to the fact that she might feel insecure as she compares herself to other girls.

It is important to recognise the early subtle signs that her body is changing and remember that the average age of the first period is 12-13 years.

Impending menstruation can often cause nervousness in young women. Teens worry about leaks and clothes stains. This is why it is important to prepare young women early on and empower your daughter with information. Experts therefor suggest that you should talk to your daughter when she is 8-12 years old. The initial discussion should cover what menstruation is, what happens to her body, what products to use and how to handle cramps, mood and fatigue.  The message should be “you’re going to be OK “and “we will deal with any issues together”.  No young women should suffer in silence!

It is also important that your daughter is informed that once her menstruation has started, she can fall pregnant if sexually active.

It is a good idea to encourage your daughter to track her period to establish a pattern and therefor know when to expect her next bleed. A normal calendar or a smartphone app can be used.

Many girls fear getting their first period at school or when they are away from home. Many parents have found that it helps if they prepare a small zippered pouch with essentials that include a couple of teen-sized sanitary pads and clean underwear. It is a good idea if mom keeps a spare pouch as well, just in case. There is no physical reason why girls can’t use tampons from their first period, but it is usually better to wait a few months as it often is beyond some girls’ emotional development at this early stage. A common fear is that a tampon can get lost inside and it is important to explain to your daughter that it physically can’t! Showing her a diagram can reassure her and help with the technique of insertion and removal. Make sure she knows tampons should be changed every 4 hours to prevent leaks and infection. Tampons labelled for teens are ideal. Panty liners can be used for extra protection. It is a good idea if your daughter has a trusted adult that she can ask for help when she is away from home. Girls can also be encouraged to look out for each other and advise a friend if they are leaking etc.


What if the periods disappear after the onset of puberty?

This problem is usually related to weight changes, but pregnancy must be excluded if applicable. Excessive weight gain, on its own or as part of a hormonal imbalance, can contribute. Thyroid problems can also disrupt the control of menstruation in a woman of any age. Excessive weight loss, as well as stress can have the same effect.

We can usually arrange appropriate testing to pinpoint the cause and treatment can be instituted to help a young woman’s body develop normally. High level dietary assessment to find the correct balance between caloric intake and expenditure is usually needed in those who are underweight.  Exercise programs will need to be adapted if she is taking part in strenuous training and if she has a low body mass. Stress levels need to be managed effectively.


What does a more in-depth assessment entail?

The initial consultation is usually more to build a trust relationship and to provide information. Only a general examination is done, if indicated, not a physical examination. The aim of a general examination is to assess iron balance, look for signs of a bleeding tendency and to assess the developments related to puberty.  Weight and height will be assessed. Test that could be arranged include an abdominal ultrasound and blood tests to assess her iron status. A treatment plan would be discussed and this would encompass a form of symptom monitoring, as well as treatment to limit monthly blood loss and other symptoms, if indicated. This could include hormonal and non-hormonal medication, as well as dietary interventions.