Puberty, Normal, and Menarche Paul B.

Kaplowitz MD, PhD Basics Description Puberty refers the appearance of certain physical findings, primarily a progressive increase in breast development, related to increase in estrogen secretion. t is a result of activation of the hypothalamic!pituitary!gonadal a"is. #ithin $ months of the appearance of breast development, the beginning of the pubertal growth spurt usually occurs, during which the rate of growth increases from % inches per year to &'( inches per year.

)he appearance of pubic hair and a"illary odor, although occurring in many girls at about the same time, is due to adrenarche, or the age!related increase in adrenal androgen secretion.

*ge!+elated ,actors n -. girls, the average age of appearance of breast development and pubic hair is /0'/0.1 years with a range of 2'/& years in whites, and earlier in blac3s. +ecent studies suggest the mean age of menarche in the -. is about /%.$ years in white and /%.0 years in blac3 girls.

)he interval between thelarche and menarche can vary from /.1'( years, but is between % and & years in most girls.

4pidemiology )he mean age of menarche has declined from the /200s to the mid!/500s, presumably due to improved health and nutrition. t is less clear how much additional decline has occurred over the last 10 years.

n the -., evidence suggests that the age of appearance of breasts and pubic hair is occurring earlier than &0 years ago. Poorer, less!developed countries and countries in warmer climates show continued declines, while in northern 4urope the mean age of menarche has been relatively stable at 6/& years.

+is3 ,actors .everal studies have suggested that obesity or BM above average for age is a ris3 factor for earlier onset of breast and pubic hair development and earlier menarche. )hinner girls tend to have later onset of breast development and later menarche. t has been suggested that estrogen!li3e chemicals in the environment, including metabolites of DD), P7Bs, and phthalates, as well as estrogens in meat and in hair care products, could contribute to the earlier onset of breast development, but there is no hard evidence for this. 8enetics

)here is a strong genetic component to the onset of puberty, in that mothers who had early onset of breast development and early menarche are more li3ely to have daughters who are also early maturers. Pathophysiology Precocious and delayed puberty are discussed in separate chapters 9see Puberty, Precocious and Puberty, Delayed:. Diagnosis .igns and .ymptoms ;istory 8rowth charts may be helpful. Pubertal growth spurt noted by parents Physical 4"am *ppearance of breast tissue that can be palpated under the nipple is the most reliable sign of the onset of puberty. n chubby girls, it is easy to confuse fat tissue with breast tissue.

Pubertal girls usually have a thic3ening and dar3ening of the nipple and areola. )he vaginal e"am may show a pin3 mucosa and thin mucous in the vault. -nli3e breast development, pubic and a"illary hair and body odor are not related to increased ovarian estrogen production and may appear years before the true onset of puberty.

)ests <abs 9.ee Puberty, Precocious and Puberty, Delayed.: maging 9.ee Puberty, Precocious and Puberty, Delayed.: P.&5 Management 8eneral Measures #hen breast development has progressed to )anner stage , parents may wish to prepare their daughter for the onset of menses, which is li3ely in the ne"t $'/% months. Medication 9Drugs: )he treatment of precocious puberty is discussed in a separate chapter. ;owever, one may occasionally consider use of medications to prevent regular periods in girls whose timing of puberty is normal but who are so developmentally delayed that hygiene becomes a problem and they may not be willing to wear pads. )he use of Depo!Provera /10 mg M every /% wee3s is a safe, effective, and ine"pensive option 9see Menstrual .uppression:. ,ollowup Disposition ssues for +eferral Precocious or delayed puberty may prompt referral to pediatric endocrinologist.

Menstrual suppression in girls with developmental delay may prompt gynecologic consultation 9see Menstrual .uppression:.

Bibliography Biro ,, et al. Pubertal correlates in blac3 and white girls. = Pediatr. %00$>/(2?%&(' %(0. Kaplowitz PB. Pubertal development in girls? .ecular trends. 7urr @pin @bstet 8ynecol. %00$>/2?(2A'(5/. Kaplowitz PB, et al. 4arlier onset of puberty in girls? +elation to increased body mass inde" and race. Pediatrics. %00/>/02?&(A'&1&. Patient )eaching B *7@8 Patient 4ducation Pamphlet? 8rowing at http?CCwww.acog.orgCpublicationsCpatientDeducationCbp0(/.cfm B **,P Parent Brochure? #hen Eour 7hild is 7lose to Puberty at http?CCwww.aafp.orgCafpC550A00apC550A00d.html