The Tween-Age Years; When Puberty Sets In. Questions and Answers to Common Concerns in Young Women
Adolescents are an interesting subset of humans. They walk the tightrope between childhood and adulthood and experience a myriad of physical, emotional and social changes. For females, the physical changes are dramatic, with the onset of breast development, hair growth in places that it never was before, and of course, periods begin.
There are so many questions that arise in the tween-age years, it can be difficult for these young girls to navigate the changes. Who should she ask, mom, girlfriends, the internet or the doctor? If mom and doctor do not work together to empower young girls with accurate information they will seek out other sources which may not be as appropriate or correct, such as obtaining their information from friends or the internet.
It is critical to teach tween-age girls that the body changes of adolescence are normal and expected, and no question is silly or too embarrassing. Once we have educated our girls about the basics of breasts, body hair and what you can do with it, underwear pros and cons, and teach them all there is to know about their period, we can then build on this knowledge as they grow to include other more sensitive and difficult topics that we will go over in an upcoming segment. In the meanwhile, knowledge is power and the mother-doctor team is the winning one for the tween.
PERIODS. HOW, WHY and WHEN?
The average age of menarche (first period) is about 12 or 13, but it is completely normal for girls as young as 9 to get a period. The schools usually do a pretty good job in health class at preparing girls for their period, but you never know who hears what in class, and it never hurts to start going over this with young girls so they are not frightened when the time comes.
Usually we can predict that girls will get their first period about 18 months after breast development. Once this development begins, it’s a good idea to explain that menses are a normal part of being a woman and cyclic bleeding is normal. Having young girls who have begun the maturation process keep sanitary napkins with them in school and also having them at sleep away camp is prudent, as the first period may not be predictable.
ARE HER PERIODS NORMAL?
Many young girls worry their menses are not normal. Girls talk to each other and if your daughter’s period lasts 5-7 days she may be concerned if her best friend’s only lasts 2-3 days. Or coming every 2-3 months when their friend’s occurs monthly.
Length of menses varies from woman to woman and anything from 3-8 days is normal. If bleeding is very heavy and prolonged, accompanied by weakness, dizziness, anemia or syncope (passing out) you should see the gyn for blood work to make sure there are no deficiencies in blood clotting factors.
If bleeding lasts regularly for more than 8 days you should also talk to the gyn. With regards to irregularity of menses, it is normal for the first 2-3 years after menarche for menses to be irregular and come too often or not often enough because it takes about 2-3 years for the hypothalamic-pituitary axis to completely develop.
WHEN IS IT SAFE TO START USING A TAMPON AND HOW DOES SHE DO THIS?
Tampon use is safe at any age, even if periods begin at 9 or 10 years old. Usually in the early years, young girls prefer the use of sanitary napkins and will start to ask about tampon use when they participate in swimming, gym or athletics where pads can be prohibitive.
It is also very important to review healthy hygiene with these young girls because they must be responsible enough to remember to change tampons on a regular basis (no longer than every 6-8 hours). Girls should be instructed that tampons cannot get lost because the vagina is a blind pouch and they cannot injure themselves with a tampon.
It is usually more comfortable for these young girls to use junior slim tampons that are specifically made for teens. They are much easier to insert and remove than tampons made for adult women. As teens become curious about tampons it is a good idea to put a box of junior slims in the bathroom so they can experiment at their leisure. It is also a good idea for mom to offer up help if needed.
If the adolescent is uncomfortable placing a tampon and does not feel comfortable involving mom for assistance, it may be helpful to involve the gyn. Explaining to the adolescent that professional assistance may help her achieve her goal of tampon usage in a relaxed and comfortable environment may greatly assist in achieving her goal. Rarely, young girls present to the office having tried and failed tampon use. Sometimes involuntary muscle contraction prevents success, but rarely there is a real anatomic reason for failure like a micro perforate hymen that requires a minor surgical procedure.
PAINFUL PERIODS. WHAT CAN I DO?
Painful periods, or dysmenorrhea is common among young women. The first steps as a mom is to reassure your daughter this is common, benign and treatable. Over-the-counter non steroidal anti-inflammatory drugs (NSAIDS) such as motrin, advil and anaprox work very well for dysmenorrhea. They should be taken with food and for a limited time.
Starting NSAIDS with the first cramp, preferably before the bleeding begins gives us a jump start toward off the prostaglandins that cause the pain before they have a chance to take effect. If over-the-counter medications are not working and the pain is severe and incapacitating where school or activities are missed, it’s time to go to the gyn.
Don’t worry, we’re not just going to throw the birth control pill at your adolescent. We will discuss the options of prescription medications that are non hormonal such as AnaproxDS or naprelan (nice because you only have to take it once a day) or ponstel which is mefanemic acid (not an NSAID but similar category).
If those don’t work or for medical reasons shouldn’t be taken, we would then offer the birth control pill. The pill is incredibly efficacious in helping dysmenorrheal whereby preventing ovulation and the release of the prostaglandins which cause the pain. Instead of taking medications that work as anti-prostaglandins, the pill prevents the formation of prostaglandins. The pill has risks and benefits but viewed as being cancer protective (radically decreases the risk of ovarian and uterine cancer and neutral on breast cancer) and fertility protective. It makes the periods light, short, regular and predictable.
ONE OF MY BREASTS IS BIGGER THAN THE OTHER- WHAT DO I DO?
It is very common to have one breast larger than the other and it is not uncommon for the difference to be significant. Just like one hand is bigger than the other (you can’t put the ring on your right hand over onto the left hand) and one foot is bigger than the other, breasts follow suit. In many cases, there is an entire cup size of difference between one breast and the other.
Gyn answer: Except in very rare cases of great disparity, we provide reassurance and do not recommend or offer any surgical intervention.
THERE ARE LITTLE BUMPS ON MY NIPPLES- IS THAT OK?
It is normal to see small raised symmetrical bumps on the nipples or areola. These bumps are called Montgomery glands and are lubricating glands of the nipples. When the breasts are cold they become more raised and apparent and when the breasts are warm they become flattened.
MY LABIA ARE TOO BIG- AM I ABNORMAL? ONE IS ALSO BIGGER THAN THE OTHER- WHAT SHOULD I DO?
Just as with differences in breast size, labial size varies as well. Just like some people have big noses and some have little noses, some girls have larger labia than others.
It is very unusual for there to be a need to reduce them, and the American College of Obstetricians and Gynecologists have put out a statement discouraging gynecologists from performing labial reduction surgery unless there is a remarkable discrepancy in labial size or unless the labia are truly pathologically abnormal. Most young girls who present with concerns have a distorted view of the size of their labia which may be related to the fact that they get rid of all of their hair (the hairless vulva makes the labia appear larger). Surgical reduction of labia can lead to scarring and dyspareunia (painful sex).
As a mother you have limited experience with knowing what is normal and not normal with regards to labia, and even if you do, your daughter may not believe you if you tell her she is normal. Please bring her in to the gyn so that we can truly reassure her that she is normal. We see about 30 pairs of labia per day, and will be able to give stronger reassurance about her labia. It will also enhance her self esteem and give her emotional relief.
DOES THE TYPE OF UNDERWEAR MATTER?
Oh yes it does.
This is an unfortunate conversation we have to have as both mothers and gynecologists, because many women love wearing thong underwear and hate panty lines.
The problem lies in the fact that women are built with their vagina and anus/rectum in very close proximity, allowing bacteria and yeast to travel from the anus/rectum (the anus/rectum is the body’s reservoir for yeast and bacteria). That thong acts as rectal dental floss bringing bacteria from the rectum to the vagina, increasing the risk of yeast and bacterial infection. Changing to standard cotton crotch underwear would be the recommendation, especially in girls who get recurrent infections, but trust me- this is a hard sell.
Gyn Answer: We will treat the yeast infection or bacterial infection and will be the bad guy with regards to swearing them off of the thong underwear. (Don’t try this at home, they won’t listen to you).
PERSONAL GROOMING: IS IT OK TO SHAVE, WAX OR LASER?
Personal grooming is just that; an issue of personal preference.
There is no right or wrong answer, and many mothers come to me with great concerns that something bad will happen to their daughter from getting rid of all of their pubic hair. There should be no worry here, as hair provides no important function and there is no safety issue. In young girls, clipping and shaving of hair is most common and the only time where concern comes into play is when ingrown hairs occur. If this is recurrent and painful, an alternative method of hair removal may be employed for future grooming.
Waxing is completely safe as well, as long as it is done by a reputable, clean salon. The person performing the waxing should be licensed and should test the wax to make sure that the temperature is not too high, as burns can occur on this sensitive skin if the wax is too hot.
In addition, a new applicator should be used for each dip into the wax (no double dipping). Laser hair removal is also a safe modality and can be used in the adolescent female. With regards to ingrown hairs, laser is probably the best modality (shaving worst, then waxing, then laser with regards to worst to least formation of ingrown hairs). Laser can be somewhat uncomfortable but the discomfort is greatly alleviated if pre-treatment with emla cream is used. Laser should also be done by a qualified professional who is licensed to perform laser hair removal.
Note to moms; don’t stress about this. Pick and choose your battles because this should not be one of them. All moms tend to freak out a bit when they find out that their daughter has removed all hair down there, but remember there is no medical worry here.
Few women under 30 keep hair down there.
No worries about clipping, shaving, waxing or laser unless significant boils ensue. This is where we see young girls in the office; when they get folliculitis (ingrown hairs) and they become red, raised and painful. Most of the time, warm soaks and drying agents like benzoyl peroxide work well and only rarely if there is a cellulitis (infection of the surrounding skin) are antibiotics necessary. Even rarer are the times where a true abscess forms that will require surgical drainage in the office. If you’re unsure, visit the gyn to check.
WHEN SHOULD I GET MY FIRST PAP AND WHEN SHOULD I HAVE MY FIRST GYN VISIT?
The first pap should be at age 21, no sooner.
That doesn’t mean that you should wait until you are 21 to come in for your first gyn visit. We encourage teens to come in for a gyn visit if they are not having any issues at age 15. Under 21 we do not do an internal pelvic examination unless you are sexually active or experiencing a specific problem.
Most of the visit is spent in education and discussion. We talk about abstinence, and we educate about transmission of sexually transmitted disease, condom use and safe sex, sexual practices, birth control options, menstruation and many other issues including avoidance of smoking, drinking and drugs. In addition, we teach the adolescent how to do a breast self exam. We leave ample time for question and answer.
It is very important for a young girl to establish a trusting relationship with a gynecologist at a young age, so that if questions arise, they will feel comfortable calling or coming in. We do the routine history and family history with mom in the consult room, and then we have mom go to the waiting room while we ask more personal questions about sexual activity, smoking, drinking, and drugs.
We leave a lot of time for open ended questions from the teen, and then we do the appropriate physical exam based on the teen’s history, concerns, symptoms and sexual history. Sexually active teens are offered testing for STDs.
Adolescence is an exciting and evolving time in a young girls’ life. It is also a time where many challenges arise as these girls walk on the border of childhood and adulthood.
Many of these issues may be sensitive and difficult to talk about. The opening of that conversation is best initiated at home between adolescent and mother, but creating and establishing a relationship with a gynecologist adds another important facet to the adolescent’s armamentarium of knowledge, THAT WILL GUIDE AND HELP TO PROTECT THEM NOW AND IN YEARS TO COME.
**Have Questions About Your 1st Gyn Visit or Planning to Schedule Your Daughter's 1st GYN Visit? **
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