Q&A: Physicians can ease ‘great anxiety’ surrounding puberty in girls

Potential behavioral changes stemming from puberty were among the most common concerns of parents whose daughters presented for a premenarchal visit, researchers wrote in the Journal of Pediatric and Adolescent Gynecology.

Those concerns were more pronounced in parents whose children had autism spectrum disorder, attention deficit disorder, ADHD and nonverbal status, Y. Frances Fei, MD, a clinical lecturer in the department of obstetrics and gynecology at the University of Michigan School of Medicine, and colleagues wrote.

To alleviate the “great anxiety” surrounding puberty, the researchers recommended that primary care physicians, pediatricians and other health care providers have conversations with parents and patients about it as early as possible. In an interview with Healio Primary Care, Fei discussed how to address parent and patient concerns, when hormonal suppression therapies are appropriate, when to refer patients to a specialist, and more.

Healio Primary Care: Can you talk about the most common concerns among caregivers of prepubescent girls with developmental disabilities?

Fei: Caregivers often have a variety of concerns. These usually come from their own experiences with puberty, especially menstrual cycles, and what they have heard from others. These include timing of different stages of puberty, potential mood lability, behavior changes with puberty, cramping pain with periods, not being able to tell if the girls are in pain, the girls not being able to handle the sight of blood, playing in the blood, not being able to keep up with hygiene, sensory issues with wearing pads, etc.

Healio Primary Care: How can physicians alleviate those concerns?

Fei: Reassurance! And providing information about the expected progression of puberty. The average age of menarche is around 12 to 12.5 years; usually about 2 to 2.5 years after they start to notice breast development. Parents are often worried that periods are going to happen immediately when they start to notice pubertal changes, and it can be reassuring to know they probably have a couple of years to prepare.

We usually recommend that caregivers start teaching girls about menstrual periods and practice wearing pads or period underwear before periods start so they can get used to the feeling. We also reassure caregivers that oftentimes girls do a lot better with periods than they anticipate.

Healio Primary Care: In what instances are hormonal suppression therapies appropriate?

Fei: There are two types of hormonal suppression. One is pubertal suppression for girls who have precocious puberty. This is for girls who start pubertal transition earlier than age 8 years and we can give them medications to pause puberty temporarily. If they start puberty too early, they may not be able to grow as tall or bones become as strong as they need to be.

The other type of hormonal suppression is to regulate or suppress periods. For the most part, these are also used for birth control and are available as pills, patches, vaginal rings, shots and implants. We generally talk to girls about these options if they have irregular bleeding that is bothersome, painful cramping with their periods, very heavy periods, mood issues around the time of periods, worsening seizures around periods or otherwise generally cannot tolerate having a period. We almost never start hormones before girls at least have a few periods to see how they do, since their periods often are not as bad as caregivers fear.

Healio Primary Care: In what instances might a specialist be needed? If one is not available — for example, if patient lives in rural area — what resources can PCPs and pediatricians use to best help their patients?

Fei: A pediatric endocrinologist should be seen if girls have precocious puberty.

Otherwise, pediatricians and primary care physicians are generally well equipped to deal with many issues with menstruation. Most of our visits with these families are centered on counseling, letting them know what to expect, helping them prepare, etc. Having families start practicing with menstrual pads before periods has been very helpful.

The widespread availability of period underwear has been a life changer for many families, so they no longer have to deal with pads. They should be referred to gynecology if primary care providers do not feel they are able to adequately counsel the family or they are unable to improve the bleeding or cramping issues with initial trial(s) of hormonal suppression method. Very few of these patients (if any) will need an exam, so virtual visits have been another time‐saver for families.

Reference:

Fei YF, et al. J Pediatr Adolesc Gynecol. 2021;doi:10.1016/j.jpag.2021.03.008.