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Have you ever thought about how vulnerable puberty can be to young teenagers? I know it’s common for people to understand what it’s like, and to be forgiving with some teens having trouble coping with their bodies changing and developing so suddenly. But something I don’t think is talked about enough, and can definitely be overlooked, is delayed puberty. Imagine you’re a 13-year-old girl with a flat chest. You're insecure about how slowly your body has developed, while all your friends get to go to Victoria's Secret and bra shop together on the weekends. When you're hiding your chest with your arms in the locker room out of embarrassment and feeling ashamed in yourself, can you imagine how that feels?
Now imagine you're 15, being unable to contribute in period gossip with your girlfriends during sleepovers, watching them get to confide in one another and complain of bloody embarrassing stories as you sit in shame, wishing you had some stories to tell of your own. You know time is ticking and these kinds of changes should be happening by 16. You have no large curves, no period, you feel stuck. Can you imagine if this were you? Now I wouldn't have to because I was that little girl and I know what it feels like, because I was feeling ashamed of myself every day from ages 13 to 15 waiting and wondering, when it was going to be my time? My time to finally look like and be the young woman I was on the inside. It sounds dramatic I know, but girls are very much so, and I just wanted to be caught up with every other girl teen girl my age.
In my favor, I was always a tiny and petite girl, so I kind of got to get away a little with my small figure. It diffused the teasing in my lack in growth from my peers and that was good, but I always knew. I knew my body was behind even if others didn’t notice, and I was ashamed. I just wanted my body to get it together already. I did not want to be turning 16 soon and look like I was 14 anymore. Luckily for me, my body caught up to my 16-year-old self, getting my first menstrual cycle at 15 and a half, and my body sprouting in between, I finally felt more like a woman my sophomore year of high school. I had a late start you can say.
My envy to tell period stories surely subsided as I grew to loathe my period just like every other teen. As the years have gone by now, and I'm turning 19 soon, I begin to think back to all of the years when I thought my body wasn’t growing right. I think back on all of the fear and embarrassment I felt, and I just want to tell that little girl she was going to be okay. It also makes me think, of the little girls who indeed did experience a delay in their puberty like myself, but even for much longer than I. I would love for someone to give them the answers they need, and the comfort they deserve. No young women deserves to feel ashamed in their body at such a vulnerable stage in development. Delayed puberty is a fear that some young women face every day and it should be talked about with young women, so they aren’t afraid like I was.
As an Obstetrician and Gynecologist, I know all of the reasons why someone may go through puberty later than their peers. I know the hormones, genetics, and science that explain the reasons for this happening. However, I also understand the emotional toll this may take. As you stated, you were this girl and so was I. As a gymnast, my body lagged behind my peers. I was more muscular and faced intense self-consciousness when it came to the way I looked. I can tell you many girls feel what you were feeling, and not enough of us talk about it. I hope that, together, we can change that.
Let’s begin by talking about what is considered “normal.” When we use the term “normal” in medicine, we are typically talking about averages. Just because a patient may fall outside of these normal ranges, it does not mean that something is inherently “wrong.” What it does is clue us in to begin investigating further. Typically, girls will begin puberty with breast development (thelarche), then pubic hair development (pubarche), and then a growth spurt, followed by menstruation. Although this is what is considered the “normal” order of development, the steps can certainly be interspersed. There are also slightly different signaling pathways that lead to the development of breasts, menstruation, and pubic hair. However, to keep things relatively simple, this cascade begins with the pituitary gland signaling to the body with two hormones (LH and FSH) that it is time to begin this process. All in all, there are two definitions for delayed puberty. One is lack of breast development by age 13, and the other is lack of menstruation by age 16.
So, what are the reasons someone may have a delay in puberty? The most common reason is what we call constitutional developmental delay. What this means is that everything is working normally, but puberty is just happening later than what we consider “normal” or average. This is mostly related to genetics. Typically, if your mom or dad went through puberty later than normal, so will you!
Another reason for delayed puberty is what we call hypothalamic hypogonadism. This is a fancy term that means your hormones are too low to get your ovaries going. In most girls, this often has to do low body fat percentages. This can be due to exercise and activity and is often seen in gymnasts, ballerinas, runners, and various other athletes. It may also be connected to malnutrition for any reason, including anorexia or lack of access to food. It may also be associated with some chronic illnesses.
High levels of hormones may also cause delayed puberty. This may be associated with primary ovarian insufficiency and typically alerts the doctor to an issue with development or injury to the ovaries. High levels of hormones can be caused to several different factors. One of the more common reasons for teenage girls to have this issue is something called Turner’s Syndrome, which is a chromosomal issue. Other reasons may include a history of radiation or chemotherapy, as well as autoimmune diseases that may “attack” the ovaries.
Lastly, there may be structural anomalies that lead to delayed menstruation. This means that the hormones and ovaries may be working normally, but, for whatever reason, menstruation has not occurred. These anomalies can include an imperforate hymen or vaginal septum. Often, girls will get monthly cramps and other symptoms of menstruation, but no bleeding. There are also multiple uterine anomalies that may cause lack of menstruation, including uterine agenesis, or the lack of development of a uterus.
If at any time a girl or her parents are concerned about her development, it is important to contact either her pediatrician or a gynecologist to discuss their concerns. Here, the physician will perform a thorough personal and family history. If what is happening is considered normal, the doctor may provide reassurance and prescribe patience or “expectant management”. If the concerns warrant more workup, a girl can expect a few things to happen. One of the most important things that may occur is an exam. This can be scary, but it is necessary for the physician to determine if there may be a structural issue causing the delay. Additionally, imaging may be performed, with the most common being an ultrasound. Lab work to measure hormones may also be ordered. If these are abnormal, further workup may be warranted, such as imaging of the bones to check for bone age, imaging of the brain to make sure the pituitary is not being impacted, or a karyotype to look at the makeup of your chromosomes. Treatment will depend on the cause. Once again, by far, the most common reason for delayed puberty is a constitution developmental delay, which can only be treated with time.
Finally, I would like to address the emotional toll this may take. It is important to talk to your parents, friends, or a doctor if you have concerns about your development. These can weigh heavily on teenagers and can begin to impact mental health. Depression and anxiety may be common, in conjunction with the feelings associated with what your body is or is not doing. If your feelings begin to have an impact on your everyday life or if you begin to have feelings of hopelessness, sadness, or suicidal or homicidal thoughts, it is very important to discuss this with a medical professional and to know that you are not alone.
-Dr. Danielle Prentice
Thank you to Dr. Danielle Prentice and Dr. Jocelyn Fitzgerald for being guest bloggers for this series of blogs, Things Teenage Girls Always Wanted to Know About Gynecology. Have more questions about delayed puberty? Make a virtual appointment with a premier Las Vegas OBGYN.
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