By Dr. B. J. C. Perera MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician
There are many phases of growing up in children. Some aspects are specific to boys while others are explicit for girls. Up to about the time of puberty when sexual development and maturation takes place, there is very little difference between girls and boys. At the stage of puberty there is a distinct pubertal growth spurts when certain physical characteristics show enhanced development. The most obvious of these are body stature, muscle mass, height and body curvatures. Children do change virtually beyond recognition during this stage of their life. They become somewhat adult like in many respects.
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This is a vital phase of development for girls. Puberty is not just one single event or a short milestone but a characteristic interlude of development. It usually begins between 9 and 14 years. Rarely, it can begin as early as 8 or later, perhaps delayed up to 14 years and this could still be normal. It is well known that in girls involved in intensive sports and major forms of physical training, puberty and other associated events may be considerably delayed. It takes approximately 2 years from the initial body changes of puberty until a girl has her first period. Her body will develop more into the shape of a woman over the next 2 years. Her hips will become rounded and become shapelier. Once periods have begun, girls continue to grow in both height and weight but much more slowly. On the average, following the onset of puberty, girls grow 5 - 11 centimetres per year in height and add an average of 3 to 5 kilogrammes per year of weight for 3 to 4 years.
The visible initial physical changes start with changes in the breasts which enlarge considerably. The hips will widen and pubic hair will begin to grow. Both breasts do not necessarily grow at the same rate. The difference in size is not permanent. However, if there is a very marked difference, it is necessary to seek medical advice. Hair in the armpits develops next and the hair on legs and arms will become darker. Girls attain most of their growth spurts, in both height and weight, in the first 2 years of puberty. They may start to have regular mood swings and even abdominal pain up to a year before periods start. This is also a time at which many psychological changes occur.
The virtual landmark of this stage of development is the onset of menarche or the start of menstruation or periods. The word 'menstruation' is from the Latin word 'menstruus', meaning monthly. When a girl first starts menstruating her periods may be irregular, the period loss may be very slight or quite heavy and a period may last from three to seven days, with a heavier loss at the start of the period. Many of them get pain on the first day of the period. Usually, girls do not ovulate for the first few months and even up to a year or so after their periods start. There may be a whitish discharge from the genitalia at the time of ovulation. Once they start to ovulate or produce eggs, they are fertile meaning that they are able to have babies. Periods are a natural part of being a woman and girls need to know how to manage them so they do not interfere with the way they live their lives. Girls need to know sound scientific details about menstruation before they start to have periods so that they are not surprised or distressed by this normal part of their development. Exactly when a young woman starts to have her first period depends on many things including the body size and shape and the pattern of development that she has inherited from the parents.
In some areas of our country, especially in the rural scenarios, the event of the onset of the first period is associated with certain rituals and celebrations. Depending on the locality, these may include the child being locked up in a room and provided with bland food for up to a week followed by a day of celebration. Many believe that the future progress of the child and prospects for a happy wedded life are dependent on these rituals and practices. Although there is no scientific basis for these, traditions have to be followed and honoured according to our culture.
The period is part of a cycle of hormone and body changes which enables women to become pregnant. How long a period lasts and the length of time between periods varies widely for different people. During each monthly cycle, the lining of the inside of the uterus (womb) gets thicker, so that if the egg (ovum) which forms in the ovary at each cycle is fertilised by combining with a sperm, the uterus is ready to provide a place for the baby to grow. A period is when the lining separates from the rest of the uterus because it is not needed for this egg to grow, the old lining is 'lost' and the uterus gets ready to make a new lining for the next egg. The 'loss' is mostly blood, which can be bright red, dark red or dark brown, and sometimes has some clots better described as dark lumps of blood in it.
Periods tend to come around the same time each month for many women, around 28 days from the start of one to the start of the next. However, it could occur more often, perhaps 3 weeks apart or further apart, around 5 or 6 weeks. When a girl first starts having periods they are often quite 'irregular'. This means that at one time there could be a gap of 3 weeks, and the next may be 5 weeks later. Usually after a year or so they settle down into a more regular pattern. This pattern can vary because of other things such as illness, stress, diet and exercise and also some inherited factors. Someone who does a very large amount of exercise or who loses a lot of weight can have a change in the pattern of periods. However, the most common reason for periods to stop coming, even in young girls, is pregnancy.
Often a period will last for about 5 days, but it can be shorter or longer. When a girl first gets her periods they can vary in how long they last, but like the time between periods, they will usually have a more regular pattern after the first year. The loss is mostly blood, but also some mucus and other tissues from the lining of the womb. Sometimes it seems like a lot of blood but it is usually less than 100 millilitres. If a girl weighs 50 kg she will have about 3.5 litres of blood in her body. In that sense, losing 100 millilitres of blood with a period will not cause health problems. The blood that is lost will be quickly replaced by the blood-forming cells in the bone marrow. Some girls have very heavy periods and sometimes pass clots of blood. It may be necessary to get medical advice if the losses are very heavy.
Many women have some changes or different feelings during the week before their period known as pre-menstrual symptoms. This is because of the major hormonal changes that their bodies experience. These can include feeling bloated and heavy, experiencing cramping around lower abdomen, cramps in the legs or sometimes in the lower back, getting more pimples than usual, feeling tense, irritable, sensitive, emotional and tired, breast tenderness and hair becoming more greasy. For some girls and women, the changes in the second half of the cycle which is the chronological time of a week or so before a period comes, can be distressing both emotionally and physically. This is known often as pre-menstrual tension or pre-menstrual syndrome (PMS). These are repetitive and similar symptoms may come on every month.
When girls start to have periods, usually for about the first year, most of them do not have much or any pain with the periods. After about a year, they start to ovulate regularly and the periods may be more painful. About two thirds of girls have pain with their periods. This pain comes from the muscles in the uterus or womb contracting or tightening. This is sometimes called 'cramps'. Some girls, about one in ten, have very painful periods. This can interfere with their normal activities and may interfere with schooling. The period pain is usually a cramping pain in the lower abdomen and sometimes in the back. Some girls feel quite unwell when they have period pain. If the pain is not too bad, simple things like a hot water bottle on the tummy, some exercise and perhaps simple pain-killers like paracetamol could help. If a girl or woman is having a lot of pain, she needs to see a doctor. There are some medicines which can make a difference. It will be useful to mark when the periods are coming on a calendar because some of the medicines work best if they are taken just before the period pain starts.
As for protection during periods the choice is between pads and tampons. Which to use is a matter of choice but most girls find pads easier to use when they first start to have periods. Even young girls can use tampons successfully and they need not be sexually active before using a tampon. However it might be uncomfortable trying to put them in when the entrance to the vagina is small. Inside a tampon box there are step by step instructions about how to use them. Tampons cannot 'get lost' inside a woman's body as they cannot go any higher than the top of the vagina. One serious but rare infection that has sometimes been caused by not changing a tampon often enough is toxic shock syndrome. This is caused by toxins or poisons made by bacteria which can get into the lining of the vagina when it is damaged by becoming too dry or having something irritating, like a tampon, up against it.
A girl or woman can swim and have baths during a period. The bath or pool water can only enter her vagina but not the rest of her body and it does not cause any health problems. When a girl has a period, bath water, swimming pool water or sea water will enter her vagina and some blood can be washed out. If blood gets into bath or pool water this does not cause any health problem but may be embarrassing if others see it. In the sea, the amount is rarely enough for anyone else to notice. After the first few minutes the loss will be small and no-one will see it. Going to the toilet before going swimming will lessen the amount of blood that 'leaks out'. It is not necessary to wear a pad or a tampon while bathing or swimming, but many women prefer to wear a tampon as then there is no leaking of blood. The tampon needs to be changed as soon as the girl or woman gets out of the water because pool or sea water would have got into the tampon.
Most women often start having a period at a time they were least prepared. This has probably happened to many of them several times in their life. Girls need to know that ALL women know what this is like and they can ALWAYS ask for help from another woman. It could also be useful for them to know that about one in six of their friends will probably have her period at the same time and a friend may be able to help if they need a pad. They could keep some pads in their school bags 'just in case'. They also need to know how to wash blood out of clothing. Usually periods start slowly so they get a bit of a warning before there is a lot of blood. If blood does get onto clothes, some girls recommend tying a jumper around the waist. It hides the blood and is 'in fashion'.
It may feel like just yesterday that a mother was teaching a little girl the ABCs and then, right before her very eyes, her daughter is growing into a woman. As she develops, she is bound to have questions about the physical and emotional changes of puberty. As a parent, it is a mother’s job to listen to her concerns and keep the lines of communication open. The mother needs to let a daughter know that she is available any time to talk. By the time a girl is 8 to 10 years old, she should know what bodily changes are associated with puberty. That may seem young, but it needs to be done. It is necessary to talk about menstruation before she gets her period. Girls who are unaware of their impending period can be frightened by the sight and location of blood. Girls often express insecurity about their appearance as they go through puberty. Some develop breasts at a younger age or get their period early while others may not start until they are a little older. It is a very good thing to assure a daughter that there is marked variation in the timing of these milestones. Everyone goes through them, but not always at the same pace.
It is the duty of both parents to help girls to see that puberty is an important and exciting milestone in growing up. They need to talk about many different aspects of growing up. Younger girls may need help in understanding how to use a pad or tampon and what to do with used ones. They need to be taught the importance of hygiene such as changing pads or tampons regularly including not using tampons overnight. It is necessary to make sure that her school has a place where she would have privacy, a place where she can dispose of pads, someone to turn to if she is having too much pain etc. They need to be reassured that it is usual for a girl's breasts to be slightly different in size but that the difference is not noticeable to others and to other details such as the possibility of periods being irregular both in how much blood she loses and how often they happen. If she has a considerable amount of pain with her period, simple measures need to be tried but if it is troublesome, medical help may be needed.
KEY POINTS
* Puberty is an important period of life for girls.
* There is rapid development of typical female characteristics during this time.
* Young girls need to be educated on these aspects well before the arrival of menarche.
* Menarche is signalled by the first period.
* Menstruation varies widely in girls and women
* Pre-menstrual symptoms can be troublesome
* Girls should be instructed on how to handle the periods and how to seek help during menstrual accidents
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