Early Puberty in Girls

Excerpted from
Early Puberty in Girls: The Essential Guide to Coping with This Common Problem
By Paul Kaplowitz, M.D., Ph.D.

On February 20, 2001, the subject of early puberty and the normally low-profile academic discipline of pediatric endocrinology graced the front page of the New York Times. In an article titled "Doubters Fault Theory Finding Earlier Puberty," science writer Gina Kolata brought to national attention what had previously been a minor disagreement among specialists in my field, and I found myself at the center of the controversy.

At issue was a study published in April 1997 that appeared to show that girls, especially black girls, were starting puberty at earlier ages than previous studies had documented.' As a member of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society (LWPES), I was asked, along with my colleague Dr. Sharon Oberfield, to review the study and report to the membership our opinion of its scientific validity. I reviewed the paper in detail, read the earlier literature on the subject, and interviewed the lead author, Dr. Marcia Herman-Giddens. Dr. Oberfield and I eventually concluded that the study, in which the stage of puberty was determined in over seventeen thousand girls between ages 3 and 12, was not perfect but provided the most reliable and current data yet on the timing of puberty in girls in the United States. We wrote up our findings and recommendations, the most controversial of which was that we acknowledged that girls are maturing earlier than in the past, and that our guidelines on the age at which puberty should be considered "precocious" reflect this change. We suggested revising the definition for when breast or pubic hair development was too early from age 8 to age 7 for white girls and to age 6 for black girls. The paper was reviewed by the members of the Drug and Therapeutics Committee of LWPES in May 1998, and a revised draft then went to the Executive Committee of LWPES; with a few minor changes, it was approved. Although the paper was never put to a vote of the entire LWPES, it did have the approval of the leadership of the society.

The first rumblings of conflict came when we got back the reviews from the first journal to which we submitted our paper. One of the reviewers liked the paper, while the other reviewer argued forcefully that the original study was so flawed that any recommendations based upon it were also flawed. We resubmitted the paper but it was rejected, so we next sent the paper to Pediatrics, the official journal of the American Academy of Pediatrics, the largest organization of pediatricians in the country. Two reviewers looked favorably on what we had written, and after more changes (it had probably been through about fifteen drafts by then), it was published in the October 1999 issue of Pediatrics.

Within a few weeks, calls from reporters began coming in, and articles began appearing. On October 26,1999, Sandra Boodman of the Washington Post headlined her article "New Guidelines Say Early Puberty May Be Normal."3 It started, "Girls as young as 6 or 7 years old who display the first signs of puberty are in many cases normal and do not routinely require workups by specialists or injections of hormones to delay maturation, according to new recommendations by endocrinologists." I pointed out that the new recommendations in our article reflected a realization that the standards we had been using for when puberty in girls should be considered too early are really out of date.

A few days later, on November 1, the Philadelphia Inquirer weighed in with its take on the puberty problem with the headline "Early Maturing in Girls Is Common, Experts Say." Its author, Marie McCullough, did an excellent job reviewing the topic. She also pointed out a recurring theme in the debate over early puberty, which is that although breast development seems to be starting earlier, the average age at which white girls have their first period has not changed significantly in the past forty or fifty years. A discussion followed on the social implications of early puberty, including the question of whether schools should start teaching kids about puberty earlier than the fifth grade.

A month later, on November 30, Jane Brody made early puberty the subject of her "Personal Health" column titled "Yesterday's Precocious Puberty Is Norm Today." "Many parents become worried when their 7- or 8-year-old daughters begin to develop breasts or grow pubic hair." They wonder if the hormonal changes of puberty will adversely affect their daughters' behavior, moods, or physical growth and if girls who are still immature can adjust to early physical maturation. She went on to say, "But whatever the reasons, the phenomenon is real and, to many parents, worrisome. The new report by [Dr.] Kaplowitz . . . [and Dr.] Oberfield . . . should prove reassuring." She went on to give a lucid summary of all the key points made in our article, including the warning signs indicating when puberty in 6-to-8-year-olds might represent a more serious problem requiring evaluation and treatment.

As 1999 turned into 2000, I fully expected that the puberty story would fade from the news, but the calls and e-mails requesting interviews continued. The Wall Street Journal ran a story by Tara Parker-Pope in the July 21,2000, issue titled "Rise in Early Puberty Causes Parents to Ask, 'When Is It Too Soon?'" The mother of an 8-year-old who had early breast development and mood swings was concerned that "she wasn't prepared emotionally to have breasts and for boys to look at her" and said that the girl had started doing better once she began taking shots to suppress her puberty. I countered that a lot of healthy 7-year-olds undergoing early puberty appeared to be handling it very well. By this time I was saying the same things over and over, and I assumed people would soon get tired of the subject. I was wrong.