Understanding Female Puberty:
The first thing to remember about puberty is that everyone goes through it, so you are not alone even if you feel like you’re the only one experiencing these changes around you right now.
All over the world, ‘growing up’ or attaining puberty is considered to be a significant time for a girl – it is the first evidence that you have begun to grow into a young woman, which is why parents make a big event out of your first period and celebrate the moment with your loved ones.
We understand that this can be a little embarrassing sometimes, especially because you don’t quite understand all the changes that come with your first period, both physically and emotionally.
Let us help you understand this very interesting but confusing time in your life by taking a look at some of these changes and find out why they happen – if you haven’t reached puberty yet or are at the beginning stages of transition, this area can also give you a good idea on what to expect in the coming months and years.
The first thing to remember is that all the changes that occur at puberty are driven by hormonal changes in your body.
You see, when your body reaches a certain age, your brain releases a special hormone called GnRH that kicks off puberty. This in turn causes many changes in your body, both within and on the outside including the development of secondary sexual characteristics such as breast enlargement and growth of pubic and armpit hair.
On the inside, your reproductive organs, such as your uterus [womb], ovaries and vagina also begin to enlarge. All these changes then lead to first period, when you will expel menstrual blood for a period that lasts roughly three to four days and upto one week.
This may defer from one young woman to another.
Even at which point in your adolescent life you attain puberty are determined by various factors so not everyone will begin to have their periods at the same age.
These factors include genetic elements, your diet, your background, weight (and fat) and the levels of physical exercise you engage in regularly.
If you are under weight for instance, you run the possible risk of delayed puberty.
Please read on to understand the different stages of puberty and get reacquainted with your body and emotions during this period on your life.
Puberty usually occurs in four stages in ordered sequence of events as follows:
Stage 1: Adrenarche
This is the onset of puberty is preceded by an event called “adrenarche”. This is when your adrenal glands (two small pyramid shaped glands that are situated above your kidneys), start to produce androgens. The androgens are later converted to Oestrogen. Androgens are also responsible for acne which is a good sign that you are in this stage of your pubertal development.
Stage 2: Thelarche
This phase is when you begin to notice a marked development in your breasts. It is the first physical change that is noted in a majority of girls when puberty is onset. Breast buds are formed, areolas widen and the breast begin to enlarge – this stage is called “thelarche”. Stage
Stage 3: Pubarche
Pubarche is the third stage of puberty where a noticed growth of hair in the pubic region and armpits occur.
Stage 4: Menarche
The first menstrual period is called menarche. Menstruation is a result of the various hormonal changes (especially Oestrogen) that take place in your body. The initial cycles may often be irregular, often resulting in scanty or heavy menstrual bleeding. These irregular cycles may persist for a year or more and is due to the regulatory mechanisms of the hormonal changes as the process starts up.
1. THE INTERNAL ORGANS
The female reproductive system is made up of external and internal organs. The internal bodily organs are the uterus, the two ovaries, the fallopian tubes, the cervix and the vagina.
Uterus
The uterus or womb is the major reproductive organ in females. It is a pear shaped muscular organ that expands when pregnant. The uterus provides support and protection for the growing baby until delivery. The fallopian tubes are connected on either side of uterus at its upper-most end. The inner lining or the endometrium of the uterus is responsible for your menstrual cycle. The uterus also has a thick muscular wall called the myometrium. When eggs fail to fertilize each month, it results in a shedding of the inner lining together with blood which results in menstruation.
Ovaries
The ovaries are almond shaped organs that are found on either side of the pelvis. The ovaries store the eggs that are later released into the uterus during ovulation. The ovaries are also responsible for your body’s production of Oestrogen and Progesterone hormones.
Fallopian Tubes
The Fallopian tubes are long tortuous tubes that are connected to the uterus at one end and are open at the other. The open end has finger like projections called fimbriae. These fimbriae pick up the released ovum or egg after ovulation and push it towards the fallopian tubes. The egg is then transported by the fallopian tubes to the Uterus.
NOTE – Fertilization, a process where the female egg [ovum] unites with the male sperm, takes place in the fallopian tubes. The fertilized egg is transported to the uterus where it will develop and grow into a baby.
Vagina
The vagina is a fibro-muscular tube that leads from the exterior of the body to the cervix and the uterus. The vagina is also commonly referred to as the birth canal. During Intercourse, semen is deposited in the vagina.
Cervix
The cervix or the neck of the uterus is the conical shaped part of the uterus that protrudes into the vagina. The sperms in the semen have to travel through the cervix to enter the uterus or the womb.
2. THE EXTERNAL ORGANS:
The external genitalia or the vulva is the external portion of the female reproductive system and comprises the following element:
Labia Majora
The labia majora are two large folds of skin extend from the front of the vaginal opening to the back of it. The outer surfaces of the folds have darker-coloured skin and stronger hairs, while the inner folds are smoother.
Labia Minora
The labia minora are two smaller folds of skin found between the labia majora. They protect the vaginal and urethral openings.
Urethral Opening
The urethral opening is a small opening located below the clitoris and above the vaginal opening. It connects to the bladder and facilitates urination.
Vaginal Opening
The vaginal opening, visible from the outside, is protected by the two labia. The vagina [birth canal] connects the uterus to the outside world. The vaginal opening is covered by a thin sheet of tissue called the “hymen” and is damaged during the first time you have intercourse, which sometimes leads to bleeding or spotting.
Clitoris.
The clitoris is a small protrusion of tissue that is extremely sensitive to stimulation.
The female reproductive system is made up of external and internal organs. The internal bodily organs are the uterus, the two ovaries, the fallopian tubes, the cervix and the vagina.
Figure 1 - The female internal genitalia
Figure 2 - The female external genitalia
The menstrual cycle is the monthly series of changes a woman’s body goes through in preparation for the possibility of a pregnancy. Each month, one egg is released from one of the ovaries in a process called ovulation.
Hormonal changes that take place simultaneously causes changes within the uterus preparing it for pregnancy. If ovulation takes place and the egg is not fertilized by the sperm, the inner lining of the uterus sheds through the vagina resulting in a menstrual period. The inner lining of the uterus becomes rich with nutrients and is able to provide nourishment to the developing foetus, if the egg is fertilized.
A baby girl is born with all the eggs her body will ever use. The eggs are stored in the ovaries, each inside its own sac called a follicle. As the girl matures and attains puberty, various hormonal changes take place. These changes cause the eggs or the follicles to mature.
The various hormonal changes are brought about by the hypothalamus, a small area in the brain that is responsible for regulating the body’s thirst, hunger, sleep patterns and libido. It is the main centre that ensures the smooth functioning of the body’s organs through its endocrine functions.
The hypothalamus releases a chemical messenger called Gonadotropin Releasing Hormone or GnRH which acts on the pituitary gland causing it to release further chemical messengers / hormones.
The pituitary gland produces and releases, into the blood stream, Follicle Stimulating Hormone or FSH, and Luteinising Hormone or LH. These hormones help in the maturation of the eggs in the Ovary. The maturing follicles then release another hormone, Oestrogen.
Oestrogen is the principal hormone that is responsible for the body changes that develop in girls, at puberty. Oestrogen also causes the lining of the uterus to thicken and causes the cervical mucus to change. As the follicles mature further, they produce more and more Oestrogen. The high amounts of Oestrogen in the blood stream cause the hypothalamus to secrete GnRH at an increased frequency. This result in a sudden release of large amounts of Luteinising Hormone which is commonly called the “LH surge”.
The surge of LH triggers the one most mature follicle to burst and release the egg from the ovary. This is called “ovulation” and generally happens in the mid cycle or around the 14th day of the cycle.
Note - Ovulation takes place haphazardly during the initial years soon after a girl has attained puberty, and often ovulation may not take place at all. This often results in menstrual periods that are irregular. Such anovulatory menstrual cycles are very common as it takes time for the entire reproductive system to start up and function normally.
Release of the egg by the ovaries may cause a fleeting lower abdominal pain or mid cycle pain which is referred to as “Mittelschmerz”.
The released egg finds its way into the fallopian tubes. Inside the fallopian tubes, the egg is carried along by tiny hair-like projections, called cilia towards the uterus. Fertilization occurs if sperm are present.
Note - If fertilization occurs before the egg has reached the uterus, the fertilized egg might get implanted in the fallopian tubes. Any implantation that occurs outside the uterus is termed an “ectopic pregnancy” and is a life threatening condition.
After ovulation, the follicle from which the egg burst becomes the Corpus Luteum. As it heals, it continues to produce Oestrogen and large amounts of the hormone Progesterone.
Progesterone is the principal hormone of pregnancy. Progesterone causes the inner lining of the uterus, the endometrium to become covered with mucous secreted from glands within the lining it self.
If the egg is fertilized, and pregnancy occurs, the Corpus Luteum persists and usually, there are no periods until after delivery. If fertilization and implantation do not occur, the Corpus Luteum degenerates, eventually getting replaced by white scar tissue, forming a Corpus Albicans. The amount of progesterone and Oestrogren produced by the degenerating Corpus Luteum also diminishes. Thus the hormonal support of the inner lining of the uterus is withdrawn. The lining gets thinner and the long spiral arteries that supplied blood to the inner lining coil and close off. Pools of blood collect within the lining which, once full, burst and, with the sloughed endometrial lining form the menstrual flow. And with menstruation, a new cycle starts.
The second half of the cycle, from the mid cycle ovulation to menstruation is remarkably constant at about 14 days. This corresponds to the lifespan of the genetically preprogrammed Corpus Luteum. Variations in the length of the menstrual cycle are due for the most part to variations in the length of the first half of the cycle.
Adolescents are faced with many problems as they attain puberty and continue to grow and develop. Menstrual irregularities are a common cause for adolescent girls to seek medical advice and the help of a Gynaecologist.
A normal menstrual cycle is regular.Menstruation often takes place every 28 days, with range of 21 - 35 days. Average blood loss during the cycle is 30 - 50 ml. Though the amount of blood loss is subjective, objective ways of measuring blood loss would be the usual amount of sanitary pads used.
Abnormal menstrual cycles are common in adolescent girls. They are more common soon after the onset of menstruation - menarche. It normally does not need extensive investigating. And often, an Ultra Sound Scan [USS] of the abdomen and pelvis will rule out any underlying problem.
Abnormalities in menstruation may include any of the following,
- Quantity - Excessive amount of blood loss, during your menstruation, is known as “menorrhagia”. Excessive blood loss may result in iron deficiency anaemia if not treated properly.
- Timing or frequency - The menstrual cycle may be too frequent where there is more than one period per calendar month or it may be infrequent.
- Duration of bleeding - During a menstrual cycle, the normal duration of bleeding is 3 - 7 days. Prolonged duration of bleeding, with a regular menstrual cycle, is also known as “menorrhagia”.
- Pain - Lower abdominal pain during menstruation is not uncommon. Pain during periods is called “dysmenorrhea”. Often, the pain may be sufficiently severe to cause frequent school absenteeism. The pain often starts at the onset of periods and may last for 24 - 48 hours. It is frequently associated with nausea, vomiting, back ache and pain in the thighs.
- Regularity - Menstruation is a cyclical process that commonly takes place once every month. Yet, some women might experience irregular cycles.
- Time of onset - Menarche or the first menstrual period quite early in life, before the age of 8 years is termed “precocious puberty”. While the absence of menstruation or “primary amenorrhoea” up to the age of 16 years is called “delayed puberty”.
The common menstrual irregularities are discussed below in the table below.
| Menstrual Irregularity | What is it called | What is it? | How is it Investigated? | Are there any medication? |
| Infrequent or Irregular periods | Oligomenorrhoea |
Infrequent menstruation that occurs at intervals of greater than 35 days. |
An Ultra Sound Scan [US Scan] of the abdomen would usually reveal any underlying cause. | Infrequent menstruation during adolescence is usually normal and does not warrant further investigations , unless the symptoms persist for over a year |
| Women who suffer from oligomenorrhoea have between 4 to 9 menstrual cycles a year. Menstrual flow during a period may be light or heavy. | ||||
| Irregular or infrequent menstruation is a result of anovulatory menstrual cycles. | ||||
| These are common soon after the onset of menstruation. But they also may be a manifestation of obesity or low body weight. | ||||
| Extremely painful periods | Dysmenorrhoea | Excessive menstrual pain that interferes with daily activities. | An Ultra Sound Scan [US Scan] of the abdomen would usually reveal any underlying cause. |
First line of treatment with
1. Mefenemic acid. [This is an antiprostaglandin agent that prevents the production of prostaglandins, chemicals that mediate pain during menstruation.] If the pain does not respond to mefenemic acid, the next line of treatment should be with 2. Combined Oral Contraceptive pills [COCP] COCPs reduce pain as well as alleviate the symptoms of Pre Menstrual Syndrome or PMS. |
| Secondary dysmenorrhoea is diagnosed when there is an underlying disease, disorder or a structural abnormality either within or outside the uterus. Primary dysmenorrhoea is diagnosed in the absence of the above. | Secondary dysmenorrhoea may warrant laparoscopy to rule out any pelvic problem. | |||
| Extremely heavy / long periods | Menorrhagia | The menstrual cycles are regular, but there is excessive bleeding or the duration of bleeding is prolonged. | An Ultra Sound Scan [US Scan] of the abdomen would usually reveal any underlying cause. |
First line of treatment with 1. Mefenemic acid. [This is an anti-prostaglandin agent that prevents the production of prostaglandins, chemicals that deter the uterus from contracting and stopping heavy menstrual flow during menstruation.] If the blood loss does not reduce with Mefenemic acid, the next line of treatment should be with 2. Tranaxemic acid. [An anti-fibrinolytic, it helps stabilize blood clots and reduce blood loss.] Both Mefenemic acid and Tranaxemic acid are often used in combination to effectively reduce heavy menstrual bleeding. 3. Norethisterone. [A progesterone analong, Norethisterone helps maintain the inner lining of the uterus in a steady state thereby reducing blood loss. This is often used if the combination of Mefenemic acid/Tranaxemic acid is ineffective.] |
| If untreated, and due to the excessive nature of the blood loss, women may become anaemic. | ||||
| Absent periods | Amenorrhoea | Primary amenorrhoea is the absence of menstruation. The girl has never menstruated before. The presence or absence of secondary sexual characteristics is vital and would help in the diagnosis. | The absence of menstruation till 16 years, with the presence of secondary sexual characteristics such as pubic/axillary hair and development of breasts, requires further investigations by a Gynaecologist | Treatment varies depending on the investigation and diagnoses. |
| Secondary amenorrhoea is the absence of menstruation for 6 months or more. | Whilst the absence of both menstruation and secondary sexual characteristics till 14 years of age requires further investigation by a Gynaecologist. | |||
| An Ultra Sound Scan [US Scan] of the abdomen would usually reveal any underlying cause such as Poly Cystic Ovarian Disease, which can cause secondary amenorrhoea. | ||||
| Abnormally early puberty | Precocious puberty | Puberty occurring at an unusually early stage. | It is essential to seek the advice of a Gynaecologist. | Treatment varies depending on the investigation and diagnoses. |
| The stages of puberty, as discussed earlier, happen at an early stage. |