Precocious Puberty

My nine-year-old daughter has just started her period. She has consistently been tall for her age, and began developing breasts at age seven. I know that it is unusual to begin menstruating at this age, but is it abnormal? Will it alter her growth pattern? Are my friends accurate when they say it could be caused by too much bovine growth hormone in the fast foods she eats? And how do I help her cope with this? She is mentally and emotionally still very much a nine year old.
Groton, New York

Precocious Puberty

Dr. Greene’s Answer:

There is crucial information your daughter needs to know.

First, some background: The age of onset of puberty varies widely. In girls, the breast bud is usually the first sign, and is seen on average at 10-11 years. Pubic hair usually begins to appear 6-12 months later. Next comes the pubertal growth spurt. Lastly, menstruation begins (called menarche), on average, 2-2.5 years after the onset of puberty. The mean age for a girl’s first period is 12.75 years. Wide variations are seen in the sequence and timing of these events, but peak growth velocity (fastest growth rate) always precedes menarche.

For boys, the testes and scrotum begin to enlarge first, usually at about 10 to 13 years. A few months later, pubic hair develops (facial hair comes about 2 years later). The pubertal growth spurt usually follows about 6 months after pubic hair. Lastly, the penis grows longer about 1 year after the testes grow, and is accompanied by changes in the voice.

Precocious puberty is defined as the onset of true puberty before 7 to 8 years of age in girls or 9 years of age in boys. (Isolated breast development which doesn’t progress to the rest of puberty is called premature thelarche, and is a different, benign condition). Precocious puberty is 10 times more common in girls than in boys. Sexual development may begin at any age. Pregnancy has been reported as early as 5 1/2 years old.

Most precocious puberty is simply early maturation. Nevertheless, the Lawson Wilkins Pediatric Endocrine Society recommends evaluating for an underlying medical condition in Caucasian-American girls who have development of breast and/or pubic hair before age seven and in African-American girls before age six (Kaplowitz and Oberfield, Pediatrics 1999 Oct;104(4 Pt 1):936-41). These medical conditions include ovarian cysts, thyroid problems, McCune-Albright syndrome, central nervous system disorders, or external sources of estrogen. In girls over age 6, these other causes are quite rare, but should at least be considered by your pediatrician.

Your friends have suggested that bovine growth hormone is the cause of your daughter’s precocious puberty. I strongly doubt that. The only external compounds clearly implicated in girls’ early puberty are estrogens. Moreover, when human growth hormone is intentionally given to children to increase their heights, in doses far higher than your daughter could accidentally consume, precocious puberty has not been a problem. Your friends are right to be concerned about the chemicals used by agribusiness, but from bovine growth hormone I would be more concerned about cancer.

Early maturation in girls is categorized in two main types: rapidly progressive and slowly progressive. Most girls who begin puberty early (especially those who begin before age 6) have the rapidly progressive variety. They go through each of the stages (including closure of the growth plates of the bones) at a very rapid pace, and thus lose much of their adult height potential. About 1/3 of these girls will end up shorter than the 5th percentile of adult height. Many girls, however (particularly those beginning puberty after their 7th birthdays), will start puberty early, but still go through each of the stages at a more typical pace. While their “adolescent” growth spurts are over early, they will continue to grow until their bones reach final maturity at about age 16.

Now for the crucial information: The earlier before age 12 a girl starts her period, the higher her lifetime risk for breast cancer (probably from the prolonged estrogen exposure). The highest average risk for breast cancer is in non-Hispanic white women, where it is 1 in 8, or 12.5%. In all girls who start their periods before the age of 12, taken together, the risk is 16.25%. As she reaches maturity, she needs to be made aware of controllable risk factors for breast cancer, such as use of estrogen-containing birth control pills (10 years of use would raise her risk to about 22%), first pregnancy after age 30 (if she did this also, it would raise the risk to about 35%), high-fat diet, alcohol use, fertility drugs, pesticides, and radiation exposure. Each of these factors multiplies her accumulated risk. If she is aware of these, she can make informed decisions for herself.

She can also learn what can reduce her risks. During adolescence, it is vital to teach her the habit of regular breast self-exam. If she has a child, breastfeeding will lower her risk. Strenuous exercise (particularly before the first baby), such as running, gymnastics, and ballet have all been shown to reduce estrogen exposure and thus reduce risk. Diet seems to be more important in the development of breast cancer than any other single risk factor. A low-fat diet, high in natural sources of vitamins A, C, E and zinc, is protective. Vegetables seem to be protective for other reasons as well, which is why the National Cancer Institute has come out with their “five a day” plan (which sounds hard, but is not so bad when you see what they call a “serving” — one carrot is a serving). A healthy diet is also one low in pesticides (wash fruits and vegetables thoroughly and/or use organically grown foods). It should also be low in artificial hormones, like those found in beef in the U.S. (your friends are friends indeed).

Although your daughter is still emotionally and mentally a nine-year-old, she now has the hormones of an adolescent. She undoubtedly feels a range of emotions that are difficult for her to cope with. As a parent, it is very important for you to carefully watch and listen to her. Help her put her feelings into words, and be careful not to make judgmental comments. She will probably express many diametrically opposed emotions in the same sentence and then feel confused about what she just said. This is normal.

One of the most difficult things she is facing is finding a peer group. She no longer entirely fits in with her nine-year-old friends, but it would be a big mistake for her to develop a peer group that is much older than she is (even if they would accept her). She needs people to help her bridge the gap between being a little girl and a woman. As a parent, this is an important time for you to be involved in the daily activities of her life. It may seem like a challenge to get excited about the things that she is interested in, but there is no one better equipped to help her through this difficult time than you.

Dr. Alan Greene

Dr. Greene is the founder of (cited by the AMA as “the pioneer physician Web site”), a practicing pediatrician, father of four, & author of Raising Baby Green & Feeding Baby Green. He appears frequently in the media including such venues as the The New York Times, the TODAY Show, Good Morning America, & the Dr. Oz Show.

  1. Leslie

    My daughter, who is 9, came to me yesterday afternoon and told me that she is bleeding below. I looked seriously at her and said to not joke with me and if she is we need to get cleaned up. She then denied it. We went to the bathroom and sure enough my daughter has now become a young lady. I told her its normal, she wasnt scared. I went and go the right size pads for her (I was not expecting a 9 yr old to start) I should have seen more of the signs as she started to wear training bras half way of school last year and had hair already growing prior to that. A few months ago she got her first pimple, and her face clearned up nicely! Earlier this week she complained of a sore tummy but nothing else. I will be switching her to a female ped soon so she will be more comfortable talking about girly things. I know its part of life but it feel as if my little girl is leaving me. :( I plan on letting her keep being a 9 yr old !!! Shes so young and still a child. So for those reading this: My daughter started to develop a chest about 7 months ago. Hair I would say a year ago. In the past month her chest has gotten a little bit bigger and has started her monthly.

  2. Sonia

    Hi my daughter is 7 year old and her breast starting develop. She is very Young in her age. I feel so worried can u suggest me what shall I do to stop her early puberty.

  3. Melinda Valdez

    My 8 yr old has just started discharging a clear thin white mucous. While I’ve been reading that that is normal…what I am alarmed about is that I’ve read that this is indication that she will start her period within a yr. My concern is that she hasn’t even began developing the symptoms of puberty such the development of breasts…nothing other than this a sign she is going to go into puberty and not necessarily get her period?

  4. Jenny

    Hi Dr Greene,

    I have a wonderful 9 year old and she is also developing quickly. We have been back and forward to our doctor over the past year with pain in her tummy, she has been complaining of sore breasts with a small lump behind nipple and has started developing pubic hair. Last week she had a sore throat and then developed a pain in center of her chest, which has continued since Friday, we have seen our doctor and he feels that it is all growing and developing pains. I’m very worried. She showed me a lump on right side of pubic bone the size of golf ball this evening, which has since gone down after an hour or so. Is all of this connected?

  5. Helen Choi

    Thank you Dr. Greene. Your message has helped me to understand my child’s emotional state and how I can help to bridge the gap for her from being a child to a woman by listening and to be a friend to talk to.

  6. Anish

    I have a 9 year old daughter. She’s got all of the above signs and more.

    Her breast are quite developed. She has pubic hair, a bunch of them, even on her armpits. She already has been through menarche, now she has regular period, once every 28-30 days. She has pimples on her face, more pronounced on her forhead.

    These are only physical changes and bodily changes. However, the other issue that I am facing is that she has started hanging around more with boys than girls. And, moreover she likes a boy a year older to her. In fact, have come to know that they hug each other in the store room at school. She likes other boys in the school too.

    Being a single father, this has left me very tensed & worried. Her mother left her when she was 4 years old. She doesn’t even remember her mother. I have been taking care of her myself for the last 5 years. We are from India, Asian in origin.

    Kindly give me guidance as to how to deal with this. Should I take her to a Child Counselor or Psychologist. Or should I go myself initially.

    • sara

      Yes take her to a female pediatrician, so she can talk to your daughter and explain about being a girl and growing up. Your daughter will be more comfortable that it is a female doctor, also it would be good for a woman counselor at the school to talk to your daughter and you as well so you can understand what your daughter is going through.

      Don’t forget to ask the doctor for some pamphlets on girls and puberty when you take your daughter to the doctor. There is no such thing as too much information. It will help you both understand it more. Also it’s good idea to urge your daughter to visit a counselor to talk about how she feels with her mom being gone. Your daughter needs to open up about what she is feeling. Leaving feelings inside and not expressing them will cause her to be angry. I know you don’t want that. Keep being a great and understanding Dad.

      Your friend and mother of 3 daughters ages 15, 11, and 10. SARA.


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