It's Your Health Radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to It's Your Health Radio Henry Mayo Newhall Hospital. I'm Melanie Cole. And we are having discussion about puberty and child development. I have a panel today with Dr. Neela Sethi, she's a pediatrician on the medical staff of Henry Mayo Newhall Hospital, and Victoria Schooler, she's physician assistant with Henry Mayo Newhall OB-GYN.

Ladies, thank so much for joining us today. And puberty, I mean, we're going to have a great discussion. It's certainly something we've all three been through. So, we have knowledge and then the expertise that comes with what you both do for a living. So Dr. Sethi, I'd like start with you. Tell us a little bit about—I mean, we've talked before about what different, you know, stages of life mean, and puberty is a big one. So, tell us a little bit about what it is, kind of when it starts. What are we talking about here today?

Neela Sethi, MD: Puberty is just such a huge topic, and I think sometimes often stigmatized with parents and for kids. And, you know, I'm on this personal mission to really do exactly this and to talk about puberty so that these kids are empowered with their body changes instead of feeling self-conscious or that something's wrong with them. Puberty just involves all of the body changes that occur and can start as young as eight or nine years old and as late 16 years old. So, you have big range of when the onset of puberty is, and then it usually lasts somewhere between two to four years, depending on how quickly—some kids will kind of blow through it, and I feel like I see them at 12 and they are like little kids, and then I see them at 13 and they're like young men and young women. And then, there are other kiddos that I see that take longer through the process. But it essentially is that transition from child to young adult.

Melanie Cole, MS: Well, we know that you have one of those who just really became a young adult, right? We've had her with us before. And so, not only are you an expert pediatrician, but you're an expert mom. So, tell us a little bit why the reproductive health discussion is so important to have before some of these major changes, which we're going to talk about, but before some of these major changes take place, why is this such an important discussion to have?

Neela Sethi, MD: I think puberty and mental health play a really, you know, sort of big role with each other. And I think that it's really difficult to see your body change. And a lot of times these young kids relate to themselves and their body image based on how they look, and then so quickly and sometimes so drastically changes. And if they are not prepared, meaning parents aren't having discussions and destigmatizing the idea of breast development or pubic hair development or hormonal changes or changes in hair just in general. When it happens, they feel self-conscious, and it makes them go in, and it makes them feel like something's wrong with them, instead of feeling like, "Wow, I'm, you know, becoming this young adult. And look at me, I am so healthy, and my body is producing all these amazing hormones and allowing this to happen," instead they can feel self-conscious.

And so, I think part of what I'd like to really sort of scream from the rooftops for parents today is talk about it with your kids. You went through it. You remember how it is. And the more that they are empowered. Melanie, you and I have talked about this a lot, you know, knowledge is power with children and with young adults. So, the more that they feel like they have information, the better they're going and the more kind of empowered that they're going to And then, we'll get into it later, and I'm sure Victoria will be able to chat about it. But, you know, they have hormonal changes too. So, it's not just the fact that their bodies are changing. They're also having hormone changes, which makes them even more self-conscious and feel so, you know, sort of uncomfortable in their body and their environment. So, it's just like a big storm of changes that all happens at once that we want to sort walk them through and make them feel good about themselves.

Victoria Schooler, PA-C: Yeah. To chime in on it too, I feel like I see a lot of the people later in their 20s and 30s who later on say, "Look, no one told about that," or "Oh, that was happening or this is happening now and no one told me about it. And how am I in my 20s and 30s and just hearing about it?" So, I do think that age-appropriate conversations with these kids are so important.

Melanie Cole, MS: That's a great point, Victoria. Because some people, you know, we know we get through it and we're like, "Why didn't somebody tell us? Why didn't somebody have that discussion with us? I kind of missed out on knowing ahead of time what to expect." So, Victoria, let's talk specifically about females for a minute. I mean, you're in OB-GYN. So, what physical changes typically happen during this prepubescent and puberty period? And when you're seeing young ladies for the first time, what are of those changes and those first signs that maybe you have to tell them about or they come to you with?

Victoria Schooler, PA-C: I feel like I don't see them, like, when they initially go through those stages as much, but maybe later on. So, the changes with odor, like hormonal changes can cause odor, which can be normal. And a lot of people think it's totally abnormal. So, you know, they mask it. And then, they also wonder about obviously the breast development. Are breasts supposed to develop equally, or is it totally normal for one side to be bigger than the other? So, that's another, I feel like, big thing that I see. And of course, body hair, pubic hair, and the hygiene on that side. More physical aspects is, like, our bodies literally change with puberty. You know, with that estrogen development, our vaginal tissue and our vulva, they literally change.

Neela Sethi, MD: So, I think as a pediatrician, what we often see is exactly what Victoria said. We'll start with breast development. That's probably the first thing that I see in the office or the first visit where, you know, around that sort of eight, nine, 10 years old, we'll have visits for breast bud development and that are actually tender. And so, you know, we'll have our young girls come in and say like, "This hurts me." And a lot of times it can be unilateral, which is a really important topic. And so, they'll just have one breast bud, and they'll honestly think that they have a tumor. So, we'll have parents come in for that, and that's always one of my favorite visits to be like, "That's totally normal. You don't have to do anything about it, and you're becoming a young woman."

But breast development, I think, is the very first thing that I see. And then, the early start of pubic hair development, which gets fuller and fuller just as the breast development gets fuller and fuller. Some hormonal changes and just body hair as well, you know, under the arms, on the legs, on the body. And then, that sort of curvier figure that comes with that where, you know, their hips kind of widen out. And then, they get little bit of that hourglass sort of look to them.

And then, once I kind of see all in the checklist, then I believe that the period comes. And sometimes it's in the middle of that. But for the most part, when they come and see me and have breast development, pubic hair development, body hair, body odor like we talked about, and then that hourglass figure and they start looking like young women, I'm like, "Okay, honey, I think that period is on the way, and let's talk about how we can prepare you when you get to school for all the things so that you're not caught off guard with, you know, your period and not having all the things."

Victoria Schooler, PA-C: And then, the periods come in. It could take, you know, one to two years for them to even regulate out too. So, that's another thing that we see.

Melanie Cole, MS: Oh, we all remember that. The beginning, learning to use a tampon. You know, all those things were so pivotal that I don't know about you two, but those were such pivotal times to learn to use that or put a pad in for the first time.

Victoria Schooler, PA-C: I remember that.

Melanie Cole, MS: I mean, I remember it too. One of my sisters showed me how to do it. So, I remember, and I think I never will forget it. And then, I showed it to my daughter. Now, Dr. Sethi, I mean, we could talk about females, the three of us all day long, right? But we have to include our young men in there. So, what are some of the first signs that you see in our young men?

Neela Sethi, MD: I think similar to the breast development, what we see in young men is just testicular, like, size and enlargement. And so, we see that the testicles grow in size and they grow and they get bigger. And their testicle, they sort of like descend a little bit more as well. And so when they're younger, they tend to be sort of higher and sort of tucked under the penis. And what we find as they get bigger is that they kind of start hanging a little bit lower and testicular size increases. And then, they don't have the same sort of breast development, but they will become sort of broader chested, as you would sort of expect as, you know, they become young men and their penis size will grow. And their testicular size, as we talked about, will grow, and then they will develop the body hair, body odor. And then, they will also start developing pubic hair.

And I think it's important to mention, I think this is a great sign too for parents, is the hair, the pubic hair will start coming in kind of more fine and more sparse. And then, as they get further and further into puberty, that pubic hair will become coarser and curlier and just more profuse. And that's a really good indicator to me as well, that they're kind of heading into the later stages of puberty. Because if you imagine, ethnicity has a big sort of component of this, right? I'm Indian, and we are just, generally speaking, a little bit hairier. And so, sometimes you can even see pubic hair in sort of young children, but it's not pubic hair. It's just sort of fine and it just exists. But what we'll find when they're hitting more pubertal stages is that it will go thicker, coarser, curlier, and just be more profuse. So, those are just things we use, and we tell parents that as well.

Melanie Cole, MS: There's so many similarities with how male and female bodies develop. But now also, Dr. Sethi and Victoria, because you both have mentioned now hygiene a couple of times, and I remember with my son more so than my daughter, but being like, "Okay, dude, here's what you got to start doing."

So, Victoria, why don't you start with the young ladies that you see in your office as far as hygiene and the questions that they come to you with or that you notice. And you've mentioned odor before. So, tell us a little bit about that.

Victoria Schooler, PA-C: Yeah, I think for me, my general tips are an unfragranced body wash. And I usually tell them, you know, we're not wanting to wash and use that soap inside the vaginal area. We can let it put on our body and let it run off, but we just want to vaginal area with just water. A lot of people, you know, they're like, "I don't know if I feel comfortable with that," like just using water. So then, in those cases, I would say like, okay, like a Dove soap, you know, just around the vulva, but still not in the vagina.

I think there's a big, big market out there for female hygiene. Like, you walk down the aisle, and there's so much. I think almost every day someone, every week someone shows me a product I had never even heard of, and my rule of thumb is you don't need it. You don't need it. Vagina is self-cleansing. There's bacteria in there to help our vagina keep the pH and the balance. And when we're introducing these products, it's like you're introducing a stranger and our body's going to panic about it, and infections can come about. So, that's my general rule of thumb. Simple, keep it simple. Water is all you need. Of course, you know, you can put perfume, body spray on in your body, but yeah...

Melanie Cole, MS: And back in the day of douches and things, I mean, I don't even if those are still available.

Victoria Schooler, PA-C: They are.

Melanie Cole, MS: But that was all what we did, and I'm older than both of you. Are they—I mean, that issomething that we would try because we were like, "Ooh, didn't—" you know. But Victoria, I want to ask you one other question. When you talk about the odor, and these young ladies, and I remember feeling it myself, we smell it. Can other people smell it when you're working with a girl?

Victoria Schooler, PA-C: No, for the most part. I don't. No, I don't. Yeah. I usually tell them that too.

Melanie Cole, MS: Interesting. They want to know if they're sitting on musk, right, if other people can smell.

Victoria Schooler, PA-C: When I, you know, do the exam and I tell them, they're like, "Okay, good." Like, they are really reassured. Like, I do tell them, "I want you to know that it's not as obvious as I think that you might feel, and that's okay. But I want you to know that I'm not smelling it." And they really do feel reassured when someone's telling them, because otherwise no one's to tell you

Melanie Cole, MS: I think that's important. And Dr. Sethi, what about males, the hygiene concerns that they have generally? Because I mean, there's a lot of them with them.

Neela Sethi, MD: Yeah. I think cleanliness is a huge part of just, you know, being a young man. And, you know, they all hit that phase they to brush their teeth and they don't want to wash their hair well, and they don't want to, you know, scrub their body. But similar to Victoria with the young females, it's similar with males. It's like you've got to actually lift the testicles and, like, clean under there. You've got to, like, lift the penis and clean the area between the penis and the testicles, and you just want to use, you know, warm water. You don't need to be using a lot of heavy soaps with a lot of fragrance. And same with the urethral opening on a penis, you don't really want to put a whole lot of just soap or fragrance around that area, because it is sensitive as well. And I do have young men come to me where they've used a lot of heavy soaps or, you know, they get into, like, the body washes, these, like, young men body washes that are totally unnecessary. But they'll go really aggressive and clean their penis and then, you know, cause irritation at the urethral opening and come to me. So, I think, with just genitalia in general, less is more, warm water.

I also have kind of taught my young kids about using a warm washcloth and the idea that, you know, it's not as common. But when we were young, like, my mom taught us how to use a washcloth to sort of get in areas. We didn't put soap on it or anything. We just had a washcloth that you put in the dirty laundry every day. And we teach them that idea too of just sort of cleaning underarms and cleaning the genitals with a warm washcloth and with no soap on it.

Melanie Cole, MS: These are all really great points. I mean, we really hitting all these different points here. And now, Dr. Sethi, one of the things that every parent dreads with puberty and with this kind of development time is the emotional changes. I'd like you to speak a little bit about it. Because first of all, they're starting to, as we've talked about, physically change. But then, the teenage brain, and you and I have talked about that for a long time. And so, that's kind of a weird and mysterious thing, the teenage brain. They're thinking about driving. They're thinking about the opposite sex. They're thinking about, you know, whatever they're thinking about. And so, tell us what's going on there.

Neela Sethi, MD: It's a difficult transition for them, because they go from not being very self-conscious and just being sort of free to play and free to move and not being sort of aware of their body in that way to becoming self-conscious of their body and their body changes. And then, simultaneously being sort of self-conscious of what is happening around them as well. And this is what we start seeing, especially with the young females, of comparing their body to other kids and, you know, group dynamics and getting included versus not included.

And what I always tell parents at this age is their little brains are lying to them, and they can develop negative self-talk very quickly and easily during puberty. So, it's your job as a parent to do the opposite. It's also very common for them to pull away from their family structure and really start craving alone time and wanting to be alone and to figure things out by themselves. And a lot of times we joke, like at two years old, they do the "I do it, I do it, me do it, I do it." And they sort of kind of go back to that when they're teenagers of like, "Leave me alone, Mom and Dad. I want to figure it out. I know what I'm doing. I don't want to talk about it." Just sort of pulling away from you, which I think a lot of why it is so difficult as parents because we're seeing them emotionally struggle and physically change and then also pull away from us, and that's where that sort of like that storm comes in for a parent where they're like, "Oh my gosh, you're no longer my baby and you don't need me as much and you're pulling away." And so, there's just a lot of big emotions and big feelings involved with that time period.

Melanie Cole, MS: I agree, and I think that's, for parents, the most terrifying aspect of all of this, is that pulling away, that, "I don't need you so much anymore," you know, "I'm a big girl now." But also, with the hormones, you know, there's some attitude that changes. And that's when they slam the door or they're, you know, just staring down at their phones or whatever they do. You know, those attitude changes are really mystifying.

Now, Victoria, because of what you do and in your practice, what are some of the common concerns that parents—you mentioned a few before when it's like, "Oh, only one breast is developing a little bit faster than the other." What are some of the common concerns that parents come to you with when they bring their daughters in during this whole period to see you?

Victoria Schooler, PA-C: For myself, I don't experience that as much, I think. I think when the parent comes with the patient, it's more concerns on like, you know, birth control, stuff like sexual education, and are the period symptoms normal, like the flow and just kind of talking about that. That's kind of more of what I'm seeing. So, that's just an opportunity for me to educate them on like what a normal menstrual cycle is and if what their experience is outside of that normal. And then, the opportunity to talk about sexual education too, which I feel like it is a great place and space to start. like when they come to me, I totally feel comfortable talking about it too, and a lot of times the parents and the daughter agree, like just to have someone do the spiel. But again, I feel like that's another situation where if we can expose them to it prior, could give a lot of education.

Melanie Cole, MS: Those are great points, really. And sexual health is where most of those questions are going to lie. And Dr. Sethi, how do parents know then what's normal teenage behavior, expectations, and when it's something that maybe raises a red flag to you as a pediatrician? They come to you that, you know, sometimes. And I'd like you to mention this right now, you speak to the kids at this point in their development separate from the parents, right?

Neela Sethi, MD: Yeah, yeah, we do. We pull parents from the room around this time, 12, 13. and to get an assessment of their mental health and their sexual health and just safety concerns and the more that you can sort of empower parents to trust their gut instinct. And Melanie, you and I have talked about this a lot, where, you know, everything with teens, I feel, is cyclical, right? So, they're like boomerangs. And so, the more they pull away, the more they come back. And so if you're seeing them pull away and stay away, that's a red flag. If you're noticing that they're eating habits, you know, they can eat everything in sight and then also eat like birds. But if you're seeing extremes with their eating habits, that's a red flag. If they're eating everything in sight or they're not eating for long periods of time, that's a concern. Same with sleep. You know, sleep, they need a lot of sleep, 12 to 14 hours, not even 8 to 10 at this age. And so if you're noticing the, you know, 16, and it's happening over and over and over, and it's not just the weekends and it's difficult to wake them up, that's a red flag.

Same with joyfulness and happiness. And as much as they pull away and want to be in their room, they also do have moments of wanting to be with you and wanting to be with the family and having moments of joy. And if you're noticing, you know what, it's all pulling away and there's no joy, those are things that you come to me for to say, "Hey, is this normal?"

And I think one of the most important things that we can tell parents during this stage is you got to trust your gut instinct. You know, maternal and paternal sense is very, very accurate. Historically, you know, sometimes, mother instinct, you know, bats about a 90% average for being accurate. And so, we often don't give ourselves that credit as females. And we could have a whole nother discussion as to why society has put that sort of doubt in us. We could have a whole podcast about that.

But for me, I really try to have my mothers and my fathers, but my mothers really trust their maternal instinct and say, "If you feel like something's wrong, come and see me. Worst case scenario, going to reassure you. But, you know, we may catch something where I could catch it on the earlier side and have your kid not suffer by themselves."

Melanie Cole, MS: Well, along those lines then, Dr. Sethi, how should parents respond and start that conversation? Maybe you've reassured them, but maybe now they need to really have that conversation with their young child, with their young adult, and kind of get that conversation going. And you and I have talked about communication and how important that is. And at this time of their life, it's like the most important, because this is when they're deciding how cautious to be, how intelligent to be, how much to pay to school, how much to pay attention to this and that. And, you know, they're trying to sort and compartmentalize all these different things. And so, how do parents bring that out into the open and start that conversation?

Neela Sethi, MD: I think it's gentle, but I think that it's also concerned. And I think that there's a, like, juxtaposition of the two of, you know, "Honey, I've noticed blank. I feel like you've spent a lot of time in your room and it makes me worried as your mother or your father. And I just want to a check-in and make sure that you are good because I love you and I care for you, and I'm not saying that anything is wrong, but it's my job to make sure nothing is wrong. And I'm not labeling I'm not judging you. It's because I love you and I'm concerned, but these are the patterns that I'm noticing for you. And could you give me insight into sort of what's happening behind closed doors? What is that inner voice of you saying? And are you having more good days than bad days? Are you experiencing joy?"

You know, a lot of times we will tell parents just to come out and say like, "Are you sad, honey? You know, are you sad? Do you feel sad?" Just to sort of open up the convo of, "Hey, I'm noticing these patterns. I'm not saying you're depressed, I'm not saying you're anxious, but I'm just having concerns." And very quickly, you're going be able to tell because if these kids come in and they, you know, start bawling hysterically and say, "Yes, I am sad and I'm so glad you noticed," okay, that's something, versus you have the kid that's like, "Mom, you're being crazy, I'm totally fine," then that's it. That's, you know, an answer too. And not that you would just go based on the first time, but it just starts that discussion.

And one of that I tell parents a lot that's very empowering is just to go to your kid at a young age and just teach them about mental health. "How's your mental health?" I do that with my kids all the time at fourteen and sixteen. When they're quiet, I just say, "Hey, hey, guys, hows your mental health?" And it's like, "Meh, meh" or "Good" or "Great" or "You know what? A little bit in the dumps." Okay. Well, that just leads into a conversation of why? Why isn't your mental health great? What is it? Is it a friend thing? is it a body dysmorphia thing? Is it a stress thing? Is it a school work load? Is it Dad and I? Are we doing things to make you upset?"

Melanie Cole, MS: Everything, all of the above.

Neela Sethi, MD: All of the above. Exactly. So, just having the discussion and coming in from a place of concern without judgment, without labeling. I see a lot of parents come in and say, "Johnny, I think you're depressed." It's like, "Well..." i mean, think of it as an adult. if someone were to say that to you, you know, you would immediately feel labeled, and you would immediately pull back, versus if I had a girlfriend say, "Hey, Neela, I'm, you know, noticing these patterns with you and I'm genuinely concerned," that would make me feel seen and heard and want to open up more.

Melanie Cole, MS: Wow, that was really well said. And as a mother of two kids in their 20s now, I can tell you that that does—and you have this to look forward to—that that does change. When their mental health is suffering, there are big signs. It's not as subtle and, you know, they're more likely to tell you. You know, my kids will come to me and be like, "Okay, I need to get a counselor now because..." Whatever the reason. So, that is something that kind of does grow. And having those conversations, like you're saying, Dr. Sethi, is what makes that happen, right? So as parents, we can propagate that confidence in our children to come to us on their own with these concerns.

And I want to give you each a final thought here. So, Victoria, based on what you see every single day with these young ladies, what do you want to tell parents and the young ladies about this time, these changes, what they can expect, and seeing an OB-GYN at that time, why you think that's so important?

Victoria Schooler, PA-C: A big thing

out of all this too is that everyone can experience everything in a different way. Like, people can experience the physical changes, the mental changes, and like the emotional changes all differently too. So comparison, I feel comparing is really common, I feel like, in this stage too for parents and the children, I think. You know, like parents will look at other kids and compare in that sense. So, I think a big thing is knowing that everybody develops in a different way. And it's okay to develop in that way, maybe just meeting them where they are.

Melanie Cole, MS: I do too. That is great advice. And Dr. Sethi, last word to you. How can parents really best support their children during this time if they're eight, nine years old? And as you said at the beginning, sometimes kids develop at different rates. They develop different ages. It starts around the eight or nine years old and goes all the way up to however long it goes. Best advice. You do this every day with parents. What do you want them and the kids that you talk to on their own for their first time talking to doctors by themselves, what do you tell them?

Neela Sethi, MD: For kids, I always tell them, "You are normal. You are normal. Everything is normal. Your body is changing and growing and developing at the rate that it should, and you're doing a great job." I think there's just a lot of reassurance. And then, of course, just sort of destigmatizing things that they've heard and seen online and on social media. Like, "Nope, that's not true," "Nope, that's not true," "Yes, this is true." And then, I think paving the way for the future. Like, "No, honey, your breasts are going to get bigger. See the hair that you have down, you're going to have more of that." So, that they can kind of have a roadmap as to what's going to happen in their body, so they're not scared, and a lot of reassurance.

For parents, I think the best thing they can do during the teen years is just, I always say, be a stable grounding force, right? Like, you're like the wallpaper. You add by just being there. And you don't need to be loud and verbal and in their face, but just being the constant in their life where they know it's there, and when they turn the lights on, you're there, is huge.

And so, stable, grounded. When they go up, you can't go up. And when they go down, you can't go down. You've got to just sort of stay as best you can even-keeled and just be that sort of force where they know if they need something, you're there. And that there's very little judgment behind it, and there's very little what you're doing is wrong to the child because they already feel that. They already feel like they're doing all these things wrong. So if you're coming in saying, "And you didn't do this, and you didn't do that, and you didn't help me with the dishes, and you didn't call me when I..." It's like their negative self-talk is just going to get worse.

And it doesn't mean either toxic positivity either.It's not that. It's, "Hey, i'm noticing these things. Hey, when you get a chance, could you? Hey, I really love the way that you played with your brother today, and tomorrow, maybe we can work on screen time." It's sandwich method. It's just constant, grounded, and consistent. I think that's really the key to survival during these teenage years. And believe me, yes, this is one my expertise, but I don't always do that perfect.

So to all those moms and dads out there, know, there are days they go high, and I go even higher, right? And they go low, and I'm like, "Oh, God, it's so bad." But that's live and learn, and that's part of the human experience. You know, just leading with love is always going to be the answer always.

Melanie Cole, MS: Oh, that's so lovely. What a ending for this, leading with love. And when you talk about that, you know, fear, I mean, the survival, is that for parents or for the kids? I think it's both, right? Because we're all just trying to survive those teenage years. But I want to thank you both so much for joining us. We all remember we were all there, right? So, we're all experts in our own way. But thank you both so much for joining us today and helping parents to really understand this transition, this time, especially for parents that have not been through it with their kids before. You know, it can be a little bit mysterious, but you've cleared so much of it up.

Thank you so much, both of you, for joining us. And to book an appointment with Victoria Schooler, please visit our website at henrymayo.com/schooler. And to book an appointment with Dr. Neela Sethi, you can visit henrymayo.com/sethi. You can also visit the free Henry Mayo Newhall Hospital online health information library at library.henrymayo.com. And that concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Thank you so much for joining us today.