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Prakash Chandran (Host): Puberty is a physically and emotionally challenging time that we all go through at some point in our young lives. It's a time that brings about many changes in the brain and the body, causing us to look, think, and act differently than we did before. Although each individual will have a unique experience with puberty, Adolescent Medicine allows us to gain a better understanding of what changes to expect and how to help our children mature in a healthy way. We're going to talk about it today with Dr. Mike Guyton, an Adolescent Medicine Specialist for PRISMA Health. This is Flourish, a podcast brought to you by PRISMA Health. I'm your host, Praskash Chandran. So Dr. Mike, thank you so much for joining us today. I truly appreciate your time. So we're talking about puberty, and I'd love to start with, when does puberty typically occur, and also the differences in occurrence for both boys and girls.

Mike Guyton, MD (Guest): Sure. So, puberty typically starts different for girls than it does for boys. For girls, they typically go through puberty earlier, or they start puberty earlier, roughly around the age of maybe nine or 10 years old. And for boys, they typically start their pubertal changes around 11 or 12. And you know, I tell my boy patients that they get lucky because when their bodies start changing with puberty, all those changes are kind of in places where people can't really see. However, the changes that we see for girls, usually start with breast development which are changes that can be seen, oftentimes and can lead to some challenge down the road.

Host: Now, you started to touch on this, but what are some of the signs that tell both boys and girls that they might be going through puberty?

Guest: Sure. So for girls, a lot of times people will think the first thing that happens with puberty is, is getting a menstrual cycle, right? But in fact, that's actually a late occurrence in puberty. The very first thing that happens for girls is breast bud development. Now prior to the secondary sex characteristics such as breast bud development, you will see a little bit of vertical growth. So height will change. The same thing happens with boys as well. But the first big noticeable change that we'll see are those breast buds. For boys, and actually the first thing that happens is their testicles begin to grow, which again, may not be incredibly noticeable, not only to, to the, the patient, but also to family.

Oftentimes for boys, we start saying, oh, we're about to go through puberty, when we start experiencing, again, that vertical height growth or if we start noticing other things such as body odor or, or increased occurrence of hair in certain parts of the body.

Host: Okay, and you were saying that for girls, the breast bud development happens first. When does the menstrual cycle usually happen?

Guest: On average, we see the menstrual cycle happen anywhere from about a year and a half to maybe two years after the breast bud development begins.

Host: Okay. Understood. And you know, typically, I know it's different for every person, how long does puberty last?

Guest: You're absolutely right. It is different for every person. Some people have a slightly longer puberty, some people have a slightly shorter puberty, but on average we say both for guys and girls, anywhere from three to five years.

Host: Okay. And before we move forward, I wanted to ask a fairly basic question. You know, most of us, I think, know the answer, but maybe this will help us explain it to our children. Why do we go through puberty?

Guest: Yeah, so if we want to get bare basics here as far as why this occurs, really it's so one day our bodies can participate in helping to repopulate the earth to, to undergo reproduction. That's the sole physical reason why our bodies do make this change from the child body to the adult body. Now, of course, there are many other things that puberty brings along with it other than just reproductive capability.

Our brains begin to change, where we can actually see the world in different ways. We can interact with the world in different ways. We start building more relationships through puberty that allow us to not only have personal growth, but also growth within our community. So gosh, there's so many ways to answer that question. Ithink it really depends on your perspective.

Host: Well, thank you for that. I think that was a very comprehensive answer and I will be using that when I speak to my children. I wanted to get back to the different, I guess, stages of puberty. I know that there are official stages. Is this something that you can speak to?

Guest: Yeah, sure. So, back in the day there was this doctor named Dr. Tanner. And I can't remember what specialty he was with, but he felt that it was really necessary for, for us as physicians to have a structured way to determine if kids are going through puberty the correct way, if there's any abnormalities, if there's anything we need to worry about.

So he actually created what we call Tanner stages. Now we're starting to use different terms now such as sexual maturity rating or SMR but many physicians will still use the term Tanner stages. When we talk about Tanner stages, they are stages that are from Tanner one to Tanner five. There's no Tanner zero and Tanner one are individuals who have not gone through puberty yet, so pre-pubertal. Tanner two is when puberty starts. So again, for girls, when breast buds develop, for boys, when testicles begin to grow, and then we see a progression through 2, 3, 4, all the way up to five, which means that the body is now the adult body. Now, there are inherent differences with each of those stages, whether we're going through puberty as a boy or puberty as a girl.

And there's even, even more complexity that we see when we're going through puberty as a girl. So, the vast majority of folks can understand the stages of puberty through Tanner stages one through Tanner stages five.

Host: Yes, absolutely. So I know that you mentioned that there is no Tanner Stage zero, but I have heard of the term early onset puberty. Can you talk a little bit about what this is and what causes it?

Guest: Sure, sure. So another term that we use for early onset puberty is precocious puberty, meaning that puberty is starting earlier than it should. And really what that means is that we're starting to see secondary sex characteristics. So again, breast bud development, pubic hair development, testicular growth, penile growth. We're seeing these changes earlier than they should happen. So we consider precocious puberty in boys to be if we see before the age of eight.

Host: Okay. And when there is early onset puberty or precocious puberty, is that a problem?

Guest: You know, in, in girls who go through precocious puberty, roughly 90% of those cases, so the vast, vast majority are what we call idiopathic, meaning there's not really anything big, bad, and scary that's causing it. It's just something that the body's doing. And in that case, we just need to identify what the goals are and ways to make sure that we keep their body, including their bones as healthy as we can, as their body continues to develop.

In boys it is a little bit different. There is a slightly increased risk that if boys go to puberty too early, it could be due to something that we need to investigate further, either with lab work or, or some of the diagnostic studies. But it is still possible that early puberty in boys could be that idiopathic cause nothing big, bad, and scary. Regardless, if you have your child and you feel like there are signs of puberty much earlier than there should be, that's a great time to talk to your doctor so we can help you figure it.

Host: Now, this might be a related question, but I've also heard of puberty blockers. Can you talk a little bit about what they are and why they're used?

Guest: Sure. Absolutely. So puberty blockers are a specific subset of medications that honestly have been used for an incredibly long time. The first thing I want to say about puberty blockers is these are safe medications. The primary reason we use puberty blockers is for one of those things we mentioned earlier that precocious puberty.

So if puberty starts too early, there's a chance that not only could it affect how tall an individual grows and what their final height will be so again, worrying about a final height being too small, it also can affect the way that their, their bones just develop themselves. And you can run into some, some bone density issues down the line.

And again, of course the social stigma, all those other things we talked about. So we may need to use a medication to actually stop puberty that is happening too early. And these medications typically are injectables that last anywhere from three to six months. There's even an implant, and this medication is incredibly safe.

We can use it down to five, six years old depending on when that precocious puberty started. What's also great about it is they're completely reversible, meaning that once we reach an age where puberty is ready to get started or should be starting to kind of catch up with our peers, we stop the medication and the puberty that was going to start before, it starts now, and it progresses as a typical fashion.

No effect on fertility, no effect on any future concerns. There are other, other ways puberty blockers are used which I'm happy to talk about through another cast. But I will say the primary use of puberty blockers is to block a puberty that started too early.

Host: Okay. So on the other side of that, I imagine there's something that is also considered late puberty. And I guess the question is, at what point should parents be concerned and reach out to their doctor when their child hasn't hit puberty yet?

Guest: Yeah. One thing I encourage as an adolescent doctor is anytime you have questions about how your kiddo is developing or, or whether or not things are moving forward the way they need to, or also if your kiddo's bothered about something as they're growing up, please never hesitate to reach out. There's no such thing as a wrong question.

We're here to help you with all of that. To be more specifically to your question, though, we consider puberty be delayed for girls if we're not really seeing any breast bud development by the age of about 13 or if we don't see menstruation by the age of about 16. So again, girl puberty is a little bit more complex than, than boys going through puberty.

So we look for both of those things. For boys, we really start to think about a concern of puberty being delayed if it hasn't, we haven't really seen any significant testicular enlargement until about, you know, or at least by 14 years old. You know, you can also say that if puberty hasn't completely finished by about five years, then we also need to maybe look into a few things to make sure there's not something interrupting the process.

Host: Okay. And so let's say that there is a delay. Are there any sorts of treatment that is available for these late bloomers?

Guest: Absolutely. So if, if we find that our patients are generally healthy, there's no signs of any, what we call systemic disease or disease that affects all parts of the body. So, for example, sometimes autoimmune conditions like Crohn's disease can lead to a delayed puberty, if we're not really seeing any sign of that; we just continue to watch them, make sure that they come to their doctor every year for a well visit. Make sure that we follow all the recommendations regarding screening for bone health and cholesterol health and, and just general social wellbeing. We just kind of watch them, right? If we identify one of those causes, then of course we would aim our treatment based at what needs to be done for that.

So for Crohn's disease, we would involve certain specialists for, for other conditions, we would, we would do the same.

Host: Okay, so I want to move on to a child's height. Especially during puberty, I know that sometimes there can be growth spurts. Is there actually a way to determine what your child's height is going to be and how it will be affected by puberty?

Guest: Yeah. Believe it or not, there is. So we actually have have something called a midparental height, and it's a, it's a calculation that we can use and there's no secret to it. You don't have to talk to a doctor specifically. You can actually Google midparental height and find it. Um, but easiest way to remember it is the first thing you do is you take the height of mom and the height of dad, so biological mom and biological dad, and then you take those two heights, divide them by two to get the average, and then for those who are male, if we have a, if we have a male patient, a male kiddo; we actually want to add five inches to that. And if we have a female patient, a female kiddo, we want to subtract five inches from that number. And what that'll give you is an estimate based on the genetics that promote height.

So, what mom and dad's height are, it'll give you an estimate of roughly how tall we can expect them to be. And again, it's not perfect, so you're not looking at something that's going to be exact. I definitely want to set that expectation. On average, two to three inches on either side of that number that you get is the range that we would see for this kiddo's expected height.

So for example, if your, your calculation gave you 67 inches, we're talking that this kiddo could be anywhere from about 65 inches to maybe 69.

Host: Wow, that is so cool that a formula like that exists. Another thing I wanted to talk about is, I've heard that hygiene is especially important during puberty. Can you speak to why that is?

Guest: Oh my gosh. Hands down. So as we talked about, even sometimes, even before the body changes of the breast changes and the testicular changes, we have other hormones at work, right? Kind of prepping the body to regulate, drastic transformations, right? So growth hormones at work and that helps out a little bit with some vertical growth.

But we also have some of our sex hormones, so testosterone, estrogen starting to flow and do their thing before we see the physical changes. So, what that can actually lead to is increased sweating, increased concerns around acne. It also leads to body odor. Body odor is one of those things that it's very interesting. Body odor, everyone's body odor is somewhat unique because it's how bacteria that we all have on our skin, the good bacteria that we have interacts with our own specific sweat glands that are stimulated during puberty. And so you're going to see body odor and sweat and all these things happen, and that makes our body just a little bit on the dirtier side, right?

So we've got to get all that extra sweat and all that extra oil off our body so it doesn't set up for any infections or skin irritation or things of that nature. So making sure that we bathe our body regularly. I generally recommend for my patients to take a bath at least every other day, if not every day. Making sure that we have good discussions with our kiddos around proper use of things like deodorant and especially when we start seeing more body hair. Proper conversations around shaving, which is a whole different podcast in itself. These are things that'll not only help keep our body healthy from potential infections, irritation, but it also help with the other part of puberty that can be a struggle, which is social perception. We really want to help our kids be perceived in a way that allows them to socially grow and feel accepted.

Host: So, I mean, related talking to our children about good hygiene can be difficult sometimes. Given all of your experience, do you feel like you have a good framework around how we can have that discussion effectively?

Guest: You know, I think one of the things that I pride myself on, and I think most Adolescent Medicine docs will, is that we, we like to make fun of ourselves. We like to joke around, we like to get our patients laughing, so we can get them engaged, right. So, sometimes I'll turn into a riddle, right? So, you know, gosh, when your body starts changing, how many soda cans of sweat do you think your body makes in a day with typical activity or with increased activity?

And, you know, turn into a little bit of a guessing game. And then when I tell them that actually it could be up to six cans, soda cans of sweat a day, depending on what you're doing, they go, oh my gosh, that's gross. Or, oh my gosh, I don't, I don't want that to be on me. And then it opens up a conversation, right?

Or I tell, actually a funny story. When I was going through puberty and I was trying to figure out deodorant, I'm like, I want my whole body to smell good, so I put deodorant all over and man, did that irritate my skin. And so that opens up a conversation of how we actually use deodorant and all these things.

And you can kind of start laughing at it where kids see that you know what, we've gone through the same thing too, and while we're going to help you with it, you know it's okay to not know how to do it.

Host: Now you mentioned shaving, and I know that that's like a whole separate podcast, but at a very high level, why is it important to have good hygiene around shaving?

Guest: Yeah. So number one, if we don't take care of the, the hair on our body, it can harbor bacteria, particularly if hair grows in such a thick way or on certain parts of our body where the hairs can kind of irritate the underlying skin. Sometimes you can get what's called ingrown hairs where the hair will kind of fold back in on itself and, and irritate the skin.

And you get, you get a little source of infection. We sometimes call it a folliculitis, right? So, being able to recognize how to care for certain hairs on the body can be incredibly helpful. So our body hair, for the most part, like on our arms and legs, that's relatively easy. If you take a bath, take a shower, you'll be able to clean that hair pretty, pretty easily because it's pretty wide spaced.

But the hair on our face, it's much, much closer and over time, if it continues to grow and, and there's not kind of kept up, whether it be by shaving or by other cleansing means, then you can actually get not only odor, from that area, but sometimes you can get different types of bacteria and fungus growing in that area.

So having a conversation, what shaving is, how to do shaving so it's safe where you can avoid extra cuts on your skin or also to make sure that you know, what parts of your body can be shaved and what parts of your body should be shaved in certain ways. It just really opens up a whole new dynamic where kids can not only get a sense of independence in their own hygiene, but they also can, again, add to that social perception any way they would like to.

Host: Yeah, totally makes sense to me. So, you know, one of the things that I mentioned up at the top is that, you know, puberty can be challenging time, obviously, emotionally and physically for kids as they're going through it. Maybe you can speak to some of the more common challenges that you see kids go through and how you help them through it.

Guest: Yeah. One thing I like to say is that any body, whether it's bodies that have already changed, or bodies that haven't changed yet, can be a source of teasing. And unfortunately, as much as we, we'd love to live in a world where everybody is completely supportive of all differences, that's not the world that we're in.

And teasing and bullying and conversations that honestly shouldn't be happening, happen in our schools. And I think the first challenge that we see is, kids learning how to take the changes that their body is doing that are beyond their control, and turn that into a way to interact with others in a very positive way.

Now most kids will be able to do that pretty easily cause they've been able to identify their friend group and, and they've been able to get that acceptance. But there are some who, who struggle with that and that's where we can fit in. Whereby explaining the changes and how we can not necessarily stop the changes per se, but more so help the changes progress in a very predictable fashion. It really gives them reassurance. And so I think that's the first challenge is the physical changes. I think the other thing too, we can't forget that the brain changes as well, during puberty. The brain grows, new connections are made, which lead to new emotions and emotions man, they can be, at the beginning, you could have a sad emotion. By lunch you might be angry, and by the end of the day you might be happier than anybody else. So within a 24-hour period, you can go through all the emotions. That's the brain changing during puberty. And we as parents and guardians and, and doctors, that's another part we really need to help our children with because they don't have a guidebook.

They, they need help identifying these emotions and learning how to recognize other people's emotions. So I think that behavioral aspect is a big part of it.

Host: So Dr. Mike, there's going to be a lot of parents listening to this with children that are going through puberty or that are about to go through puberty, and one question I always like to leave with is, you know, given all of your experience working with children, working with parents, what is one thing that you just know to be true that you want our audience to take with them today?

Guest: You know, I would say hang on. Everything is going to be okay. I like to tell my patients particularly that especially if they're in that awkward phase, their body's going to be building a masterpiece. And just like the Mona Lisa, it took several different brush strokes in many different ways to actually make the beautiful thing that we see, the Mona Lisa. Your body's the same way. Some of the brush strokes are not going to make sense. Some of them are going to seem like they don't go together, but the end of it, you're going to end up with something pretty darn amazing and really focusing to let the parents know our job during puberty is to build up our kids' self-esteem as much as possible.

Our job as parents is always going to be to love our kids and keep them safe, but particularly when their body starts changing, our job then transitions to also build up their self-esteem so we can prepare them for this world and everything it's going to bring their way and they can navigate it as successfully as possible.

And don't forget, us doctors, we're always here to go along for the ride and, and help you anytime you need it.

Host: Dr. Mike, I think that is the perfect place to end. Thank you so much for your time today.

Guest: Absolutely. I'm always available. And you know what, we love it. Adolescent Medicine docs, we're, we're a unique breed and we're so happy to involved in conversations like this.

Host: Yeah, that definitely comes through and we truly appreciate everything that you do for the community.

Guest: Thank you.

Prakash Chandran (Host): That was Dr. Mike Guyton, an Adolescent Medicine Specialist for PRISMA Health. For more information, you can visit our website at prismahealth.org

Prakash Chandran: And to listen to other podcasts just like this one, you can head over to prismahealth.org/flourish. This has been flourish, a podcast brought to you by Prisma health. My name's Prakash Chandran Thanks again and be well.