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Health concerns as girls reach puberty earlier than ever

For no clear reason any experts appear able to confirm, girls are starting to develop breasts as early as six or seven, with researchers now studying the role obesity, chemicals and stress might play in early puberty, saying this could result in later health issues, like certain cancers.

Marcia Herman-Giddens first realised something was changing in young girls in the late 1980s, while she was director for the child abuse team at Duke University Medical Centre in North Carolina, USA.

The New York Times reports that during evaluations of girls who had been abused, she realised many had started developing breasts when they were just six and seven-years-old.

“That did not seem right,” said Herman-Giddens, now an adjunct professor at the University of North Carolina Gillings School of Global Public Health. At the time, she wondered whether girls with early breast development were more likely to be sexually abused, but she could not find any data keeping track of puberty onset in girls in the US.

So she decided to collect it herself.

A decade later, she published a study of more than 17 000 girls who underwent physical examinations at paediatricians’ offices across the US. The numbers revealed that, on average, girls in the mid-1990s had started to develop breasts – typically the first sign of puberty – at around the age of 10, more than a year earlier than previously recorded.

The decline was even more striking in black girls, who had begun developing breasts, on average, at nine.

The medical community was shocked by the findings, and many were doubtful about a dramatic new trend spotted by an unknown physician assistant, Herman-Giddens recalled.

But the study turned out to be a watershed in the medical understanding of puberty. Studies since have confirmed, in dozens of countries, that the age of puberty in girls has dropped by about three months per decade since the 1970s.

A similar pattern, though less extreme, has been observed in boys.

Although it is difficult to tease apart cause and effect, earlier puberty may have harmful impacts, especially for girls. Girls who go through puberty early are at a higher risk of depression, anxiety, substance abuse and other psychological problems, compared with peers who hit puberty later.

Those who start menstruating earlier may also be at a higher risk of developing breast or uterine cancer in adulthood.

No one knows what risk factor – or more likely, what combination of factors – is driving the age decline or why there are stark race- and sex-based differences. Obesity seems to play a role, but cannot fully explain the change.

Researchers are also investigating other potential influences, including chemicals found in certain plastics and stress. And for unclear reasons, doctors worldwide have reported a rise in early puberty cases during the pandemic.

“We are seeing these marked changes in our children, and we don’t know how to prevent it,” said Dr Anders Juul, a paediatric endocrinologist at the University of Copenhagen who has published two studies on the phenomenon. “We don’t know the cause.”

Obesity

Around the time that Herman-Giddens published her landmark study, Juul’s research group examined breast development in a cohort of 1 100 girls in Copenhagen. Unlike the American children, the Danish group matched the pattern long described in medical textbooks: girls began developing breasts at an average age of 11-years-old.

“I was interviewed quite a lot about the US puberty boom, as we called it,” said Juul. “And I said, ‘it’s not happening in Denmark’.”

At the time, Juul suggested that the earlier onset of puberty in the US was probably tied to a rise in childhood obesity, which had not occurred in Denmark.

Obesity has been linked to earlier periods in girls since the 1970s. Numerous studies since have established that overweight or obese girls often start their periods earlier than do girls of average weights.

In 2021, British researchers found that leptin, a hormone released by fat cells that limits hunger, acted on a part of the brain that also regulated sexual development. Mice and people with certain genetic mutations in this region experienced later sexual development.

“I don’t think there’s much controversy that obesity is a major contributor to early puberty these days,” said Dr Natalie Shaw, a paediatric endocrinologist at the National Institute of Environmental Health Sciences who has studied the effects of obesity on puberty.

Still, she added, many girls who develop early are not overweight.

“Obesity can’t explain all of this,” she said. “It’s just happened too quickly.”

Chemicals

In the decade after the Herman-Giddens study, Juul began noticing an increase in the number of referrals for early puberty in Copenhagen, mostly of girls who were developing breasts at seven or eight-years-old.

“And then we thought, ‘Is this a real phenomenon?’” Juul said. Or, he wondered, had parents and doctors become “hysterical” because of the news coverage of Herman-Giddens’ study?

In a 2009 study of nearly 1 000 schoolgirls in Copenhagen, his team found that the average age of breast development had dropped by a year since his earlier study, to just under 10, with most girls ranging from seven to 12-years-old.

They were also getting their periods earlier, around age 13, about four months earlier than what he had reported before.

“That’s a very marked change in a very short period,” he said.

But, unlike US doctors, he did not think obesity was to blame: the body mass index of the Danish children in the 2009 cohort was no different than it had been in the 1990s.

Juul has become one of the most vocal proponents of an alternate theory: that chemical exposures are to blame. The girls with the earliest breast development in his 2009 study, he said, had the highest urine levels of phthalates – substances used to make plastics more durable, that are found in everything from vinyl flooring to food packaging.

Phthalates belong to a broader class of chemicals called “endocrine disrupters”, which can affect the behaviour of hormones and have become ubiquitous in the environment over the past several decades. But evidence that they are driving earlier puberty is murky.

In a recent review article, Juul and a team of researchers analysed hundreds of studies looking at endocrine disrupters and their effects on puberty. The methods of the studies varied widely; some were done in boys, others in girls, and they tested for many different chemicals at different ages of exposure.

In the end, the analysis included 23 studies that were similar enough to compare, but it was unable to show a clear association between any individual chemical and the age of puberty.

“The big takeaway is that there are few publications and a paucity of data to explore this question,” said Dr Russ Hauser, an environmental epidemiologist at the Harvard TH Chan School of Public Health and a co-author of the analysis.

That lack of data has led many scientists to be sceptical of the theory, said Hauser, who recently reported on how endocrine disrupters affect puberty in boys. “We don’t have enough data to build a strong case for a specific class of chemicals.”

Stress and lifestyle

Other factors may also be involved in earlier puberty, at least in girls. Sexual abuse in early childhood has been linked to earlier puberty onset. Causal arrows are difficult to draw, however.

Stress and trauma could prompt earlier development, or, as Herman-Giddens hypothesised decades ago, girls who physically develop earlier could be more vulnerable to abuse.

Girls whose mothers have a history of mood disorders also seem more likely to reach puberty early, as are girls who do not live with their biological fathers. Lifestyle factors, like a lack of physical activity, have also been linked to changes in pubertal timing.

And during the pandemic, paediatric endocrinologists worldwide noticed that referrals were increasing for earlier puberty in girls. A study last year showed that 328 girls were referred to five clinics across the US during a seven-month period in 2020, compared with 140 during the same period in 2019. (No difference was found in boys.)

Anecdotally, the same thing might be happening in India, Turkey and the United States.

Several factors are most likely contributing at once. And many of these issues disproportionately affect lower-income families, which may partly explain the racial differences in puberty onset in the US, the researchers said.

A new normal?

For decades, medical textbooks have defined the stages of puberty using the so-called Tanner Scale, which was based on close observations between 1949 and 1971 of about 700 girls and boys who had lived in an orphanage in England.

The scale defines normal puberty as starting at age eight or above for girls, and age nine or above for boys. If puberty begins younger than those cut-offs, doctors are supposed to screen the child for a rare hormonal disorder called central precocious puberty, which can spur puberty as early as infancy.

Children with this disorder often undergo brain scans and take prescribed puberty-blocking drugs to delay sexual development until an appropriate age.

But some experts argue that the age threshold for alarm should be lowered. Otherwise, they said, healthy children could be referred to specialists and undergo unnecessary medical procedures, which can be physically taxing and expensive.

“There are plenty more data that age eight is not the optimal cut-off for separating normal from abnormal,” Kaplowitz said.

In 1999, he argued that the age cut-off for normal puberty should be lowered to seven in white girls and six in black girls. “That did not go over too well,” he recalled.

That stance, though, was bolstered by a recent study from Juul’s group showing that, of 205 pubertal children under eight who underwent brain scans, just 1.8% of girls and 12.5% of boys had brain abnormalities indicating central precocious puberty.

But lowering the age cut-off remains controversial, with many paediatricians arguing that the risk of a disorder is still large enough to justify extra precautions.

Others, like Herman-Giddens, say that the changes are a sign of a legitimate public health problem and should not be accepted as normal.

“It might be normal in the sense of what the data are showing,” Herman-Giddens said, “but I don’t think it’s normal, for lack of a better word, for what nature intended.”

 

BMC Paediatrics article – The relation of menarcheal age to obesity in childhood and adulthood: the Bogalusa heart study (Open access)

 

Int Journal of Andrology article – Recent data on pubertal milestones in United States children: the secular trend toward earlier development (Open access)

 

Paediatrics article – Recent Decline in Age at Breast Development: The Copenhagen Puberty Study (Open access)

 

Nature article – Neuroimaging in 205 consecutive Children Diagnosed with Central Precocious Puberty in Denmark (Open access)

 

Characteristics of Puberty in a Population-Based Sample of Danish Adolescents (Open access)

 

The New York Times article – Puberty starts earlier than it used to. No one knows why (Restricted access)

 

See more from MedicalBrief archives:

 

Violence and trauma in childhood accelerate puberty

 

Adolescence ‘now lasts from ages 10-24’

 

Stress of sex abuse impact on girls’ physical growth and maturation

 

Early menstruation linked to sugar in drinks

 

 

 

 

 

 

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