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The question: My 14-year-old daughter hasn't gotten her period yet. How normal is this and should I be worried?

The answer: Although many girls have had their first period by the time they are 14, the lack of menses at this age does not necessarily mean there is a problem. The timing of pubertal changes can vary widely and this can be extremely stressful for teens who desperately want to look like their peers.

For girls, puberty can start as young as seven, with the "late bloomers" commencing their pubertal changes as late as 13. For boys the changes occur a little later, typically starting between the ages of nine and 15. Puberty usually proceeds in a fairly predictable pattern in girls, starting with breast enlargement, then the appearance of pubic hair, followed by a growth spurt and finally the onset of menstruation. Girls can expect to have their first period about two years after they start to develop breasts.

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For North American girls, the average age for starting puberty is 10 ½, with the average age of menarche (the first period) at 12 ½. Doctors don't usually get concerned unless a girl has had no breast development by the age of 13 or has failed to have her first period by the age of 16.

There are several reasons why a young woman may be later to develop than her peers.

  • Family matters: One of the best ways to predict what age a young girl will have her first period is to ask her mother how old she was when she started menstruating. More often than not, there is a close relative who was also a late bloomer. This is by far the most common reason for delayed puberty.
  • Malnutrition: Teens who fail to take in enough calories or who are missing key ingredients in their diet, can also be slow to develop. Eating disorders, restrictive diets, and strenuous exercise are potential considerations. This combination of factors is particularly prevalent in young female, high-performance athletes. Weight loss can also be caused by certain medications, particularly those used to treat attention deficit disorder.
  • Medical conditions: Teens with chronic health problems such as diabetes, bowel disorders, and even severe asthma can be slow to enter puberty. It is generally believed that the body is so preoccupied with the illness that there is little energy left to devote to producing the hormones necessary for puberty.
  • Hormones: Although rare, some children can have a medical condition that affects their pituitary gland or ovaries, the organs primarily responsible for hormone production in young girls. These disorders can be present since birth or they can develop at a later age. Almost always other symptoms are present, such as growth abnormalities.

Fortunately, a visit to your family doctor or pediatrician is usually all that is required to rule out an underlying medical or nutritional problem. Occasionally a blood test or X-ray may be recommended. Expect your physician to provide reassurance to your daughter that she is normal. Unfortunately what is usually needed most is patience, a quality not often found in abundance in teens.

Dr. Michael Dickinson is the head of pediatrics and chief of staff at the Miramichi Regional Hospital in New Brunswick. He's a staunch advocate for children's health in Atlantic Canada through his involvement with the Canadian Paediatric Society.

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