• Dr Andy Raffles

Puberty & Other Issues In The Teenage Years!

We will be providing an occasional series of articles on “The teenage Years” which strictly speaking is a prolonged period of transition from child to adult – adolescence - but which incorporates periods of rapid growth, development, and change challenge in physical, psychological and behavioural maturity.


This transition can be uneventful or challenging to the young person and can be an emotional assault course for all concerned. Adaptation to this period of change by parents, carers and their children during transition from child to adult involves so many levels of change that it is something of a miracle that any of us survive the process as a child or as a parent carer! One of the many reasons many of us find it so hard is because it is a time of rapid physical development and deep emotional changes.


In the first part of our series, we will look at some of the physical issue which challenge us all, as parents, carers, health providers and the young person themselves.


These problems may include:

  • Delayed Puberty – more common in boys than girls and usually genetically determined

  • Precocious Puberty (Early Puberty), when puberty starts in one way or another 2-3 years earlier then peers and siblings. This can be divided up into whether it is true puberty i.e. normal but early, or is disordered puberty where the physical changes happen in the wrong order and too early, which is much more concerning

  • Paediatric Contra-sexual Pubertal Development - a condition where a male or female child develops characteristics of the opposite gender – such as breast development in normal boys

  • Premature Thelarche (Early Breast Development), usually before age 10 years

  • Premature Adrenarche (Early Puberty Changes Due to Androgens), usually before age 10 years

Here’s a problem we frequently get asked about:


Abnormal Breast Growth in Boys & Girls


Both boys and girls have breast tissue. Normal breast development first appears shortly after birth, and then again at the beginning of puberty. The timing of breast development varies greatly from one person to another and in some girls may not occur until well into the teenage years.


Enlarged Breasts in Boys


This is called Gynaecomastia. It is the presence of enough breast tissue in a boy to appear like a breast mound is developing. Gynaecomastia can range from prominent breast bud tissue that does not go away to a feminized breast with a mound and rounded nipple. Half of all teenage boys will have tender, prominent tissue in the nipple area during puberty, particularly in the first 2-3 years of pubertal change. This is due to the simple fact that both boys and girls produce oestrogen, the hormone responsible for breast development, the amount diminishes in boys as testosterone levels rise. For the majority of boys this tissue will reduce in size over 2-3 years. If it does not, and the boy is otherwise healthy, consideration can be given to removing the tissue surgically. It does appear that boys with a higher BMI are more prone to this, presumably because a lot of oestrogen production occurs in the adipose (fat) tissues.


Sometime boys especially, but also less commonly girls, experience pain in the nipple which varies considerably during a typical day, and also quite marked variations in swelling during the day. This is quite normal during the first 2-3 years of puberty, and is often aggravated by exercise, but all that is needed is reassurance.


It is important to note that some substance abuse, including marijuana use, can aggravate the condition. It is not uncommon for teen boys with this abnormality to become self-conscious or bullied. Although breast growth in boys is often hereditary, parents should seek health advice to ensure there are no a hormonal or other causes, most of which are extremely rare.


Unusually Large Breasts in Girls


Macromastia is the word to describe girls' breasts that are disproportionately large compared to the rest of their body. Large breasts can cause a teen girl not only emotional distress but also physical distress. For example, large breasts can be associated with upper back pain, tingling in the arms, and skin irritation. Socially they can be burdensome as teenagers, and they can restrict athletic participation. Initially, management is with physical therapy, skin care, proper bra fitting, and pain medicine as needed.


Breast Reduction Surgeries


When breast size causes other problems or interferes with activities, surgery can be considered. Typically, this is two to three years after a girl's menstrual cycles have begun and after shoe size stops changing. Reduction mammoplasty surgeries should only be undertaken after counselling and support, and by expert surgical and nursing services.


Breast Asymmetry (different size or shape between the two sides)


Up to 25 percent of teenage girls will have breasts growing in an asymmetrical fashion, and many women reach full maturity with one breast that is larger than the other. Sometimes, this is because they are shaped differently and grow differently.


Other cases of asymmetry require consideration about how to balance the breasts. Balancing can be a combination of enlarging one side, reducing one side, or working on both sides. While parents or teens who are concerned should seek a medical evaluation, padded bras can often provide camouflage.


Absence of Breast Development


When a girl does not have breast tissue by the age of 13, her breast development is considered delayed. Although rare, the breast bud may be non-existent due to a chest wall deformity or failure of the underlying pectoralis muscle to develop properly. Girls with chronic illnesses like Crohn's disease, Turner syndrome, or an eating disorder may also fail to grow buds by the age of 13.


Breast Masses in Children and Teenagers


Because of heightened awareness of breast cancer, any lump in a child often creates a great deal of anxiety. Breast cancer is extremely rare before the age of 20; less than 0.1% of all breast cancer occurs in children or teens. Ultrasound studies can help determine whether a lump is a cyst that can be drained or a fibroadenoma.


If your child has a breast mass, talk to your child's doctor. He or she can refer you to a paediatric specialist or paediatric plastic surgeon who specializes in caring for growth problems in breast tissue. Breast operations on young girls should be carefully undertaken because of the risk of adverse effects upon future breast development.


All girls should be taught breast self-examination once their breasts are developing and they are going through their menstrual cycles. This should be the beginning of a lifelong habit.


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