What is a Bone Age?

Bone age is helpful in assessing a child who is shorter or taller than predicted based on parent heights or if a child has early or late pubertal changes. It is simply an x-ray of the child's hand and wrist. It involves minimal radiation and does not hurt. The bone age can help us approximate how much longer a child will grow and the expected height, but does not tell us why a child is shorter or taller than expected or hitting puberty at an unexpected age.

A delayed bone age means that the bones think they are younger than the child actually is. This can mean catch up growth after peers have stopped growing. A delayed bone age can happen for many reasons, but a common one is due to late puberty and can run in families. A history, physical exam and possibly labs can help asses the reason for delayed bone age.

If a child has an advanced bone age it means the bones appear older than the child's actual age. With this we expect them to stop growing earlier than most kids. This means that even if they are tall for their age, they could end up shorter than average. This is often associated with early puberty and childhood obesity. An advanced bone age needs further evaluation to identify the cause.

If the bone age equals the actual age, you can estimate the final height to be about the same percentage as the current height.

We often repeat bone ages to see if they are changing at a different rate than the child grows.

Radiologists and endocrinologists use books with x-rays of standard bones of various age groups to assess which age the child's x-ray most closely resembles. Since there are different bones that can develop at different rates, it is possible that two doctors will assign a different bone age. It is not an exact science, but can give a good estimate of how much longer a child may grow. 

The photo above is from Amazon's bookstore. You can see how the bones of the youngest hand on the left are very different from those in the hand on the right. The radiologist or endocrinologist finds the image that is most like the child's x-ray and call it that bone age. 

In the boy growth charts pictured below, the top set of lines is the height (stature) for age chart. The bottom set is the weight chart. The ages that are used to plot a height at a given time are listed at the top and bottom. The heights are listed on the right and left of the graph. The middle line is 50%, which reflects a height of 50% (taller than half/shorter than half of boys of the same age). The other lines are also labeled for their respective height percentiles on the far right. Hopefully this looks familiar because you've seen a graph like this at your child's doctor. If you haven't, be sure to ask to see it next time you're there.

There are many "normal" heights, usually determined by genetics. Tall parents tend to have tall kids, short parents have short kids. There is no "correct" height or "best" height, the percentiles simply give us a way to follow the growth over time and estimate final adult height if a child hits puberty at a typical age (early puberty stops the growth early, late puberty allows for later growth).

In Figure 1, I filled in a fictitious child's heights with blue dots. You can see that from 3 to 5 years this boy was at the 50th percentile for height. That means he was taller than half the boys his age and shorter than half. The fact that he's in the middle doesn't make it "normal" it just means that if his parents are average height, he is growing as expected because it's consistent year to year and he is of average height like his parents. At 6 years, he dropped to the 25th percentile, and at 8 years he fell to the 10th percentile. This consistent drop in growth often triggers a physician to look for reasons of the drop. Maybe the parents are both very short. Maybe there is a medical problem. Or maybe there is a family history of people having late growth spurts (something called "constitutional growth delay"). Treatment (if needed) varies depending on the cause.

Figure 1

The red arrow on the right marks the actual height at 8 years (blue) at about 47 inches (120cm). For this fictitious child, the bone age is 7 years, and if you plot 47 inches (the actual height at the time) at 7 years (the bone age), you will see this white dot is at the 50th percentile and marked by the red arrow on the left. A delay in bone age often coincides with a late growth spurt. I finished out the growth plots, and this kiddo actually fell more (down to the 5th percentile) before he hit a late puberty and grew into late teens/early 20s to hit a final height at the 50th percentile.

In Figure 2 below a fictitious boy is tall for his age early on. At 6 years old his height (black dot) is at the 97th percentile (he is taller than 97 out of 100 of boys his age) at about 49.5 inches (125.5cm). His bone age at the time (red dot) is 8 years 6 months, which is at the 25th percentile for height. A year later he is off the height chart, taller than over 97% of boys his age, but the bone age is 10 years 9 months, again at the 25th percentile. This chart shows an early growth spurt (as he looks taller than his peers) but an early puberty and a slowed growth faster than other boys. His final height is only at the 25th percentile, much shorter than his early heights would have predicted.

Many parents are super excited when their children are tall and can't comprehend when I talk about the possibility that it might not last. (I typically discuss this if both parents are short but the child is tall, if I see signs of early puberty, or if the child is obese - especially if parents are not as tall as the child's height predicts.) The bone age does not give a reason for the altered growth rate, but can help identify a need for further evaluation and treatment if indicated.

Figure 2

Bone age is difficult to understand, and I hope this helps parents understand with some pictures. I completely made up these growth charts. They do not reflect any real patient or any real diagnosis. They are solely to illustrate how we estimate the bone age on the growth chart to help assess final predicted height. The reasons behind altered growth patterns are many and might require further evaluation.

Take home point: At every well visit your child should have a height and weight measured. If the yearly growth accelerates too fast or slows, talk to your doctor about possible reasons. If a bone age is done, you can use a growth chart to put the bone age in at your child's height (instead of actual age) and see how tall the final height estimate would be. It isn't a guarantee, but can be helpful.

When should my child shave?

In my last blog I discussed the common question about when it is appropriate to start using deodorant or antiperspirants, which led me to think of all those questions beginning, "When is my child old enough..."

Photo source: Wikimedia

One of these questions: When is my child old enough to shave?

This is another question without a one-size fits all answer.

Girls and boys differ in needs and ages of puberty.

I told my own daughter that she could shave her legs when she needed to shave under her arms, since I know that under arm hair becomes longer during puberty, which is also when leg hairs thicken and grow. This just seemed like an easy answer to me. We are born with hairs on our legs, so deciding when those hairs are too long is tricky. It's not of a question of age, but one of quantity, color, and thickness of hairs.

When a boy starts to get visible peach fuzz on his upper lip it may be time to consider shaving, but it depends on the hair color, length, and his desires. Some schools include a "no facial hair" policy, which forces the issue.

Some kids are naturally hairier than others. Some have dark hair, others light hair. Puberty increases hair growth on the arms, legs, armpit, and in the groin in both sexes, and on the face in boys, but the age of puberty varies widely. Culture plays a part in the family's decision whether or not to shave body hairs.

The maturity of a child should be considered. A girl with thick, dark hair entering puberty at 9 years of age who is getting teased at school about her hairy legs might have a strong desire to shave, but if her fine motor skills are weak and she cannot safely handle a razor, it might not be appropriate for her to shave yet - at least not with a standard razor.

If a child has body hair that is bothersome and they want it removed but they are not able to safely use a standard razor, options might include other forms of hair removal, such as the chemical hair removal products, waxing, electric razors, or allowing a parent to help them shave. Each of these has it's own issues to consider.

Chemical hair removal products generally work by weakening the hair so that it is easily broken off at the skin level. Chemical products might lead to skin irritation or allergic reaction, but are well tolerated by most people. If you are planning to use it on the face, be sure to get a product specifically for the face and test a small area first to be sure they don't react to it negatively. Chemical hair removal products are relatively easy to use, can be done at home, and last for several days. Young children should be supervised so that the chemical does not get on other body parts or all over the bathroom...

Waxing is an option for many girls and women. It can also be used for boys and men, though is less commonly used by men. It's benefits are that it lasts several days and over time might cause the hair to grow in thinner (or not at all- which might not be a great idea for a boy who one day might want a beard). It can be painful, which might not be tolerable for some kids. You can go to a salon for a professional wax, but this is more expensive than the many do-it-yourself kits you can buy at local stores. You can look online for tips on how to find the best waxing product for your needs and how to wax.

Electric razors offer the benefit of a safer cut, but can take more time and often don't get as close to the skin as a standard razor. If your child is using an electric razor, (s)he must be warned about the hazards of using something electric next to a water source (such as the sink or tub). There are many types available, and I would recommend searching for reviews online prior to purchasing. Follow package directions on keeping the razor clean.

If you allow your child to shave with a razor be sure to get a new one just for that child. Never share razors, since this can lead to sharing of germs that cause infection. The choice of using a shaving gel or cream or just shower soap is a personal choice. Also talk about when to change the razor blade. It depends on how often (s)he shaves, how large of an area being shaved, and the body hair type. Someone with thick, coarse and curly hair that grows super fast will need more frequent blade changes than someone who is shaving fine peach-fuzz hair off every few days. Any blade that’s rusted must be changed immediately. When a blade feels like it’s tugging on the hair instead of gliding smoothly, it is time to change. If you’re using an older blade and notice nicks or rashes or razor-burn bumps, it's past time to change it. After each use a razor should be rinsed clean of all hairs and soaps/creams and allowed to dry. Don't lay it in a soap dish because it will stay wet. Wetness allows germs to grow and encourages rust, both of which are dangerous.

If you would be most comfortable shaving your child's skin, you can certainly try this with his or her permission. Be careful though, because if you nick the skin, you will never be forgiven! Kids are like that...

When it comes down to when it is the best time to shave, I think it is a very personal decision.

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When should my child start wearing deodorant?

I get asked all the time when kids should start wearing deodorant or antiperspirant.

There's no standard answer since kids have different needs. Some kids are active outside and simply carry the smells of the great outdoors and sweat on their body. This isn't puberty sweat, just musty body odor in most young smelly children. Sweat in general makes conditions ripe for bacteria to grow on our skin, and the bacteria make us smell. Kids enter puberty at different ages, and puberty affects how we smell in addition to many other obvious things because sweat glands become more active.

Image source: Wikimedia

First things first: get clean!

Body odor is often related to bathing, since some early elementary school aged kids shower independently, but don't do the best job at actually using soap in all the areas it's needed. Or they argue about needing to get clean daily. Every other day might work in the winter (if they don't sweat a lot with play) but in the summer, they really need a daily cleansing if they smell offensively.

The first step I always recommend is making sure kids who have that funky smell shower (or take a bath) daily with the same soap that the parents use, not a baby wash. Many families buy baby washes for the first year of life and keep using them during toddlerhood and childhood out of habit. Baby washes don't lather up well (which leads to less body surface areas getting lathered up) and aren't designed to get the oils, dirts, and smells off like regular soaps. There really is no need to continue to use these washes for kids beyond infancy and it might contribute to body odors.

Talk to your kids about getting soap suds on all body parts. I think using a shower pouf with a body wash makes it fun for kids to see all the bubbles - and it helps them to see what parts are done and which need suds. If your child likes to play in the bath tub, it might help for them to end with a quick wash and/or rinse in the shower, since they are sitting in the dirty water during the bath. It is hard to wash the submerged body parts with soap, since the cloth or pouf rinses out under water. They will need to stand to wash the lower half of their body properly.

A note about the poufs: Be sure to show your kids how to rinse the bubbles out of the pouf after the shower or bath and hang it to dry between uses. You'll also want to wash the poufs weekly. I sometimes throw them into the washing machine with the towels, but that takes the life out of them more quickly than soaking in vinegar and water.

Go over all the body parts to wash. I looked for a video that they could sing along to (there are a lot for washing hands and brushing teeth), but couldn't find a good one to remind kids of all the body parts. If anyone's musically talented, this would be a great project to help many kids (and parents)! If you find a good video, please share the link in the comments below!

• Hair - It is tricky for kids to massage all parts of their scalp when washing hair, so show them to use their fingertips up and down then side to side to cover all parts of the head. The frequency of how often hair needs to be washed can be debated. Hair can trap pollen and other outdoor smells and the scalp's sweat can lead to funky odor, so hair needs to be washed at least a couple days per week and daily for those with allergies to pollens that are in the environment at that time.
• Face - Kids won't want to get soap in their eyes so many parents just have them rinse with water, but many kids need to actually wash with a mild soap or cleanser. Eyelids can get what my parents used to call "sleep dust" - little crusties - if they are never washed. You can use a baby "no tears" shampoo to wash eyelashes if needed or a mild soap or cleanser with closed lids and careful rinsing. When kids start getting oily skin on the face they should wash it twice a day. A quick reminder not directly related to cleaning: A daily moisturizer with sunscreen is great all year long for our faces, which are exposed to the sun and elements every day.
• Armpits - While it seems obvious when you've talked to your kids about having smelly pits, you'd be surprised that it doesn't always equate to kids being conscious of washing those pits. With soap. Kids just don't make the connections you think are obvious. 
• The whole back - It is hard for any of us to wash our own back, so show your kids how to use a back scrubber or wash cloth to reach all areas.  
• Belly, arms, and legs - Again, have them look to see where the suds are and where they're missing to hit all the areas.
• The bottoms of the feet - Show kids how to hold on to something when washing their feet and consider adding a non-slip surface to your shower or tub. Have them wash one at a time so they can stand on the non-soapy foot. Soapy feet are slick!
• Between the legs - Kids need to be taught to wash between the buttocks and around their genitals, with special care given to rinsing these areas well. Trapped soaps can irritate the skin and cause rashes, so rinsing should get special attention in these sensitive areas. I really like removable shower heads that can come down to help rinse, but kids can also use several cups of clean water to rinse hard to reach areas. Girls might need to sit in the tub to do this rinsing with a cup because it's hard to splash the water up between skin folds sufficiently.

Clothing 

Kids might have a favorite shirt that they want to wear every day, but clothing (especially shirts, socks, and underwear) must be washed regularly. Putting stinky clothes on a clean kid just makes the kid stinky. Avoid polyester (except the special polyester in performance wear- designed to wick sweat away) and rayon clothes, since they do not absorb the sweat well. Cotton is a great choice: it absorbs sweat well and is relatively inexpensive. 

If kids have sweaty feet, white socks might be better than colored ones due to the coloring irritating the feet. Changing socks when the feet get sweaty, such as after playing a sport, can help. Changing shoes and allowing each pair to dry thoroughly between wears can help too.

Deodorant vs Anti-perspirant?

Deodorant is used to cover up smells. It is often what I recommend for those younger kids who sweat during active play or outside in the heat. 

Anti-perspirant is designed to decrease sweating and often is mixed with a deodorant. Before puberty a deodorant is probably sufficient, but during puberty our sweat glands are activated and we sweat a lot more, especially under the arms, on hands and feet, and in the groin. It is personal choice if one wants to decrease underarm sweating with an antiperspirant. 

Over the years I have seen many concerns with the aluminum in antiperspirants - everything from it causes Alzheimer's to it causes cancer. Studies do not support those claims. You can read more about the proposed risks of antiperspirants on WebMD.

When is sweating abnormal?

Sweating is abnormal if it is excessive for the body's needs or if a child has other signs of puberty before the normal ages (8 years in girls, 10 years in boys- some sources say 7 years in girls and 9 years in boys). 

There are many reasons for excessive sweat that are relatively uncommon, so I won't go into detail here. If you think your child sweats excessively or is entering puberty too early, please take him or her to their doctor to be evaluated. (A phone call isn't sufficient because they will need to look for associated signs and symptoms on an exam.)

Next up...

I will cover "When should my child shave?" next, since it is also a very common question!

First Period Q&A with a Tween

Over the years I've talked with many girls about what to expect during puberty. Some of the biggest questions we all have involve the mysterious first period. I have dug into the recesses of my brain to come up with all the questions asked over the years to put all the information down in one place, though I'm sure I've missed a few. (Note: I'm not going to cover the hormones and technicalities of the menstrual cycle. See the links below if you want to review those.)

If you have a daughter starting puberty, please share. Are there any other questions she has? Put them in the comments section and we'll tackle them!

Is there a good way to know when I'll start my period the first time?

You will never know exactly when your period will start, but good clues that it is getting close to time: 

• It's been about 2 years since your breasts started growing. (Remember those first bumps?)

• There's clear, white, or yellow stuff in your underwear sometimes. It can look like dried boogers or just a little crusty stuff in your underwear, but it's not from being unclean or peeing in your pants. Your body is just getting ready for the full cycle of ovulation (when the egg is released) and the period. Your vagina is moistened with a clear fluid that can drain onto your underwear. Another thing you might notice is mucus is released once a month, about half way between your periods when the egg is released from your ovary once you're on a regular monthly cycle. It often begins before the period starts. As long as there is no pain or funny odor, this discharge is normal. Talk to your doctor if it does smell bad or if you hurt or itch in that area.

• Pimples. Pimples are common with puberty (and for years following).  Many girls will notice that the pimples tend to worsen right before their period starts.

I'm too young for a period. None of my friends even have boobs! Can I stop it?

Puberty has such a wide range of normal ages so it is common for one girl to go things much sooner than her friends. Puberty is most common between 9 and 16 years of age (though some girls notice breast buds as early as 7 or 8 years old). The common age for a period to start is between 10-15 years old. If you are outside of this normal age range, talk to your doctor about it because there are many reasons. Some can be as simple as your family tree (when did your mom or sisters start?) but some can be a medical issue that can and should be treated.

And the opposite issue:  All my friends have had their periods for a long time, but I barely have boobs. When will I start?

Again, there is a wide range of normal (see the question above). Some families have a later puberty than others, so it might just be in your genes. There are other reasons that deserve talking with your doctor about, such as being underweight-- which delays puberty, and other medical issues that need an investigation to uncover a cause that might need to be treated. (That sounds like a mystery book, but your doctor will know what to do!)

Bottom line for early or late puberty: 

If you are outside the normal age range, please talk with your doctor. Don't be embarrassed to bring it up! They might either reassure you that things are still okay, or they might help find the reason and get your body the treatment it needs. Some of these can be serious problems, so don't be shy about going to the doctor. This is one reason that a yearly physical exam is especially important until growth is complete -- your doctor can help keep track of a normal growth progression.

How much blood will there be, and what does it feel like?

The amount of bleeding varies from day to day, month to month, and person to person.  It is common for the first 2 years to have irregular cycles, but many girls can begin to predict their blood flow volume pattern after a few cycles. 

Many girls have some pain during their period. The blood flow does not hurt, but as the uterus contracts it can cramp. Like other muscle cramps, there can be pain from period cramps, but the amount of pain varies in different people. Some girls have cramping with every period while others never feel anything. It is easy to take over-the-counter pain relievers (like ibuprofen or naproxen) to relieve pain. Some girls find it helpful to take ibuprofen or naproxen 2-3 times/day (per package directions) starting 3 days before the period is supposed to start to prevent the cramps. Eating healthy foods, getting regular exercise, and sleeping well every night also seem to help. For severe period cramps that keep you from doing what you want (or need) to do, talk to your doctor.

What do I do if I start my first period and I don't have any pads around or I'm not at home?

First, don't panic! Remember that ALL women have periods, so it is nothing weird to adult women (or men, for that matter, since they live in a world with women). Ask a teacher, school nurse, friend's mom, aunt, or whoever is around for help. She will not judge you or get freaked out. Really. 

How long should I wear a pad or tampon?

Pads should be changed if they are visibly full or after 4 hours, whichever is first. (Except overnight.) If left on longer, they start to have a foul odor, and you don't want that!

Tampons should be changed every 2-6 hours, depending on the amount of blood flow you have that day. Tampons come in different sizes for light days, regular days, and heavy days. Don't ever wear a tampon longer than 6 hours because it can allow germs to grow and cause a serious infection. For that reason I don't recommend wearing them overnight.

Once your cycle becomes more regular, you should be able to predict the flow by the day of the period (and time of day, since that often varies too). Use a calendar to track the amount of flow as well as the days of your period until you get it all straight. Either an old fashioned paper calendar or an app designed to track periods can help. (Search for "period calendar" or "menstrual calendar" in your app store if you have a smart phone or tablet.)

What do I do with the pad or tampon after it's been used?

Most pads are disposable. You can roll it up, wrap it in a little toilet paper (or the wrap it originally came in) and throw it in the trash can. (Use a single layer, ladies! Don't be wasteful with a wad of TP!)

If you use re-usable pads, they will have to be washed before the next use. Talk to your parent about where to keep them between uses. 

Many people flush tampons down the toilet, but that can lead to clogged toilets in many sewage systems. Never flush into a toilet that uses a septic tank. Tampons do not break up like toilet paper does and they will clog a septic tank system. If you aren't sure, you can wrap it in toilet paper and throw it in the trashcan.

Never flush a plastic applicator. You can either put it back in the wrapper or wrap in toilet paper and throw it in the trash.

I leaked! Not only am I totally embarrassed that everyone will know, what do I do to clean up my underwear?

When a period first starts, it often comes without warning and underwear can get soiled. Heavy flow days can also cause leakage onto your underwear. If you expect a heavy flow day, you can wear old underwear, prepare with a product designed for heavier flow, and go to the bathroom more often to change the pad or tampon. 

Despite the best techniques, all women sometimes soil their underwear and even their outer clothes. If you can change right away, fresh blood is easier to clean than dried blood. (This goes for just about any spill in the kitchen too, so clean up as soon as you spill!)

If you're at school, go to the nurse's office. She can help and it probably won't be the first time a girl has come to her for help-- really! If you're at a friend's house, see if she has something you can borrow if you don't have an emergency change of clothes. 

In general, cold water to rinse out blood is better than hot. Because blood is made of proteins that change in heat, the heat can "cook" the blood into the clothing and make the stain permanent.  If you have laundry detergent you can put a few drops on the stain and rub it in. If you have a spray or stick stain remover, you can use that. Allow that to soak overnight in some cold water before putting in the regular laundry. 

Basic tips:

• Carry a clean set of underwear (and pants if needed) in a plastic bag to use in case of emergency.

• Carry a stain stick (they sell these near the laundry detergent) if desired. 

• Rinse in cold water as soon as you can.

• Rub stain remover or laundry detergent into the stain and let it soak. Put it in the plastic bag you carry if you aren't home.  

• As soon as you get home put the soiled clothes in cold water (rub in more stain remover or laundry detergent as needed). Allow clothing to soak overnight. 

• After soaking overnight, rinse in cold water. Repeat a scrub and soak in detergent if needed.

• Once you don't see the stain any more, you can wash with the rest of your clothes like normal. 

What about when a pad won't work, like swimming or ballet? Am I too young for a tampon?

Tampons frighten a lot of girls, but they are safe to use as soon as you are comfortable using them. They do not affect your virginity. They simply are a product that will collect the blood inside you so you don't need to wear a pad on the outside. Many girls use one with their first period. Others don't use them at all. It is up to you! 

How exactly do you get the tampon in? 

First, some general anatomy. You need to know what things look like down there. You can use a hand held mirror to look at yourself and compare to this picture. This is a drawing, so you will look a little different, but you should be able to see the basic parts.

Photo source: Shutterstock

Tampons are inserted directly into the vagina. Much like an absorbent sponge, a tampon will gently swell as it becomes soaked with blood. A string allows for easy removal from the body. Tampons are convenient for swimming or exercising and can be paired with a panty liner - a type of thin pad or a regular pad for extra protection on heavy flow days. When using tampons, women should change them every 4-6 hours.  

It's time to change the tampon, but I can't find the string. Did it get lost up there somewhere? 

First: Don't panic! Your tampon is not lost forever! Sometimes the string can stick to the skin between your labia (labeled labium magus and minus above). You might need to feel around a bit. If there's a mirror nearby, you can use it to look. Sometimes going pee can help the string fall down if it is stuck around the skin somewhere. 

If the string really is up in the vagina, you can put your finger into the vagina to see if you can slip the string back out.

If you can't get the tampon out, tell an adult as soon as possible. If they can't help you get it out (or if you don't want them to try) you might have to go to the doctor to have it removed.  

NEVER forget about a tampon that has been put in... you could get a serious infection if you leave one in too long. 

I seem to always get spotting on my underwear when I wear a tampon, but the tampon isn't full of blood yet. Why is that?

There are several reasons I can think of that blood can get on your underwear. The first, of course is the tampon overflows because it was left in too long for the amount of flow you have at that time. But you can tell that when there is no more white showing on the tampon. If it isn't full, there are other reasons to consider.

First, was the blood on your skin when you put the tampon in? If you wipe after putting the tampon in, that can help this issue. Actually, more than wiping, pushing the toilet paper  (TP) up towards where the tampon is (with the string out of the way) can show if there's blood in the area. Repeat until the TP is clean. You can also wipe the folds of skin with a flushable wet wipe (sold near the other feminine hygiene products or near the diaper wipes -- same concept: wiping with a wet cloth works better than dry TP for many issues).

Another cause would be if the tampon is not inserted properly. Be sure it is completely in. Signs that it isn't in also include being able to feel it when you walk or sit. If it is in all the way, you should never feel it.

Did you pee or poop with the tampon in? This can move the tampon enough to let blood leak around it. Try changing the tampon (and wipe after placing it) each time you go to the bathroom.

Why do I need to pee so much when I'm on my period?

Many women gain water weight just before their period. (Have you heard women complaining of bloating? That's the water.) Your body's hormone changes cause this slow gain, and they also cause the release of the excess water back out of your body (called diruresis). This increases urine production. Look at it in a positive light: you have to go to the bathroom often, so it reminds you to change your pad or tampon frequently!

Can you pee or poop with a tampon in?

Short answer: Yes. But if you do, it is possible to have the tampon shift and cause leakage, especially if you have a bowel movement (poop). If it is too soon to change the tampon and you need to go, you can hold the string to the side so it doesn't get as soiled while you go. Wipe carefully so you don't pull on the string-- you can keep holding it to the side while you wipe too for "safe keeping."

My school uniform doesn't have pockets. How can I carry a pad or tampon to the bathroom?

If your uniform is a skirt, you can wear shorts with a pocket underneath. Some girls will be able to wear a tampon with a pad so that when they remove the pad mid-day, they leave the un-soiled pad on for the afternoon. If you're allowed to carry a purse, carry one every day for unexpected first period days and to get in the habit of always having it. You can also talk with your school nurse or a teacher about what other girls do.

I track my periods on a calendar, but there doesn't seem to be any pattern. Why aren't they once a month like they should be?

Once a month is more of a phrase than a reality. A typical cycle is about 21 - 35 days from start to start. Bleeding can be as little as 2 days and up to 7 days. The first 2 years after starting a period, many girls are irregular. After those 2 years, it becomes more predictable. You might be different than your friend, but your cycle should be about the same each month after the first 2 years. It does help if you track your cycles on a calendar or online app. 

My bleeding seems so heavy. I soak a pad within an hour and there are sometimes clumps in the blood. What is that?

If you are having very heavy bleeding, talk to your doctor because you can be at risk for anemia (too low of blood counts from blood loss). This can sometimes simply be your body adjusting to a period, but it can also be from a treatable condition. Your doctor can help you decide what needs to be done.

How long will the bleeding last?

The amount of bleeding and how long it lasts varies from person to person. Some days there will be barely any blood (called spotting because it looks like just a spot of blood). Other days are heavier. Bleeding can last between 2-7 days normally. Again, charting it on a calendar or app can help you figure out your pattern.

How do I keep from getting stinky?

First, be sure to regularly change your tampon or pad. If it goes without being changed, bacteria start to make a very foul odor. You should change pads or tampons at least every 6 hours (except overnight, when the pad can be left on as long as you sleep). This is important to avoid infections as well as bad smells!

You can use flushable wet wipes instead of toilet paper to help clean the area better. If you need them outside of your home you can carry some in a plastic zip lock bag and keep with your pads or tampons.

There are feminine hygiene products with deodorant available, but who wants to smell flowery? Seriously, I don't recommend these because too many girls have an allergic reaction to them and who wants to have an itchy rash in the place you can't publicly scratch?  

Another thing that's important: Wash! Once you go through puberty, your body in general smells more, so it is important to bathe regularly. Don't forget to do a daily wash of all the skin folds between your legs. You can use any soap (avoid fragrances if your skin is sensitive), but be sure to rinse well! Soap that remains between the folds can cause rashes. You can rinse the area by splashing a cup of clean water between your legs a few times. If you have a hand-held shower head available, that makes it easy to rinse the area well. You can also lift a leg so the shower water can rinse between your legs -- but hold on so you don't fall!

Do I need to wear protection between periods?

You might want to wear a panty liner when it is getting close to your next period, just in case you start, but it's not necessary.

How do I know when the next one will be?

Over time it becomes easier to predict. Keep track of the dates of bleeding as well as how heavy it is and any other symptoms. These can include pimples, cramping, mood swings, tiredness, constipation or diarrhea, back pain, sore breasts, bloating, food cravings, or headaches. All of these symptoms can help predict your cycle. There are several apps available on the computer, smart phones, or tablets, many of which are free. I suggest going to your app store and reading reviews to pick your favorite.

How much more will I grow since I started my period?

Growth speeds during the years before your period, then slows after your period. Some girls stop growing all together, but most still grow for the next 1-2 years. Ask adult family members how they grew (if they remember) because growth patterns tend to follow parents and other family members.

What is PMS?

Common effects of PMS include: bloating, cramps, fatigue, moodiness, headaches, or pimples. There are over-the-counter medications that can ease these symptoms. Ibuprofen or naproxen tend to work well. If you have severe cramping and you are expecting your period, you can start the ibuprofen or naproxen three days before your symptoms start. This decreases the pain better than starting the medicine when the cramps start. Some girls prefer wearing loose clothing or using warm compresses on their stomach. Mothers can share with their daughters their own tricks for coping.

My boobs hurt with my periods. Why is that?

Many girls notice breast tenderness during PMS (Pre Menstrual Syndrome). Your hormones are changing at this time and they can cause the breasts to swell. The swelling causes tenderness. You can help minimize this by eating right, exercising, and getting enough sleep (all month long). Caffeine can worsen it, so avoid things with caffeine.

Where can I get more information?

ThePeriodBlog has a lot of great information, including how to insert a tampon, information about your body,  counting your cycle, and more.

My favorite book for girls about puberty is now a series of books. The Care and Keeping of You and The Care and Keeping of You 2 are available from many retailers. I like that they go over everything from staying clean to eating right to the importance of sleep and more.

I rarely hear questions about the hormones or technicalities of puberty, but for more on the menstrual cycle check out All About Menstruation by TeensHealth. (They also include more related topics links at the bottom.)

A good review of puberty, including how it is staged is found on Young Women's Health (Boston's Children's Hospital).

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