Talking to Your Kids About Puberty and Periods

Dr. Richard So:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, let's talk little health.

Do you secretly worry about having the period talk with your child or feel stressed trying to figure out if their cramps are normal discomfort or a sign of something that needs to be checked out? I'm Dr. Richard So, a pediatrician at Cleveland Clinic Children's. And then on this special episode of Little Health, we're talking about how to start the period conversation, recognizing pain that needs a doctor's visit, and understanding all the different product choices available. We'll share ways to reduce your child's anxiety and ensure they feel prepared and supported every month.

My guest today is Dr. Erin Isaacson, a pediatric and adolescent gynecologist at Cleveland Clinic Children's, which makes her the perfect person to discuss this topic. Welcome to Little Health, Dr. Isaacson.

Dr. Erin Isaacson:

Thank you so much for having me.

Dr. Richard So:

Tell us about yourself and what you do.

Dr. Erin Isaacson:

Yeah.

Dr. Richard So:

It's such a, it's such a, a good subspecialty.

Dr. Erin Isaacson:

Yeah, thank you. I love it. So I am base-trained in obstetrics and gynecology and then did a fellowship specifically in pediatric and adolescent gynecology. So what I love is caring for patients from birth through young adulthood with period issues, vaginal issues, complex conditions that require, uh, gynecologist care. And it's a really fun patient population. I find that, especially in teens, they have a lot of questions that are going through a lot of change, especially on the topic of periods like we'll be talking about today. And so it's a really great time to start getting them engaged in their healthcare.

Dr. Richard So:

Yeah, let's get into it a little bit. But before we get to the teens, usually we have the conversations in primary care a little bit earlier. In our Little Health podcast in primary care, we talk about fear of parenthood or your journey through parenthood. And this is one of those really difficult conversations, you know? It could be taboo of, "Oh my God, I gotta talk about periods. Do I have to talk about sex?" Uh, there's a lot of uncomfortable talking to them. When should parents start that conversation?

Dr. Erin Isaacson:

Yeah, I'm so glad we're talking about this. I think the only wrong thing to do is to not talk about it at all. It's gonna happen no matter what. And the more informed and understanding that kids have about their bodies, the, the more comfortable they're gonna feel voicing concerns, which is usually where I come in when there's a concern. So I think that, um, something that can be really helpful is, you know, just recognizing that it's uncomfortable and starting that conversation early, especially when puberty's maybe about to happen or slowly starting. It's a slow process, so you have time, but just to kind of help kids understand what's going on with their bodies and why.

Dr. Richard So:

Yeah. I think the conversation, you know, with parents should start somewhere when puberty starts, but it's starting early. A lot of parents ask me when it's too early. And I, I think it happens more like the eight to 10 year old, even 11 year old when you should start that conversation, because that's when they start to have those feelings or where you have to teach your child about, like, embarrassment, you know? And that's a complicated feeling. One of the things that I usually tell people with embarrassment, you know, you just don't want it to develop into shame. So I think in those early opportunities with girls, there are certain books, any books that you like.

Dr. Erin Isaacson:

You know, I don't have any specifically, but I think any sort of visual learning is really helpful. And I try to do that with all my patients for any condition when they come into the office, because everybody learns differently and understands differently. And I think especially in young kids when we're talking about anatomy and in bodies, like, it's hard to just conceptualize it in your head with words. So I think pictures, especially in books, pictures are really good way to make it really basic so kids just at least understand what is going on inside of them.

Dr. Richard So:

Yeah. Uh, the, the American Girl Body books is, is b- is what we've been recommending for like a couple decades.

Dr. Erin Isaacson:

Oh, cool. I'll have to look into those.

Dr. Richard So:

So it teaches like the, the little girls about how your body is being prepared to have a baby and you build the nest. And if there's no b- baby that comes around like the nest sheds. So-

Dr. Erin Isaacson:

I love that. <laugh>

Dr. Richard So:

So that's a good way to put it with your kids. But I think there's opportunities, you know, actually for girls and boys, because what leads to the embarrassment in a child, I think it's just new to that child and making them feel more comfortable about it, I think is the most important part. So how do you overcome embarrassment? I think it's just telling them it's normal.

Dr. Erin Isaacson:

Yeah. I 100% agree. And teaching both boys and girls about what happens in puberty to both boys and girls.

Dr. Richard So:

Yeah, because when they feel judged or bullied per se, it can come from boys.

Dr. Erin Isaacson:

Yeah.

Dr. Richard So:

You know, because in girls it becomes natural. So, you know, even like when there was a family member in our family that had a hysterectomy, you know, I was the one who had to go to the store and buy some of the feminine products and he goes, "What are those for, dad?" And, and I explained it to him. So I explained what was normal, what happens in a girl versus a boy, you know, and I could have let him read the book too, but then that way if when he becomes a tweenager and there's a girl having a period, he understands. I think that's a great approach too for both sides.

Dr. Erin Isaacson:

Yeah, no, I love that. And I think that you're right, the more we can normalize it, there's no reason to feel embarrassment or shame. It's a normal thing that's happening to the body. And the more we talk about it openly, I think, and the more we talk about it both with boys and girls, it becomes not just a thing only that happens to girls. Puberty happens to everybody. So I think normalizing that conversation whenever we can is something we can really do at, in a societal level to help push out any embarrassment or shame that is around periods.

Dr. Richard So:

Yeah. I think that helps with the parents teaching the kids a little bit more, but from doctor to parent, what is too early? What is the average age for the first period? What are the physical signs that, that you're expecting?

Dr. Erin Isaacson:

Yeah. So the average age of the first period is 12 to 12 and a half, but it's a, it's an average. I see girls who started puberty, not too early, but just early and they get their first period at age nine or 10. It happens. And so puberty does happen in a process. And so we usually say kind of one of the first signs of puberty in girls is, you know, a little bit of breast development or breast budding. And we give an average of within two years after that, we usually expect a period. I tell parents if they've come to me before a girl has their first period that if her period has not come two years after breast development, that's something I would wanna know about and do further workup into because that could be a bit of a delay, but that's usually the signs I ask them to look out for of when they can expect it.

Dr. Richard So:

Yes. Puberty, it, it ranges. There's early, a lot has to do when mom had her period. I'm sure you asked that question in your clinic, and then there's ones that are late. When's too late?

Dr. Erin Isaacson:

Yeah. So I say too late would really be dependent on the patient, but we see if there's not been any periods by age 15, especially if the patient has other signs of puberty, that's definitely something we look into. And if there's been no signs of puberty at all by age 13 to 14, that's when we also start to ask some questions and wanna do further workup.

Dr. Richard So:

Um, another thing too is the opportunities to explain it. I think when you're at the store buying any feminine products, I think that's a good time to, to talk to your, your children about that. But then as they get older, it's a little bit different. Can you talk about the different menstrual products and how parents can help their children toward the best choice?

Dr. Erin Isaacson:

Yeah, absolutely. I think that there's constantly newer menstrual products coming out, which is really exciting because it gives patients more options of how they wanna manage things. There are kind of the traditional, you know, pads or tampons. And I do tell parents there's no age at which patients can or cannot use tampons. They always can use them. And sometimes it's easier for patients if they're in sports or swimming and wanna use a tampon. But beyond those just two basic options, there's now menstrual cups or menstrual discs which can be used and are much more popular, as well as period underwear, which can be really helpful and feel more hygienic for patients and can be washed. And so how I feel in my clinic for anything that I'm doing, whether it's treatment, talking about periods, I love options because you don't know what's gonna fit someone best, and it's really nice for them to have options and know that it's not one thing and, and then done.

And so, you know, we talk about all these options, all of them are great. I encourage them to try them all and figure out what's gonna work best for them or interchange them. Um, but it's really great to see newer products coming out there to help, again, make periods easier.

Dr. Richard So:

Yeah. I'm also a sports medicine specialist. [Yeah. <laugh>] And, and I'm very, very, very ... For my own information, like, what do you recommend for the runner, the swimmer, the volleyball player?

Dr. Erin Isaacson:

Yeah. I think that the thing is, is menstrual discs and cups are really newer. And so I'm constantly seeking input and advice from patients who have used them, what they like about them, what the challenges are so that I can communicate that back to my patients, because if you're not seeing that experience, I don't wanna, you know, lead patients astray. I think that definitely getting used to tampons can be really helpful. I think that's something I would encourage patients and parents to do because it's something that can make them be able to go in the pool on their period or, again, feel comfortable doing their activities more than pads, which may be a little bit more uncomfortable. Again, it's just patient to patient.

Dr. Richard So:

Is there an age?

Dr. Erin Isaacson:

No, there really isn't.

Dr. Richard So:

Okay.

Dr. Erin Isaacson:

There's not. And I think that I do get parents coming in saying, "Oh, no, no, we haven't tried tampons yet yet. She's too young." And I'm like, "But who says it's too young?" You know, I think that there needs to be a comfort level with using all sorts of products. Again, getting patients comfortable with their body and how to manage the things that are happening to their body.

Dr. Richard So:

All right. So now we explained what periods were, we got the products. How do you explain, like, the, the kid comes up to you, luckily if it's on a weekend out of school- <laugh> ... I think I just got my period, you know? Uh, how do you explain cramping, you know? [Yeah.] And what's normal? And I just wanna know what the expert says about, like, changing products, you know, to a beginner.

Dr. Erin Isaacson:

Yeah. I think the question, what is normal is my favorite question to answer because as a society, we're so skewed on what is normal. Um, and that could go down a whole other topic of why, but I think we really do need to make sure we're redefining what's normal and make sure that women are being listened to when they say things are not normal. Truly, what is normal for both bleeding and cramping? For cramping with periods, what is normal is mild cramping that can be managed with over-the-counter pain medications. That's normal. Anything past that is not normal. It's more than they should be experiencing, and they should talk to their doctor about it and possibly come see a gynecologist because it's, it's more than they should be dealing with. Dysmenorrhea are periods that are more painful than they should be leads to school absences, difficulties with their normal activities, nausea, vomiting, sleep issues, I mean, a whole array of issues that can really affect patients' quality of life.

And so it's really important that they understand how much is too much, and that's a pretty low level, you know, cramping that's managed with-

Dr. Richard So:

Yeah. I think that missing school is a big deal. If you get one period a month, you know, that's nine days of school, that's two weeks.

Dr. Erin Isaacson:

Yeah.

Dr. Richard So:

That's a lot of learning that's missed.

Dr. Erin Isaacson:

Yeah. A question I often ask if I say, "Oh, have you ever had to miss school?" And they say, no, and I say, "Have you ever wanted to miss school for your period?"

Dr. Richard So:

Ooh, that's a good one.

Dr. Erin Isaacson:

And the question is yes. <laugh>

Dr. Richard So:

Wow.

Dr. Erin Isaacson:

Yeah.

Dr. Richard So:

I haven't asked that, but I'm gonna definitely ask that in my repertoire. So when we talk about the pill, you know, and you say birth control pill, they're like, "Oh no, she's too young." Is there another words, like, do you say, like, menstrual suppression- [I do.] ... medication? [I say...] What's the proper terminology?

Dr. Erin Isaacson:

I say hormonal management.

Dr. Richard So:

Okay.

Dr. Erin Isaacson:

I say that, you know, these medications and the things that we're talking about were created as birth control, yes, but we learned over time, they can do so much more than that. I say the majority of my patients are not sexually active. They don't need birth control, but they do need management of their periods. And we found that these medications can work for both. So I tell parents, yes, traditionally, this is called birth control, but I refer to it as hormonal management because that's what we're doing.

Dr. Richard So:

Oh my goodness. Let's take a step back really quick. So go back to the girl who's having the first one. Your puberty has developed and all your friends are having it, you're one of the last ones, but there's some fear in that child of, what am I gonna expect?

Dr. Erin Isaacson:

Yeah. <laugh>

Dr. Richard So:

As a male, I can't explain that, you know, that uncertainty of what it feels like, and it's gotta be different for every girl. What do you say?

Dr. Erin Isaacson:

Yeah, I think that that's why, like we talked about earlier, it's so important to talk about this before it happens because then girls know what to expect a little bit of like when it's coming, they're like, "Okay, we talked about this. My parents talked to me about this. I, you know, I'm gonna go talk to them or gonna be like, we talked about these products, like to know what to use to manage them in the meantime and know like, hey, you know, if my cramping's really bad, okay, I'm gonna, you know, ask for some medication." Just again, once they have an idea that it's coming beforehand, it makes it a lot less scary. I have also seen, for caring for so many teens, I feel like, again, I'm not seeing them as much on their first period, but I feel like girls now are having so many more open conversations with their friends about their periods, which is amazing.

I think that really pushes away the stigma of them because they come to me and say, "Oh yeah, my friend has an IUD. Oh, my friend has the Nexplanon. Oh, my friend is on this and they like, they don't like. This is the problems they had with it. " And they are so much better informed and feel so much more comfortable talking about it than I feel like when I was in middle school and high school.

Dr. Richard So:

Gotcha. From a dad's perspective, you know, and I have two daughters who have gone through it, learning the products for a dad too is I think an ideal time is the girly bag where you, you have maybe your period underwear, your feminine products, okay? And remember, when it, when it does happen your first time and you've prepared your daughter for having it, I, I explain in my office, "Okay, we're almost there." And I asked the girl, "What, what do you do if it happens at school?" And they all say, "I go to the nurse's office," which is the right answer. [Yeah.] But I always say tie the sweatshirt or your jacket around your waist, you know, because you have to protect her for those feelings- [Yeah.] of embarrassment. [Right.] But if we train these little girls or young women, give them the knowledge that it's normal and prevent any type of embarrassment or shame, and that goes with teaching the boys as well. And now we're teaching the dads.

Dr. Erin Isaacson:

Yeah. <laugh>

Dr. Richard So:

I think that's very comprehensive education on what we're doing it. We talk about the, the girly bag where not only do you have one in your backpack or your locker, you also have one in each car, okay?

Dr. Erin Isaacson:

I like that a lot. Yeah, being prepared.

Dr. Richard So:

And, and believe or not, what I taught my girls is if they see a girl crying in the bathroom, you ask them, "Are you okay?" And if the girl says a period, that, remember, that girly bag isn't just for you.

Dr. Erin Isaacson:

Yeah.

Dr. Richard So:

You could just say, "Here, I have something for you, " and you share, and you just say, "Just keep it, okay." Or you walk that girl to the nurse's office if it was just her first one.

Dr. Erin Isaacson:

Yeah. No, I love that. And I love being prepared, having those products, you know, with the girl in her backpack at school for if the first time happens when she's at school, right? Like, I think that that's a great way to prepare. And then also exactly, like, being able to give back if someone, you know, wasn't able to have that conversation with their parents before it happened. If it happened much earlier than everyone was expecting, um, I feel like that's the best way, again, to erase the stigma and to really help everyone be comfortable and have a more positive experience.

Dr. Richard So:

Gotcha. I think now, like, back, I would say about 10, 12 years ago, there were period tracking apps like MyCalendar, Q, Pink Flower. I know when we were growing up, there was the calendar on the refrigerator and you would put dots and that was your secret message between your mom whether you were having your period or not. <laugh> But I think the, the new watches, the period tracking on, on some of the smart watches are fantastic, you know, so I think we're doing a better job. One thing I wanna, I wanna go is, what do we tell the girl the red flags, you know? I want you to touch, touch about red flags about, like, cramping, bleeding, and even, like, say they were too busy and their tampon was in too long. Talk about, a little bit about TSS too as well.

Dr. Erin Isaacson:

Yeah, definitely. The red flags. So I would say at baseline, anytime a patient is bothered or feels like what's going on with their period is too much, that's a reason to come talk about it. Even if they don't meet one of the criteria that I'm gonna talk about, if they're bothered enough by it, like, it deserves discussion. Um, and so the really big red flags that we see and that we counsel about are one is, you know, thinking about the heaviness or length of a period. So if a period is consistently lasting longer than seven days, that's longer than it should be. As far as heaviness, if, uh, patients are having clots that are coming out regularly, if they're going through a tampon every hour, if they're having to change a pad that's soaked every two hours regularly during a period-

Dr. Richard So:

So establishing their normal- [Yes.] ... and everything outside their normal.

Dr. Erin Isaacson:

Yes. And that's where, you know, you mentioned the period tracking apps can be really helpful because it's, they're busy. It's hard for them to recall sometimes. So if they're tracking it, they can say, "Oh, wait, my period is actually always lasting for 10 days." Or, yeah, like, it is really heavy. As far as cramping, you know, we talked about, you know, I do recommend management with over the counter, specifically NSAIDs if patients are able to take NSAIDs because a lot of period pain is caused by inflammation. So NSAIDs are actually shown to work better. And if their cramping is, you know, not managed by that or their pain is so bad that again, they're missing school practices, like, that's a reason to come in and see me. It's not something they should have to push through or manage.

Dr. Richard So:

And then, yeah, absolutely. Like, the concern with leaving a tampon in too long is toxic shock syndrome. So we do recommend, you know, changing tampons every three to four hours, ideally not wearing a tampon overnight. Wearing a tampon once overnight is likely not gonna cause it to get infected, but just hygienic-wise, it's, it's better to only leave it in for a couple of hours.

Gotcha. So talking about with, like, over-the-counter medicines, I don't know the studies about if you're a good tracker starting at the day before.

Dr. Erin Isaacson:

Yeah, yeah. The studies are actually really great. The recommendation actually for kind of first-line painful periods or dysmenorrhea is scheduled NSAIDs, starting ideally one to two days before the period- [Two days.] And then continuing two to three days into the period to help decrease cramping overall for the period. And again, when girls are younger, it's really common to have more irregularity in their cycles. Even up to, you know, three years after menses start, only about 70 to 80% of periods are, you know, regular, like around the same day. And that's, that's still considered normal. And so it can be hard to say, you know, when patients or parents are like, you know, she doesn't get it on the 28th every month, that's normal. And I say like, as soon as it starts, start the scheduled NSAIDs, like as much as we can.

Dr. Richard So:

Gotcha. I've heard heating pads, taking a bath.

Dr. Erin Isaacson:

Yeah. Heating pads are great. There are heating pads that, um, again, that can plug in, but also that are kind of like hot hands or hot packs that can actually go under a shirt and can be worn to school. [Oh, wow.] Um, there also has been some, some interesting studies on like oral magnesium, um, as an anti-inflammatory. And again, that's something that they can try and get over the counter. There's only been a couple that I've looked at, but they're pretty good, um, as far as inability to, again, decrease mild dyspneorrhea and mild cramping.

Dr. Richard So:

W- what about like diet and exercise during, during your period?

Dr. Erin Isaacson:

Yeah. I think that it's not definitely not something that hurts. I go by the studies of what I can recommend. And so I know that some people find benefit of eating, you know, more of an anti-inflammatory diet at some point during their cycles. I haven't, you know, I can't quote the studies because there really aren't any, but it's definitely not something that can hurt. I think every patient is different, but some patients do find that moving more exercise during their periods, again, helps decrease some of that pain and inflammation that they're feeling.

Dr. Richard So:

Let's make a switch. Go to, go right to sports and exercise. Some of my endurance athletes, you know, those are, those are the ones that, you know, they may miss a period. There's the ones we're worried about the female athlete triad of, you know, of like eating disorders, missed periods, stress fractures, you know, like my gymnasts, my divers, my dancers-

Dr. Erin Isaacson:

Long distance runners.

Dr. Richard So:

Long distance runners. Talk about even if they've delayed their period or what's normal periods for them.

Dr. Erin Isaacson:

So the female athlete triad is kind of, we refer to it now as, uh, RED S. So that stands for relative energy deficiency in sport. Um, and that really encompasses, we see young athletes with high activity level and basically their intake, although it's not an eating disorder, they're, they're taking in quite a lot. It's just not measuring up to their significant energy expenditure. And so we see a multitude of issues from that. I think we think of the period as a vital sign. If it's not coming, there's usually something else behind it. So especially in athletes, if they, you know, have never gotten their period or they got it, but it's now gone, it, you know, it's due to the low estrogen from, um, the like low production of hormones from the brain-

Dr. Richard So:

Poor protein intake.

Dr. Erin Isaacson:

... from that low, low, lower than needed energy expenditure that also leads to low bone density, recurrent injuries and have lifelong issues. So it may just be, I'm not getting a period, but it's actually more than that. We see a lot of issues with like recurrent injuries, especially in bones, muscles.

Dr. Richard So:

Yeah, in my sports medicine training, you know, and from a primary care perspective, when we fill out those sports forms and there's those ones, how many periods you have in a year. And I was trained you should have at least six or seven- [Correct. Yes.] ... even if you're in an endurance athlete- [Correct.] ... or a high level athlete. We've talked about, you know, introduction of talk, we've talked about periods, products, everything. When do you recommend kids get their first gynecological examination?

Dr. Erin Isaacson:

Yeah, I think this is a great question and something that's definitely changed over time. So a lot of parents think that, you know, teens need to come in for an exam, and that's definitely not true. Um, you know, we don't necessarily find an, as gynecologists see a need for an exam until patients need their first pap smear, which is not recommended until age 21. Even if patients are sexually active, there's not a need necessarily to do a pap smear before age 21.

Dr. Richard So:

It's not two years after being active because that's what I was trained on. So it's just-

Dr. Erin Isaacson:

No, not anymore. ...

Dr. Richard So:

It's by 21.

Dr. Erin Isaacson:

Yep. There are specific conditions like patients with HIV or other low immune, um, system disorders where we may recommend screening a little bit earlier just because of their elevated risk, but otherwise it's 21. Obviously, if patients are sexually active, have concern for STDs or need an exam for a specific reason, of course they should come in, but there's not a need for a regular exam at that time. Once patients are sexually active, we do recommend they get screened for STDs yearly.

Dr. Richard So:

So if I do have a teenager with an STD, I should make a recommendation to get a pap smear?

Dr. Erin Isaacson:

Not necessarily a pap smear, just an examination. Sometimes a, a gynecologic examination, a pelvic exam. They still don't need screening for cervical cancer earlier. Additionally, even testing for sexually transmitted infections can be done via urine, so they don't even necessarily need a vaginal swab.

Dr. Richard So:

What an insightful conversation today. It was pretty deep. Dr. Erin Isaacson, how can our patients get ahold of you?

Dr. Erin Isaacson:

Yeah, thanks so much for having me. So I see patients most days of the week. I have clinics both, uh, at the OB/GYN offices and the Children's clinic building here at Main Campus. I also can see patients virtually for some visits if travel distance is a significant concern. Like I mentioned before, a lot of our patients don't necessarily need exams, so we take that on a patient by patient basis. Um, parents can ask their primary care doctor for a referral or can call the Clinic directly to schedule with me.

Dr. Richard So:

We hope you feel more confident talking to your child about their period and recognizing when to seek help for their pain. An open and honest dialogue is the most powerful support you can give them. If you would like to schedule an appointment with Dr. Erin Isaacson or a pediatric gynecologist provider at Cleveland Clinic Children's, please call 216.444.KIDS. That's 216.444.5437.

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.