Dear Alice,

I am a mother of a six-year-old girl and have just discovered that she has a patch of fine dark pubic hair on her vaginal area. Is this normal?

I started to menstruate early (at 9 years). But my concern is about my six-year-old. Is this ok?

Dear Reader,

Mothers and daughters share a number of things, and in many ways, the age at which the latter begin puberty is one of them. However, while your nine-year-old start time was normal and just a tad early on the spectrum, the appearance of pubic hair in your six-year-old daughter is some cause for concern. A number of conditions whose symptoms are similar to those you have described include precocious puberty, precocious pseudopuberty, and precocious pubarche.

Before going into the different ways puberty can go astray, it might first be helpful to discuss the mechanism behind puberty itself. Two different hormonal processes mark the beginning of puberty in girls:

  1. Gonadotropin-releasing hormone (GnRH) production increases, starting up the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
  2. FSH and LH production stops being suppressed by sex steroid hormones

Because two mechanisms contribute to beginning puberty, it makes sense that there are two ways that puberty can be precocious. Puberty is considered precocious — too early — when it occurs in white females younger than 7 or black females younger than 6 years old.

Precocious puberty True precocious puberty (also known as Central Precocious Puberty) is caused by early maturation of the hypothalamic-pituitary-gonadal (HPG) axis. Basically, all of the typical mechanisms and changes for puberty are happening, they're just happening too early. Treatment of this type of precocious puberty would probably involve using a suppression method. Essentially, the child takes pills or uses a spray that prevents puberty from happening. When the time is appropriate, the pills or spray are halted and puberty begins as normal.

Precocious pseudopuberty
The much less common (and, as a result, less understood) type of precocious puberty is called precocious pseudopuberty (or Peripheral Precocious Puberty). In this condition, excess levels of sex hormones — estrogen in girls, testosterone in boys — appear in children, where all else remains normal. These high amounts of estrogen or testosterone kick start the puberty process and things proceed as they usually would have — but years before they should have begun. Unlike true precocious puberty, treatment of precocious pseudopuberty is highly individualized and can only be determined after a number of hormonal tests.

Precocious pubarche
Another possibility — and a condition more common than either of the two previously mentioned — is that your daughter is experiencing premature pubarche. This is characterized by the early appearance of pubic hair without any other symptoms of puberty, i.e., no breast development, no menstruation, etc. In this condition, none of the hormonal changes that accompany puberty have actually occurred; it is simply a temporary increase of estrogen, causing pubic hair to form. Typically, this condition is harmless and does not require any sort of treatment.

    Because it is impossible without testing to tell which of these conditions might best describe what your daughter is experiencing, it is important to visit your primary care provider or pediatrician. Especially in the case of precocious puberty and precocious pseudopuberty, it is critical that your provider determine the cause of the hormonal changes or misactivations, which can be brought on by anything from adrenal tumors to a new face lotion. After diagnosis, your health care provider can give you the information needed to help you determine your next steps.

    Now and during this process, one of the most important things you can do is to be supportive of your daughter. If it does turn out that she will experience all of the changes associated with puberty at this early age, the transformations in her body might be difficult for her to handle emotionally and socially. That you did notice the first change and were conscious enough to seek answers about it is an excellent sign. Continue to be there for her as you have been, and the two of you will get through this difficult situation with information, medical support, and love.


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