In Puberty, the New Things Arrive on Their Own Schedules

Acne starts appearing, clothes carry a smell that was not there before, and a few days each month bring stomach pain bad enough that nothing else can be done. Within a year or two, several things that never used to happen start piling up.

Each of these things actually began at a different time. Some started years earlier and are only now becoming noticeable; others arrive a year or two after the first period. Puberty is not a switch that flips all at once on a single day.

The Adrenal Glands Have Their Own Puberty

The adrenal glands, which sit like caps on top of the kidneys, switch on years before the gonads do. This is called adrenarche.

As the inner layer of the adrenal gland's outer shell (the adrenal cortex) becomes established, a weak androgen-class substance called DHEAS rises gradually. It can begin as early as age three or four and keeps climbing into the late teens. And this process runs on its own track, separate from the puberty of the gonads.

So before anything visible enough to call puberty appears on the outside, something has already been changing inside the child's body for years.

Smell and Skin Change First

One of the first places this substance from the adrenal glands shows up on the outside is the skin. Here, boys and girls are the same.

The armpits and groin have apocrine sweat glands. They are present from birth but stay inactive until they develop around this stage. This is why the smell that used to come only from an adult's body starts appearing on a child at this point. It is not because they are washing less.

The same substance also acts on the sebaceous glands. Oil production increases, and small grain-like formations (comedones) begin to form inside the pores. This is also why parents say a child's complexion has changed at this age.

Menstrual Cramps Do Not Arrive Together With the First Period

For girls, there is one more time lag.

Some girls get through the first stretch after their first period without much trouble, then a year or two later start suffering for a few days every month. To a parent, it can look as though something that never used to happen has shown up out of nowhere. But that is simply when it normally begins. Primary dysmenorrhea usually starts within two years of the first period, around the time ovulatory cycles become established.

The shedding endometrium releases prostaglandins, and when this substance tightens the uterine muscle, blood flow to the uterus drops and pain follows. It takes time for this sequence to fall into place. A first period does not mean cramps arrive with it, and a child who was not in pain becoming pained later on is also simply following that sequence. I covered this further in severe period pain in teens.

Sometimes Something Already There Becomes Prominent at This Stage

Not everything is something new.

Frequent eye blinking, sniffling, or making sounds in the throat — tics — are like this. They begin not at puberty but before it. They typically start between ages three and nine, and are usually at their worst between nine and eleven. If a tic was first noticed at this age, it may not be that it began then, but that something already present became more visible.

Tics wax and wane over the course of a day, and over the course of weeks. What causes them to increase or decrease is still hard to predict in advance. It is tempting to trace back what happened on a day they got worse, but waxing and waning is simply the nature of this symptom.

There is a long-held belief about what happens next: that tics disappear within a few months. But data following children with newly started tics over several years does not fully back that up. Only around one in three children remained entirely free of tics over the following five to ten years.

That does not mean the outlook should be viewed negatively. Whether it has disappeared or remained is not the axis by which to read this symptom. Because waxing and waning is its basic nature, stringing together the good days and bad days as they come will lead you to read the trend wrong.

So the standard for intervening is kept separate: it is when the child is genuinely struggling, or when it is actually interfering with school life and peer relationships. Whether it remains and whether it needs treatment are two different axes.

When to Check Elsewhere First

When a tic begins suddenly over the course of a few days together with other neurological symptoms, when intensity and frequency only keep increasing without the usual waxing and waning, when seizures or weakness accompany it, or when the tic itself is injuring the child — a pediatric neurologist comes first.

There are times not to wait with menstrual cramps as well: when they visibly worsen year after year, when there is pain even outside the period itself, when bleeding is excessive or there is bleeding between cycles, and when the pain is severe enough to keep a child home from school every month — a gynecologist comes first.

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The new things experienced in puberty arise because each one switches on at a different time. Once you know that sequence, it becomes possible to separate what is simply following the normal timeline for that age from what has strayed outside it.

At this age, sleep and eating often break down together. So rather than isolating a single symptom, I look at the whole stretch of this stage together.

Written by Dr. Heo Ji-young (PhD in Korean Medicine Pathology, Kyung Hee University · former Research Professor of Herbology, Kyung Hee University)