Puberty (girls)

• Menstrual (bleeding) phase: all the hormones are at their lowest level and consequently the womb sheds its lining and the woman has her period.
• Pre-ovulatory phase: the ovary starts to secrete oestrogen, which leads to a gradual build up of the uterus lining in preparation for ovulation.
• Ovulation: at a critical point roughly 14 days after the start of bleeding, the level of oestrogen reaches such a height that it causes the brain to release a large amount of LH, which in turn stimulates release of an egg from the ovaries.
• Post-ovulatory phase: after the release of the egg, the ovaries produce another hormone, progesterone, which maintains the lining of the womb so a fertilized egg can implant. If the egg is not fertilised, progesterone and oestrogen levels drop, the womb loses its lining, and, about 14 days after ovulation, the menstrual phase begins again.

• Menstrual phase: day one of the menstrual cycle is the first day of bleeding, which can last anything from a couple of days to a week. The bleeding is heaviest on the first few days. Women use tampons that sit inside the vagina or sanitary towels (pads) outside the vagina to soak up the blood. Many women suffer from cramp-like abdominal pains. Occasionally, they also have back pain. The pain is caused by changes in local hormones called prostaglandins.
• Pre-ovulatory phase: many women feel very well during this phase, probably due to the rising levels of oestrogen.
• Ovulation: your vaginal discharge can increase and become mucus-like, which is more welcoming for sperm. At ovulation, the body temperature rises. Some women may experience sharp pain on either side of the lower abdomen. Occasionally, a few spots of blood come from the womb.
• Post-ovulatory phase: symptoms of the premenstrual syndrome occur in this phase as the hormone levels fall. When the hormones are at their lowest, just before the menstrual bleeding starts, women who are more sensitive to the changing hormone levels can experience depression, irritability, lack of concentration, tiredness, food cravings, bloating and sore, tender breasts.

• being underweight or very overweight
• too much exercise
• stress
• illness
• pregnancy.

What happens if I stop having my period?
If you have had unprotected sex then you need to have a pregnancy test to check whether you are pregnant. You can go to your nearest family planning clinic (FPC), sexual health clinic (also known as a sexually transmitted disease or genitourinary medicine clinic), your GP, or you can buy them over the counter at the chemist.

Other reasons can be losing too much weight, too much exercise, or stress. If the problem continues you should go to see your GP.

Will tampons make me lose my virginity?
Loss of virginity is when you first have sex. There is a thin membrane inside your vagina called a hymen, which tears and sometimes bleeds the first time you have sex.

The hymen is usually very elastic and tampons can be inserted without tearing the hymen. However, even if using a tampon tears the hymen, this does not count as a loss of virginity as no sex is involved.

Rarely, the hymen can tear when bicycle riding, horse riding or climbing fences but this does not mean you have lost your virginity.

Can tampons get lost inside me?
No. Tampons lie in the vagina. The neck of the womb (cervix) lies at the top of the vagina and it is tightly closed except for a tiny hole about the size of a pinhead.

A tampon cannot move into the womb and has no other way out except the way it went in.

Sometimes a tampon can be at the top of the vagina behind the cervix and then it can be difficult to feel or pull out. If you suspect that you have left a tampon in, especially if you notice an unpleasant smelling discharge, then go to your GP or sexual health clinic to have it removed without delay.

Can I swim or have sex during my period?
Yes. You should be able to have a completely normal life during your period. Remember that you can get pregnant if you have unprotected sex during your period.

Is period blood dirty?
No. It is just normal blood mixed with the lining of your uterus. If it were dirty then it would not be a suitable place for the baby to develop. Once the blood leaves the womb it can become food for bacteria so you need to change tampons and sanitary towels regularly and discard them in a suitable waste disposal place.

I feel terrible before my periods, what can I do?
Feeling emotional, irritable, tearful, tired and bloated before a period are all the symptoms of pre-menstrual syndrome. Many women have this condition and sometimes just knowing about it and predicting when it will happen is enough to help you through it.

• exercise
• eating fresh food
• avoid processed food
• avoid too much salt, eg crisps
• avoid caffeine (remember that chocolate and cola also contain caffeine)
• eat regular small meals
• pamper yourself
• Evening primrose oil and/or vitamin B6 supplements sometimes help (note: controversy exists over whether high doses of vitamin B6 can cause nerve damage).

My periods are so painful, what can I do?

• Gentle exercise can make you feel better, (though heavy exercise can make things worse). Getting regular exercise between periods can also help.
• Hot baths relax the muscles and can reduce the severity of the pain.
• Over-the-counter painkillers called non-steroidal anti-inflammatory drugs, such as ibuprofen, can help reduce the pain if taken regularly in the first few days of the period.

Pregnancy and contraception

How do women become pregnant?

• A woman becomes pregnant if the egg released at ovulation is fertilized by a man's sperm and then travels along the Fallopian tube to implant in the prepared womb.
• Once released, the egg can survive for between 24 and 48 hours and will be discarded if it is not fertilized in that time.
• During unprotected sex (without using contraception), the man deposits hundreds of thousands of sperm in his semen at the top of the vagina. The sperm are very resilient in their long swim from the vagina through the cervix, into the uterus and up the tubes. They can survive for up to seven days waiting for an egg.

Contraception
If you choose to have sex, remember the risks of pregnancy and infection. Condoms can protect against pregnancy and sexually transmitted diseases, although they are not as reliable in preventing pregnancy as some other forms of contraception.

For further protection against pregnancy, go to your GP, FPC or sexual health clinic and get contraceptive advice. Although no form of contraception is 100 per cent effective (except abstinence!), there are plenty of safe and easy ways to protect against pregnancy. The doctors and nurses can help you find one that is suitable for you.

Good advice
Always carry a condom if you are considering having sex: you cannot rely on the other person to think about your health and wellbeing.

Can I become pregnant if I have sex during my period?
Yes it is possible. You cannot predict the exact time of your ovulation and it could happen that in any particular cycle you ovulate earlier than usual. As the sperm can survive up to one week, the egg can be fertilized and you will be pregnant.

For example, if you have sex on the fourth day of your period, and you happen to ovulate seven days later on the 11th day of your cycle, some sperm might still be around to fertilise your egg and you will fall pregnant.

Is there a safe time I can have unprotected sex and not get pregnant?
Firstly, you should remember that using a condom protects not only against pregnancy but also sexually transmitted infections. . Unprotected sex is never 'safe'.

The time when sex is very unlikely to get you pregnant occurs during the post-ovulatory period (more than two days after ovulation until the arrival of the next period). So if you have an extremely regular 28-day cycle, days 17 to 28 are likely to be safe, but if you happen to be even one day late with ovulation then day 17 would not be safe. This can happen because the time of ovulation can vary cycle to cycle (more so if your cycle is not regular). You can buy a kit from the pharmacy that detects exactly when your ovulation occurs, although this form of contraception is not as reliable as some others.

My boyfriend pulls out before he comes, can I become pregnant?
Unfortunately, pulling out or withdrawal (coitus interruptus) is not reliable for contraception because men release something called pre-come or pre-ejaculate before they ejaculate which they do not notice. This tiny amount of fluid that comes from the penis contains thousands of sperm that can fertilize your eggs.

Remember that during the teenage years and early 20s women are at their most fertile, and it takes only one sperm and one egg to make a baby.

I always wash inside my vagina after sex, will that protect me against pregnancy?
No, sperm are very agile and they reach the neck of the womb in a matter of seconds. Even the fastest sprinter could not beat them to the bathroom. In addition, the womb contracts to suck the sperm in.

What if a condom breaks?
Condoms should rarely break if they are used properly, and before their expiry date. Make sure you know how to put on a condom properly.

Within 72 hours: Go to your nearest family planning or sexual health clinic and get emergency contraception (usually the morning-after pill). On a weekend, many casualty departments supply emergency contraception.

You should also be able to obtain emergency contraception if necessary from the out-of-hours GP service. You can also buy the emergency contraceptive Levonelle one step from pharmacies if you are over 16.

The earlier you take emergency contraception the more effective it is.

Although there is a very small chance that you may be come pregnant even if you take it within the first 24 hours, the risk of pregnancy increases the longer you leave it and 72 hours is the limit.

The morning after pill is a large dose of a progesterone-like hormone called levonorgestrel (brand name Levonelle one step or Levonelle 1500).

Beyond 72 hours: you can still go to a family planning clinic, as the doctor might be able to insert an intrauterine device (a coil) into the womb to prevent the fertilized egg from implanting.

Can I become pregnant from sperm left in the bath or swimming pool?
No. . This is a myth.

How do I know if I am pregnant?
If you have had sex without using any contraception since your last period started, and your next period does not come when it should you might be pregnant.

On the day that your period should have arrived and didn't, you can test if you are pregnant using a pregnancy test. You can buy these at the chemist or you can get one free at a FPC or sexual health clinic or your GP. The test is simple and is done on your urine sample. Do not use an out-of-date test, and follow the instructions carefully. If the test is negative and your period arrives soon after, fine, but otherwise always confirm the results with a doctor.

What can I do if I am pregnant?
You should contact your doctor, a FPC, a sexual health clinic or Brook Advisory Centre. The staff can explain your options and help you to choose. It is advisable to involve your parents in any decisions you make.

Breasts

At what age do breasts normally develop? Most girls start to develop breasts between the ages of 8 and 14. For many, this is one of the first signs of becoming a woman.

Is it normal to have different sized breasts?
Yes 40 per cent of women have different sized breasts.

Do sore breasts mean breast cancer?
It is extremely rare to develop breast cancer during puberty and breast cancer is very rarely sore. Growing breasts can be very sore. Later on, the breasts can become sore during the fluid retention before the period. Sometimes reducing the salt and caffeine in your diet can help.

Pregnant women also develop sore breasts, which can be one of the first signs of pregnancy. So if you've missed a period and have sore breasts, do a pregnancy test.

Vaginal discharge
Another thing that changes during puberty is that vaginal discharge (secretions) start or change. For six months before getting their first period, girls may notice an increase in vaginal discharge.

What is normal vaginal discharge? Vaginal secretions keep the vagina moist and clean and help fight infections.

Once periods start, normal vaginal discharge can be thin, sticky and elastic; or thick and gooey, and the colour is clear, white or off-white (yellow when dried). The texture and colour can change throughout the cycle. In particular, some women notice a heavier flow of thin, sticky mucus-like discharge around the time of ovulation (day 14 of the cycle).

Normal vaginal discharge usually has no smell, and if it has, it is not unpleasant.

Remember, if you are sexually excited or emotionally stressed your vaginal discharge can increase.

What is abnormal vaginal discharge?
Keep an eye out for change, including:

• unusual increase in amount
• change in texture: for example curd-like or frothy and watery
• change in colour to grey, yellow, green or brown
• change in smell: for example fishy or yeasty.

. What causes abnormal vaginal discharge?
If you have had sex, an abnormal vaginal discharge might be caused by a sexually transmitted infection, such as trichomonas, chlamydia, or gonorrhoea. Some vaginal infections are not sexually transmitted, but are caused by an imbalance in the vaginal flora ('bugs') that normally live in your vagina. These are:

• thrush (candida): signs are a cottage cheese-like discharge with itching and soreness.
• bacterial vaginosis (BV): a grey, watery, sometimes frothy vaginal discharge that smells of fish. Mild itching can occur.

Excessive washing of the vagina, use of perfumed soaps and bubble bath, tight synthetic clothes (such as nylon knickers), lots of sex, antibiotics and stress can all lead to an imbalance in vaginal flora. Remember, if you forget to remove a tampon or a cap you can also develop unpleasant vaginal discharge.

What should I do if my vaginal discharge changes?
You can go to see your GP or you can visit a sexual health clinic. Many clinics have dedicated times for young people that cater to their needs. It is important to seek attention early, as sometimes the discharge might be a sign that you have caught a sexually transmitted infection that needs prompt treatment.

Sexually transmitted infections

What are sexually transmitted infections? These are infections that are passed from person to person during sex.

• Some infect the vagina like trichomonas.
• Some infect the neck of the womb (the cervix) like gonorrhoea and chlamydia.
• Some cause sores or ulcers like herpes and syphilis.
• Some cause lumps like warts.
• Some affect the liver like hepatitis B.
• Some affect the whole body like HIV, the virus that can cause AIDS.
• Some, like 'crabs' and scabies can be passed on just by close contact.

What are the symptoms of sexually transmitted infections?
Sometimes you do not know because you have no symptoms. Any of the following can be a sign that you have contracted a sexually transmitted infection:

• change in vaginal discharge
• pain or burning on urination
• sores or ulcers in the genital area between the legs
• wart-like lumps in the genital area
• crampy pain in the lower abdomen
• pain during sex
• bleeding after sex
• itchiness in the genital area
• dandruff-like specks that move in the pubic hair
• if your boyfriend or girlfriend develop symptoms.

How do I avoid sexually transmitted infections?

• Unfortunately, nothing on the outside tells you if someone is harbouring a sexual infection. Often the people do not know themselves, as they have no symptoms. The only way to be safe is to use a condom.
• Using a condom every time you have sex is a very good way to protect against pregnancy and sexually transmitted infections.
• You must make sure the condom is on before allowing the penis near the vagina. Remember, sexually transmitted infections can sometimes be transmitted by the penis touching the genital area surrounding the vagina (vulva).

What should I do if I think I have a sexually transmitted infection?

• First, you should try to avoid catching them.
• If you do suspect you have a sexually transmitted infection go to a convenient sexual health clinic. Many clinics now have special young persons' times and they will examine you, take swabs and make a diagnosis. They will also suggest you tell your sexual partners so that they seek advice and get treatment if needed.

If sexually transmitted infections are curable, why should we bother protecting against them?

• Trichomonas, chlamydia, gonorrhoea, syphilis, crabs and scabies are curable.
• However, chlamydia and gonorrhoea can spread from the neck of the womb to the Fallopian tubes leading to abdominal pain, inability to become pregnant, or pregnancies outside the womb. Unfortunately, not everyone can tell if they have chlamydia so it can hang around for a long time causing irreversible damage to the tubes.
• If not detected, syphilis can cause severe damage to your body long term.
• HIV, hepatitis B, herpes and warts can be controlled, but not cured, by treatment.

Can women get HIV?

• Yes, HIV is transmitted between men having sex with women as well as men who have sex with men. Worldwide, most HIV infections are transmitted by heterosexual sex.
• Women can catch HIV from anal sex and vaginal sex if a condom is not used, because the virus is present in semen and vaginal fluids.
• Women can also catch HIV during the injection of drugs like heroin and crack, so don't share your needles.

How can I protect myself from HIV?

• Always use a condom.
• Have fewer sexual partners.
• Delay the first time you have sex until you are 21 or older.
• Make sure you have no other sexually transmitted diseases as they help HIV to transmit between people.
• Never share needles.
• Remember HIV is very common in many parts of the world - Africa, southeast Asia, South America, eastern Europe - so take and use condoms when you travel.

How safe is oral sex?
Oral sex is not 100 per cent safe from transmission of HIV, but is much safer than vaginal sex, which in turn is much safer than anal sex.

If you want to minimise the risk, avoid swallowing the semen, keep good oral hygiene and avoid oral sex if you have mouch ulcers, bleeding gums or during menstruation.

What about kissing?
Kissing, hugging, mutual masturbation, touching each other's genital areas, sharing cups and sharing beds are all safe.

Can you catch HIV from a swimming pool?
No.

What are the symptoms of HIV?
Many years can pass without any symptoms so many people do not know they are infected. That is why it is so difficult to know who has and who has not got HIV. By the time the disease is obvious the individual could have inadvertently infected many people.

How can I find out if I have HIV?
There is a simple blood test to detect HIV infection. But you can have to wait at least three months after the event that exposed you to HIV before the test becomes positive. Special blood tests can be used to make the diagnosis before this time so if you think you have been exposed to HIV, it is important to seek advice early.

Why would I want to find out my HIV status?
Good treatment is currently available that prolongs life and improves the quality of life for people with HIV. By knowing your status, you can access that care. Treatment may be particularly important in the first few months of infection so if you think you have been exposed to HIV, it is important to seek advice early.

But remember, you don't have to take medication or experience other considerable difficulties that HIV infection brings. Instead, you can always use a condom.

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