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Introduction Increased fiber intake has been associated with decreased breast cancer risk, while increased animal protein intake with increased risk. The objective of this study is to examine the relationship of dietary fiber and protein intake to estrogen and sex hormone–binding globulin (SHBG) concentrations at puberty onset. Methods These analyses were conducted using the Cincinnati puberty cohort of the Breast Cancer and the Environment Research Program, with girls followed every 6 months from ages 6 and 7. The analyses included serum measurements at 6-month intervals for estrogen and SHBG concentrations, from 18 months prior to breast stage 2 (onset of puberty). Dietary intake was documented via 24-hour dietary recalls every 3 months. Dietary factors of interest included total energy intake; total and animal protein; total, soluble, and insoluble fiber; and lignan and flavanol intake. Results This study included 260 participants who generated 871 serum specimens and 3,000 days of diet intake. In longitudinal models, estradiol was associated inversely with insoluble fiber intake; estrone positively with animal protein intake; SHBG with greater insoluble fiber and lower total protein intake; and ratio of estrone to SHBG, a measure of bioavailable estrogen, positively with animal protein. Conclusions Greater protein intake, especially animal protein, led to greater estrogen concentrations and lower SHBG; greater animal protein and greater caloric intake led to increased bioavailable estrogen. This relationship may have served an evolutionary advantage in the past for greater fertility with adequate high-quality protein; in contemporary women, a modest decrease in animal protein may be beneficial in reducing breast cancer risk.

Purpose Risk markers for breast cancer include earlier onset of menarche (age at menarche [AAM]) and peak height velocity (PHV). Insulin-like growth factor-1 (IGF-1) is associated with pubertal milestones, as well as cancer risk. This study examined the relationships between pubertal milestones associated with breast cancer risk and hormone changes in puberty. Methods This is a longitudinal study of pubertal maturation in 183 girls, recruited at ages 6–7, followed up between 2004 and 2018. Measures included age at onset of puberty, and adult height attained; PHV; AAM; adult height, and serum IGF-1, and estrone-to-androstenedione (E:A) ratio. Results PHV was greatest in early, and least in late maturing girls; length of the pubertal growth spurt was longest in early, and shortest in late maturing girls. Earlier AAM was related to greater PHV. IGF-1 concentrations tracked significantly during puberty; higher IGF-1 was related to earlier age of PHV, earlier AAM, greater PHV, and taller adult height. Greater E:A ratio was associated with earlier AAM. Conclusions Factors driving the association of earlier menarche and pubertal growth with breast cancer risk may be explained through a unifying concept relating higher IGF-1 concentrations, greater lifelong estrogen exposure, and longer pubertal growth period, with an expanded pubertal window of susceptibility.

Onset of puberty, as defined by breast stage 2, appears to be starting at younger ages since the 1940s. There is an ongoing controversy regarding what is normative, as well as what is normal, and the evaluation that is deemed necessary for girls maturing before 8 years of age. There are potential implications of earlier pubertal timing, including psychosocial consequences during adolescence, as well as longer term risks, such as breast cancer and cardiometabolic risks. There are additional consequences derived from slower pubertal tempo, for age of menarche has not decreased as much as age of breast development; these include longer interval between sexual initiation and intentional childbearing, as well as a broadened window of susceptibility to endocrine-related cancers.

Study Objective Several strategies have been proposed to determine onset of puberty without examination by a trained professional. This study sought to evaluate a novel approach to determine onset of puberty in girls. Design, Setting, and Participants This study used the Cincinnati cohort of the Breast Cancer and the Environment Research Program. Girls were recruited at 6-7 years of age and followed every 6 months in the initial 6 years, and annually thereafter. Breast maturation and foot length were performed at each visit by health professionals certified in those methods. Mothers were asked to provide the age at which they believed that their daughter's shoe size had increased more rapidly. Results These analyses include 252 participants. Age at increase in shoe size was correlated to age at onset of puberty (r = 0.21) and increase in foot length (r = 0.24). The difference of reported age of increased shoe size was 0.46 years before breast development. Conclusion Reported increase in shoe size occurred somewhat earlier and was significantly correlated to age of breast development. These preliminary results suggest that mother's report of increase in shoe size appear to be as accurate as reports of other indirect methods of determining onset of puberty, such as self- or maternal estimates of breast development.

Importance The initial clinical sign of pubertal onset in girls is breast gland development (thelarche). Although numerous studies have used recalled age at menarche (first menstruation) to assess secular trends of pubertal timing, no systematic review has been conducted of secular trends of thelarche. Objectives To systematically evaluate published data on pubertal timing based on age at thelarche and evaluate the change in pubertal onset in healthy girls around the world. Data Sources A systematic literature search was performed in PubMed and Embase of all original peer-reviewed articles published in English before June 20, 2019. Study Selection Included studies used clinical assessment of breast development in healthy girls and used adequate statistical methods, including the reporting of SEs or CIs. The quality of the articles was evaluated by assessing study design, potential sources of bias, main characteristics of the study population, and methods of statistical analysis. Data Extraction and Synthesis In accordance with PRISMA guidelines, all articles were assessed for eligibility independently by 2 authors. Weighted regression analysis was performed using a random-effects model. Main Outcomes and Measures Studies examining age at thelarche (development of Tanner breast stage 2) in healthy girls. Results The literature search resulted in a total of 3602 studies, of which 30 studies fulfilled the eligibility criteria. There was a secular trend in ages at thelarche according to race/ethnicity and geography. Overall, the age at thelarche decreased 0.24 years (95% CI, −0.44 to −0.04) (almost 3 months) per decade from 1977 to 2013 (P = .02). Conclusions and Relevance The age at thelarche has decreased a mean of almost 3 months per decade from 1977 to 2013. A younger age at pubertal onset may change current diagnostic decision-making. The medical community needs current and relevant data to redefine “precocious puberty,” because the traditional definition may be outdated, at least in some regions of the world.

Screening for sexually transmitted infections (STIs) outside of traditional health-care facilities is limited by the privacy needed for sample collection. We explored the acceptability of privacy shelters for the self-collection of genital swabs and tested the use of privacy shelters during mobile STI screening. Attendees ≥14 years old at two outdoor community events completed a questionnaire that assessed participant characteristics, health-care access, and rating of acceptability of self-collecting penile or vaginal swabs in a privacy shelter and four other private spaces: portable restroom, health van, home, and doctor’s office. A privacy shelter was used during mobile STI screening. The majority (65%) of the 95 participants reported that using a privacy shelter was somewhat or very acceptable. No participant characteristics or health-care access factors were associated with the acceptability of privacy shelters. Women rated a privacy shelter more acceptable than a portable restroom or health van. Men rated a privacy shelter more acceptable than a portable restroom. During mobile STI screening, all 13 men and women who requested STI testing used the privacy shelter for self-sampling. Rating of acceptability before and after privacy shelter use was the same. Privacy shelters may enable STI screening without using a building or vehicle for sample collection.

Phenolic compounds represent a class of environmental chemicals with potentially endocrine-disrupting capabilities. We investigated longitudinal associations between childhood exposure to phenols, from both manmade and natural sources, and subsequent measures of adiposity among girls enrolled in the Breast Cancer and the Environment Research Program between 2004 and 2007. Baseline (ages 6-8 years) urinary concentrations were obtained for creatinine and phenol metabolites: enterolactone, genistein, daidzein, benzophenone-3, bisphenol A, the sum of parabens (methyl, ethyl, and propyl parabens), 2,5-dichlorophenol, and triclosan. Body mass index (weight (kg)/height (m)2), waist circumference, and percent body fat were measured at annual or semiannual examinations through 2015 (n = 1,017). Linear mixed-effects regression was used to estimate how baseline concentrations of phenols (tertile groups) were related to changes in girls' adiposity measurements from ages 7 through 15 years. Enterolactone was inversely associated with body mass index, waist circumference, and percent body fat, while 2,5-dichlorophenol was positively associated with these measurements. A nonmonotonic association was observed for triclosan and girls' adiposity; however, it was due to effect modification by baseline overweight status. Triclosan was positively associated with adiposity only among overweight girls. These results suggest that exposure to specific phenols during childhood may influence adiposity through adolescence.

BACKGROUND: Perfluorooctanoate (PFOA) has been used extensively in the manufacture of both commercial and household products. PFOA serum concentrations have been associated with adverse health effects, including lower body mass in children and infants. OBJECTIVE: To determine if there is an association between PFOA and body mass, insulin and lipid profile in exposed young girls. METHODS: We conducted a cross-sectional study of PFAS environmental biomarkers and insulin resistance in 6 to 8 year-old girls from Greater Cincinnati (n=353). In 2004–2006, blood samples were obtained to measure polyfluoroalkyl substances (PFAS), fasting insulin, glucose and lipids. Clinical exams included anthropometric measurements and pubertal maturation staging. Linear regression and mediation analyses, specifically structural equation modeling (SEM), were used to determine the strength and direction of the relationships between PFAS, pubertal maturation status, body mass index (BMI), cholesterol and insulin resistance. RESULTS: The median PFOA (7.7ng/ml) was twice the National Health and Nutrition Examination Survey (2005–2006). Only PFOA, a PFAS sub-species, showed statistically significant relationships with the outcomes. In regression models, PFOA was associated with decreased BMI and waist-to-height ratio (p=0.0008; p=0.0343), HDL-cholesterol (p=0.0046) and had a borderline inverse association with the HOMA Index of insulin resistance (p=0.0864). In SEM, PFOA retained an inverse relationship with BMI (p

Lead may alter growth and development, but prospective studies on menarche are lacking. Among girls enrolled at 6-8 years of age in the Breast Cancer and Environment Research Program cohort during ...

STUDY OBJECTIVES: Menarche is a critical milestone in a woman’s life, and historically has been determined through several approaches. The goals of this study were to: 1) determine age at menarche from multiple reports of parents and adolescent participants in a prospective study; 2) examine factors impacting age at menarche; and 3) determine correlates of menarche and pubertal tempo. DESIGN: Longitudinal observational study. SETTING: Three sites of the Breast Cancer and the Environment Research Program. PARTICIPANTS: Girls enrolled at 6-8 years of age. MAIN OUTCOME MEASURES: Parental and participant reported age of menarche, tempo of puberty. RESULTS: There were 946 girls who were assigned an age of menarche. The correlation between parent and participant reports was high (Spearman R= 0.799, p< 0.001), and the difference was insignificant. Median age at menarche overall was 12.25 years. Compared to Black participants, Hispanic girls were more likely to have menarche earlier, while White and Asian girls were more likely to have menarche later. Age of menarche was highly correlated with age of breast development (Spearman R= 0.547, p< .001), and inversely with BMI (Spearman R= −0.403, p< .001). Tempo (interval of age of breast development to menarche) was slower in those with earlier breast development. CONCLUSIONS: Parental and adolescent reports of menarche are highly correlated. Earlier breast maturation was associated with slower tempo through puberty. BMI had a greater impact on age at menarche than did race and ethnicity.

Early menarche is linked to higher incidence of adult asthma, suggesting that earlier puberty may influence type 2 immune response characteristics of allergic diseases. We examined the hypothesis that timing of breast and pubic hair development, which precede menarche, is associated with increased childhood atopic conditions.Girls were enrolled at 6-8 yr of age (2004-2007) in the Breast Cancer and the Environment Research Program Puberty Study and were followed through 2011. Pubertal stages were assessed and atopic conditions were queried annually. Associations of age at pubertal stage 2 for breast or pubic hair development with atopic conditions were assessed using prevalence ratios (PR) or odds ratios (OR) and 95% confidence intervals (CI) from log-binomial regression and generalized estimating equation models, controlling for body mass index and other covariates. A total of 1055 girls with medical and pubertal stage data were included.Asthma (ever vs. never) was associated with younger pubarche (≤10 vs.10 yr, PR = 1.15, CI: 1.04-1.28 adjusted for race/ethnicity and site; PR = 1.13, CI: 1.01-1.25 further adjusted for BMI), but not thelarche. In longitudinal models, risk of developing allergies increased with younger age at pubarche (adjusted OR = 1.60, CI: 1.10-2.34; ≤10 vs.10 yr). Risks were highest among black girls with earlier pubarche (n = 248/326); for allergies, their fully adjusted OR was 2.35, CI: 1.06-5.19 for pubarche ≤10 vs.10 yr.Atopic conditions during childhood are associated with younger age at pubarche, independent of obesity, and these relationships may vary by racial/ethnic groups.

Background: Higher socioeconomic position (SEP) has been associated with increased risk of breast cancer. Its relationship with earlier age of pubertal onset, a risk factor for breast cancer, is less clear. Methods: We studied the relationship of SEP to pubertal onset in a multiethnic cohort of 1,237 girls ages 6 to 8 years at baseline. Girls in three U.S. cities were followed for 5 to 8 years with annual clinical examinations from 2004 to 2012. SEP measures were examined for associations with pubertal onset, assessed by breast budding (thelarche) and pubic hair development (adrenarche). Analyses were conducted with accelerated failure time models using a Weibull distribution, with left, right, and interval censoring. Results: Higher body mass index percentage at entry to the study and black or Hispanic race/ethnicity were the strongest predictors of age at pubertal onset. An SEP index comprising household family income, mother's education, and home ownership was an independent predictor of thelarche in adjusted models for all girls together and for white and Latina, separately, but not black girls, and the relationship varied by study site. The SEP index was not related to adrenarche in adjusted models. Overall, girls from the lowest quintile of SEP entered puberty on average 6% earlier than girls from the highest quintile (time ratio = 0.94; 95% confidence interval 0.91–0.97) in adjusted models. Conclusions: Our results suggest that early-life SEP may influence the timing of pubertal development. Impact: Factors related to lower SEP in childhood can adversely affect early development in ways that may increase the risk of breast cancer. Cancer Epidemiol Biomarkers Prev; 26(12); 1714–21. ©2017 AACR.

Background Tobacco smoke contains known hormonally active chemicals and reproductive toxicants. Several studies have examined prenatal maternal smoking and offspring age at menarche, but few examined earlier pubertal markers, nor accounted for exposure during childhood. Our objective was to examine pre- and postnatal smoke exposure in relation to timing of early pubertal events. Methods An ethnically diverse cohort of 1239 girls was enrolled at age 6-8 years old for a longitudinal study of puberty at three US sites. Girls participated in annual or semi-annual exams to measure anthropometry and Tanner breast and pubic hair stages. Prenatal and current tobacco smoke exposures, as well as covariates, were obtained from parent questionnaire. Cotinine was measured in urine collected at enrollment. Using accelerated failure time models, we calculated adjusted time ratios for age at pubertal onset (maturation stages 2 or higher) and smoke exposure. Results Girls with higher prenatal (≥5 cigarettes per day) or secondhand smoke exposure had earlier pubic hair development than unexposed (adjusted time ratio: 0.92 [95% CI = 0.87, 0.97] and 0.94 [95% CI = 0.90, 0.97], respectively). Including both exposures in the same model yielded similar associations. Higher urinary cotinine quartiles were associated with younger age at breast and pubic hair onset in unadjusted models, but not after adjustment. Conclusions Greater prenatal and childhood secondhand smoke exposure were associated with earlier onset of pubic hair, but not breast, development. These exposures represent modifiable risk factors for early pubertal development that should be considered for addition to the extensive list of adverse effects from tobacco smoke.

Study Objective Amphiregulin is a member of the epidermal growth factor family. In breast tissue, amphiregulin is a mediator of estrogen and progesterone signaling. The objectives were to examine the relationship of amphiregulin levels during peripuberty with estrogen levels. Design, Setting, Participants, Interventions, and Main Outcome Measures The participants in this analysis were a subset from a longitudinal study of pubertal maturation, the Breast Cancer and the Environment Research Program. They were recruited between ages 3 and 7 years. Blood specimens were selected for hormone analysis between 24 months before and 6 months after breast development. Serum amphiregulin levels were analyzed using enzyme-linked immunosorbent assay. Results Amphiregulin levels were measured in 188 girls; 8.5% had a maternal history of breast cancer, and 30.9% of samples were below the limit of detection. Amphiregulin levels were greatest at 18 months before the onset of breast development (P

Background Age at female puberty is associated with adult morbidities, including breast cancer and diabetes. Hormonally active chemicals are suspected of altering pubertal timing. We examined whether persistent organic pollutants (POPs) are associated with age at menarche in a longitudinal study. Methods We analyzed data for females enrolled at age 6–8 years in the Breast Cancer and Environment Research Program from California and Ohio. Participants were followed annually 2004–2013 and provided serum (mean age 7.8 years) for measurement of polychlorinated biphenyl (PCB), organochlorine pesticide (OCP), and polybrominated diphenyl ether (PBDE) concentrations. Age of menarche was assigned based on parental and participant reported dates and ages of menarche. Adjusted hazard ratios (aHRs) for menarchal onset were calculated with Cox proportional regression. Body mass index (BMI), potentially on the causal pathway, was added to parallel analyses. Results Age of menarche was later with higher summed PCB levels (median 11.9 years in quartile 1 [Q1] versus 12.7 in quartile 4 [Q4]) and OCP levels (12.1 years versus 12.4, respectively). When adjusting for all covariates except BMI, higher POP concentrations were associated with later age at menarche (Q4 versus Q1 aHRs: PBDEs 0.75 [95% CI 0.58, 0.97], PCBs 0.67 [95% CI 0.5, 0.89], and OCPs 0.66 [95% CI 0.50, 0.89]). Additional adjustment for BMI attenuated aHRs; PCB aHR approached the null. Conclusion Findings revealed later onset of menarche with higher concentrations of certain POPs, possibly through an association with BMI. Altered pubertal timing may have long lasting effects on reproductive health and disease risk, so continued attention is important for understanding the biological processes affected by hormonally active chemicals.

Primary: To examine the relationship between relative timing of puberty with bone mineral density (BMD) in a group of adolescent girls; Secondary: To determine if family history of breast cancer was associated with bone mineral density.Longitudinal study of girls recruited between 6 and 7 years of age seen every 6 months for 5 years, and subsequently seen annually. BMD of the lumbar spine was measured by dual-energy X-ray absorptiometry (DXA) at mean age of 12.5 years; age- and race-specific Z-scores (BMDz) were calculated. Age of pubertal onset was determined by the first occurrence of breast stage 2, and participants were categorized into race-specific early, on-time and late puberty onset groups.BMDz by timing of pubertal onset, and by family history of breast cancer.DXA scans were performed on 227 study participants, and a second scan was performed on 114 participants 2 years later. Age of onset of puberty was inversely correlated with BMDz, r = -0.31 (P .0001). There was no association between BMDz and family history of breast cancer.Earlier timing of puberty was associated with higher BMD. The high shared variance of BMD and timing of pubertal onset implies an underlying biologic basis.

Purpose Early life exposures during times of rapid growth and development are recognized increasingly to impact later life. Epidemiologic studies document an association between exposures at critical windows of susceptibility with outcomes as diverse as childhood and adult obesity, timing of menarche, and risk for hypertension or breast cancer. Methods This article briefly reviews the concept of windows of susceptibility for providers who care for adolescent patients. Results The theoretical bases for windows of susceptibility is examined, evaluating the relationship between pubertal change and breast cancer as a paradigm, and reviewing the underlying mechanisms, such as epigenetic modification. Conclusions The long-term sequela of responses to early exposures may impact other adult morbidities; addressing these exposures represents an important challenge for contemporary medicine.

To examine whether the known association between early pubertal breast maturation and insulin sensitivity (SI) is mediated by adiposity.Cross-sectional analyses.Observational study examining the roles of environment, diet, and obesity on puberty.379 girls with a mean age, 7.03 years; 62% were white and 29% black.Pubertal development was assessed via physical examination and adiposity by body mass index Z score (BMI Z) and waist-to-height ratio. Fasting blood samples were obtained for insulin and glucose concentrations. SI was calculated with the quantitative insulin sensitivity check index (QUICKI). Analysis of variance and Sobel's test was used to assess mediation.Fifty-five girls were pubertal (Tanner 2 breast). Breast maturation was inversely associated with SI (P = .005) and positively associated with BMI Z (P.001) and waist-to-height ratio (P.001). The effect of breast maturation on SI was no longer significant (P = .41) after adjusting for the effect of BMI Z, which remained significant (P.001). Similar results were obtained when waist-to-height ratio replaced BMI Z in the models. Mediation analyses demonstrated that 75% of the association between breast maturation and SI is mediated by adiposity.In girls, decreased SI during early puberty is largely mediated by total and visceral adiposity.

Hormonally active environmental exposures may alter timing of puberty. We investigated urinary biomarkers of 9 phthalates and 13 phenols including 3 phytoestrogens in relation to menarche among girls enrolled at 6-8 years of age during 2004-2007 in the Breast Cancer and Environment Research Program. This multi-ethnic cohort study of 1239 girls at three US sites was followed through 2015. For urinary metabolites assayed in baseline samples, age at menarche was available on 1051 girls. Associations of biomarker quintiles with menarche were estimated from Cox proportional hazards models adjusted for race, ethnicity, and caregiver education (aHR, 95% confidence intervals [CI]). Urinary enterolactone was associated with later age at menarche (aHR 0.82 [0.66-1.03] for 5th vs 1st quintile, p-trend 0.028). Effects were stronger in girls with below-median body mass index (aHR 0.75 [0.59-0.95], 3rd vs 1st enterolactone tertile) compared to higher body mass (aHR 1.04 [0.82-1.33]). 2,5-Dichlorophenol was associated w...

Phthalates are environmental chemicals that may play a role in the development of obesity. Few studies have investigated longitudinal associations between postnatal phthalate exposures and subsequent anthropometric measurements in children. We collected data as part of The Breast Cancer and Environment Research Program at three US sites. A total of 1,239 girls, aged 6-8 years, were enrolled in 2004-2007. We categorized baseline phthalate exposures, assessed from creatinine-corrected urinary concentrations of low-molecular weight phthalate metabolites, as low

Primiparity has been associated with 3 to 4 mg/dL lower high-density lipoprotein cholesterol concentrations in black and white adult women that persist several years after delivery.To examine the lasting effects of adolescent pregnancy on blood lipids, an early risk factor for future cardiometabolic diseases.The National Heart Lung and Blood Institute's Growth and Health Study is a multicenter prospective cohort that measured fasting blood lipids for 1013 (513 black, 500 white) participants at baseline (1987-1988) ages 9-10, and again at follow-up (1996-1997) ages 18-19.Change in fasting plasma total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol, defined as the difference between baseline and follow-up measurements, was compared among 186 (145 black, 41 white) primi- or multiparas, 106 (55 black, 51 white) nulliparous, gravidas versus 721 (313 black, 408 white) nulligravidas. Fully adjusted multiple linear regression models estimated blood lipid changes among these pregnancy groups adjusted for race, age at menarche, baseline lipids, physical inactivity, body mass index, and family sociodemographics.In the 10-year study period, adolescent paras compared with nulligravidas had greater decrements in high-density lipoprotein cholesterol (mg/dL; fully adjusted mean [95% confidence interval] group differences in black -4.3 [-6.7, -2.0]; P.001 and white: -4.5 [-8.2, -0.7]; P = .016) and greater increments in fasting triglycerides (mg/dL; adjusted mean [95% confidence interval] group differences in black: 10.4 [3.9, 16.8]; P.001, and white: 11.6 [-3.6, 26.8]; P = .167).Adolescent pregnancy contributes to pro-atherogenic lipid profiles that persist after delivery. Further research is needed to assess whether adolescent pregnancy has implications for future cardiovascular disease risk in young women.

The proportion of child and adolescent obesity in the United States has dramatically increased over the past few decades, challenging public health strategies and medical needs of the individual. The medical consequences of obesity include metabolic syndrome, polycystic ovary syndrome, and cardiovascular disease. There is no definite diagnostic criterion of metabolic syndrome in children and adolescents; commonly noted features are central adiposity, insulin resistance, dyslipidemia, and hypertension. To prevent negative health outcomes and early recognition for those at risk for overweight and obesity, healthcare providers should screen BMI in children and adolescents at least annually, as well as provide anticipatory guidance to all families during health maintenance visit. This review will address the epidemiology and consequences of obesity in children and adults, and issues for health care providers and public health officials to consider. These issues include increasing physical activity, decreasing sedentary activities, and promoting healthy eating behaviors.

Background The Breast Cancer and the Environment Research Centers (BCERCs) include collaborators from basic sciences, epidemiology, and the community, conducting studies to investigate whether environmental exposures are associated with the timing of puberty. A pilot study of a subset of the study participants assessed the feasibility of measuring selected biomarkers of exposure in blood and urine in girls 6–8 years of age. In the Greater Cincinnati study population, we found an elevated serum concentration of perfluorooctanoate (PFOA) among > 90% of young girls living in a small community. Objectives The research team deliberated whether and how to report the PFOA findings to our study families. We will address the issues considered in our decision, as well as the formats we used to present the findings. Methods The results were verified as we searched for potential sources of the elevated PFOA levels. As a research team, we grappled with issues regarding the reporting of unexpected results, derived from unknown sources and with unknown clinical significance. Ultimately, we did decide to present these findings to the study families through a well-developed communication plan. Discussion Research team members came from a variety of experiences and backgrounds, which led to different interpretations about the clinical, ethical, and public health issues surrounding these findings. The ethical debates centered around the precautionary principle, the right to know, and do no harm. Conclusions Given advances in environmental biomarker technologies and greater use of the transdisciplinary research model, a communication plan must be developed for those involved as study participants.

The prevalence and severity of obesity have increased in recent years, likely the result of complex interactions between genes, dietary intake, physical activity, and the environment. The expression of genes favoring the storage of excess calories as fat, which have been selected for over many millennia and are relatively static, has become maladaptive in a rapidly changing environment that minimizes opportunities for energy expenditure and maximizes opportunities for energy intake. The consequences of childhood and adolescent obesity include earlier puberty and menarche in girls, type 2 diabetes and increased incidence of the metabolic syndrome in youth and adults, and obesity in adulthood. These changes are associated with cardiovascular disease as well as with several cancers in adults, likely through insulin resistance and production of inflammatory cytokines. Although concerns have arisen regarding environmental exposures, there have been no formal expert recommendations. Currently, the most important factors underlying the obesity epidemic are the current opportunities for energy intake coupled with limited energy expenditure.

A previous editorial in this journal (Puberty - Whither goest?) discussed whether pubertal maturation was occurring earlier in U.S. girls, and the potential causes of those changes.1 Several original manuscripts, review papers, and convened consensus groups have discussed these topics, and most of the published works have accepted that 1) there is a decrease in the age of onset of puberty, as defined by breast development, and 2) there is a more modest decrease in the age of menarche (reviewed by Kaplowitz).2 Black women experience menarche approximately six months earlier than white women, whereas their breast development appears to be up to one year earlier than white women. When examining the potential causes of the continued decrease in age of onset of puberty in girls, many have noted that there has been a coincident epidemic in rates and degrees of obesity. They concluded that increased body mass index (BMI) accounts for much of the change in age of onset of puberty in girls; the changes in pubertal onset, and association with increased BMI, are not as clear in boys.

Children exposed to endocrine disruptors are hypothesized to be susceptible for cancer development later in life. Identifying functional biomarkers of specific exposures may indicate predisposition for this disease. The objectives of this study were to identify protein biomarkers of 1) effect and 2) susceptibility for cancer from the blood of girls exposed to select environmental chemicals. In prepubertal girls, urine concentrations of bisphenol A (BPA), genistein, mono-ethyl hexylphthalate (MEHP) and mono-benzyl phthalate (MBzP) were used to identify girls in the top quintile of exposure for each of these environmental chemicals, and age-matched prepubertal girls with urine analyte concentrations below the median. Blood samples of these girls were depleted of the seven most abundant proteins using human-specific affinity spin columns. Using isobaric Tandem Mass Tags and quantitative mass spectrometry (TMT-MS), 51, 34, 57 and 47 differentially expressed proteins were identified from the blood of prepubertal girls with high urine concentrations of BPA, genistein, MEHP and MBzP, respectively, compared to controls. The data demonstrates the potential of proteomic technology to not only provide biomarkers of effect from aminimally invasive source of biological material, blood, but to identify protein molecules that are intimately involved in the pathobiology of cancer. The differentially regulated cancer associated proteins in girls with high concentrations of BPA and genistein are consistent with reported roles of BPA in carcinogenesis and of genistein in mammary cancer prevention, respectively.

Background Cross-sectional seroprevalence studies indicate that infections with herpes simplex virus (HSV) types 1 (HSV-1) and 2 (HSV-2) and cytomegalovirus (CMV) are common. However, data on the rates of acquisition of these infections are limited. Methods A 3-year longitudinal study of HSV-1, HSV-2, and CMV seroprevalence was conducted in a cohort of 174 adolescent girls (age at enrollment, 12-15 years). Results At study entry, 41% of the girls reported a history of sexual activity, and by the end of the study, 73% reported a history of sexual activity. At enrollment, 71% of all participants were seropositive for CMV, 44% were seropositive for HSV-1, and 7% were seropositive for HSV-2. By the end of the study, 81% of the girls were seropositive for CMV, 49% were seropositive for HSV-1, and 14% were seropositive for HSV-2. Among girls with a history of sexual activity, 15.5% were HSV-2 seropositive at the beginning of the study, and 18.9% were HSV-2 seropositive at the end of the study. The attack rates, based on the number of cases per 100 person-years, were 13.8 for CMV infection and 3.2 for HSV-1 infection (among all girls) and 4.4 for HSV-2 infection (among girls with a history of sexual activity). Participants with preexisting HSV-1 antibodies were associated with a significantly lower attack rate for HSV-2 infection. A generalized estimating equation model indicated that participants with a longer history of sexual activity and those who had more sexually transmitted diseases during the 6-month periods before the study visits were more likely to be HSV-2 seropositive. Conclusions This longitudinal study of adolescent girls found high baseline CMV and HSV-1 seroprevalence rates and substantial attack rates for all 3 pathogens.

There are several issues that arise regarding the evaluation of teens with urethritis and cervicitis. What are the appropriate treatments for adolescents? What are the issues regarding rescreening and do we need to consider tests of cure? Chlamydia is the most common bacterial sexually transmitted disease in adolescents in the United States. The prevalence appears to be leveling off or decreasing which may reflect several reasons. More frequent screening utilizing more sensitive diagnostic techniques such as nucleic acid amplification techniques and screening populations that are traditionally more difficult to reach may have led to the lower rates. However there still are many young men and women with high-risk behaviors who are not receiving appropriate screening. (excerpt)

Higher socioeconomic position (SEP) has been associated with increased risk of breast cancer. Its relationship with the age of menarche, which is inversely associated with risk of breast cancer, and to the age of pubertal onset, is less clear. We studied the relationship of SEP to pubertal onset in a multiethnic cohort of girls aged 6–8 years at baseline and followed for 5–8 years in the Breast Cancer and the Environment Research Program in three study sites across the United States that included annual clinical examinations performed from 2004 to 2012. Analyses were conducted with accelerated failure time models using a Weibull distribution, with left, right and interval censoring. Among 1059 girls, an index of SEP comprised of household family income, mother's education and whether the home was owned or rented was assessed for associations with pubertal onset, measured by breast budding (Tanner Stage B2) and pubic hair development (Tanner Stage PH2). Girl's BMI% at entry to the study and black or Hispanic race/ethnicity were the strongest predictors of age at pubertal onset by both measurements, but the SEP index was an independent predictor in adjusted models. Girls from the lowest quintile of SEP entered puberty on average 6% earlier (6.0–7.5 months) than girls from the highest quintile (time ratio = 0.94, 95% confidence interval 0.91–0.97) adjusted for BMI%, race/ethnicity and their interaction. The meaning of SEP in this relationship bears further study, but our results suggest that early life social circumstances beyond race/ethnicity and body size may influence the timing of pubertal development. The following are the 17 highest-scoring abstracts of those submitted for presentation at the 40th Annual ASPO meeting held March 13–15, 2016, in Columbus, OH.

Objective Patterns of pubertal maturation may have an impact on several risk factors associated with adult morbidity and mortality, such as obesity. We examined the relationship of the initial manifestation of puberty in girls with anthropometric measures, as well as age at menarche. Methods White females (n = 1166, ages 9 and 10 at intake) were followed with annual visits for 10 years. Physical examinations included height, weight, skinfold thicknesses, and pubertal maturation assessment. Results During the course of the study, 443 of 859 eligible females (51.6%) were observed to have asynchronous maturation in the development of puberty, that is, initial areolar/breast (thelarche pathway) or pubic hair (adrenarche pathway) development, without development of the other characteristic. Using a longitudinal regression model, significant interactions were noted between initial pubertal manifestation and years since onset of puberty on the following outcomes: sum of skinfolds thickness, percent body fat, waist-to-hip ratio, and body mass index (BMI). However, age of onset of pubertal maturation was the same in the 2 groups (10.7 years). Females in the thelarche pathway had earlier menarche (12.6 vs 13.1 years) as well as greater skinfolds, body fat, and BMI at the time of menarche. Females in the thelarche pathway also had greater body fat and BMI 1 year before puberty and throughout puberty compared with those in the adrenarche pathway. Conclusions Females who enter puberty through the thelarche pathway, as compared with the adrenarche pathway, had greater sum of skinfold thicknesses, BMI, and percent body fat 1 year before the onset, as well as throughout, puberty. Because larger body composition and earlier age of menarche of females in the thelarche pathway parallel the epidemiologic profiles of women who are obese or at risk for obesity, these females may be at greater risk for adult obesity.

Objective To determine the role of increasing free testosterone and estradiol in pubertal changes in male lipids. Methods We conducted a 3-year, longitudinal, observation study with biannual visits of 251 black and 285 white boys who were 10 to 15 years of age at enrollment. Sex hormones, lipid parameters, and body composition measures were obtained according to a standard protocol. The body mass index (kg/m 2 ) was used to characterize obesity. Results White boys had higher triglycerides, lower high-density lipoprotein cholesterol (HDL-C), lower apolipoprotein (apo)AI, and higher apoB than black boys. In boys of both races, increased body mass index was associated with increases in triglycerides, low-density lipoprotein cholesterol, apoB and decreases in HDL-C and apoAII. Within this framework, increased free testosterone was associated with increased apoB and decreased HDL-C and apoAI, whereas increased estradiol was associated with increased HDL-C and decreased triglycerides, low-density lipoprotein cholesterol, and apoB. Conclusion Changes in sex steroid hormones have significant effects on changes in lipid parameters—increasing free testosterone levels has atherogenic effects and increasing estradiol has antiatherogenic effects.

Study Objective To evaluate the effectiveness of a sexually transmitted infection (STI) intervention by a health educator that included partner notification, condom use, and retesting within 3 months. Design, Setting, and Participants Retrospective chart review was conducted, and data were collected from 274 sexually active adolescent girls, aged 15 to 19 years, who were diagnosed with gonorrhea (GC), Chlamydia (CT), and Trichomonas (TV) infection, during a 9-month span in an urban hospital–based adolescent medicine clinic. Methods Data regarding recurrent STIs (GC, CT, and TV) were collected for 12 months following the incident infection. There were 161 in the intervention group (health educator counseling), and 113 controls who received usual care. Differences between groups were analyzed using χ2 and survival analyses. Results There were no significant differences in age, gender, or race between the intervention and control groups at baseline. The majority in both groups were diagnosed initially with CT infection (57% CT, 16% GC, and 5% TV in the intervention group; 46% CT, 21% GC, and 12% TV in the control group). There was a significantly lower rate of STI in the intervention group for those retested within 12 months of the initial diagnosis (P = .002). The median (SD) time to recurrence in the intervention group was greater: 134 (14.7) days versus 116 (12.1) days (P = .034). Health education counseling, initial diagnosis with TV, and duration of time from initial diagnosis to retest (interval to retest) were significant protective factors for recurrent STI. Conclusions Health education counseling in an urban adolescent clinic is effective in reducing recurrent infection at 12-month follow-up and can serve as an important component in reducing STI recidivism.

Objective: This study examined the relationship between timing of sexual maturation and eating disorders symptoms in adolescent girls. Method: Data were collected over 10 years for a cohort of 1,213 Black girls and 1,166 White girls who were either 9 or 10 years old at study entry. Annually, girls' height and weight were measured and, biannually, girls completed self-report measures of eating disorders symptoms. Results: Early-onset menarche is a risk factor for the development of body image and dieting concerns, but the effect of timing is due to the impact of early and late maturation on body weight. Discussion: Findings underscore the importance of adiposity as a risk factor for poor mental health. (C) 2001 by John Wiley & Sons, Inc.

Purpose: To evaluate the relationships of overweight and fat patterning with cardiovascular disease (CVD) risk factors in black and white boys. Design: Cross-sectional analysis of CVD risk factors by weight and central adiposity groups in black and white boys, aged 10 to 15 years. Mean adiposity, lipid, and blood pressure variables were compared between weight and central adiposity groups within race by using linear regression models. Observed clustering of risk factors within weight and adiposity groups was compared with the expected clustering under an assumption of no association. Results: Within each racial group, overweight boys had greater skinfolds, lower high-density lipoprotein cholesterol levels, higher low-density lipoprotein cholesterol and triglyceride levels, and higher systolic and diastolic blood pressure than non-overweight boys. Among overweight boys, greater central adiposity was associated with higher risk factor levels and increased clustering of risk factors. Conclusion: Overweight and central adiposity together profoundly affect CVD risk factor levels and risk factor clustering in black and white boys.(J Pediatr 1999;135:451-7)

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.

Purpose: We examined changes in self-esteem and feelings of competence with physical appearance and social acceptance over approximately 5 years in 1166 white and 1213 black girls, aged 9 and 10 years at baseline. >Methods: Maturation stage and body mass index (BMI) were assessed annually. Biennially girls completed Harter's Self-Perception Profile for Children. Changes were analyzed in the context of race, sexual maturation, BMI, and household income. Longitudinal regression models were used to compare trends with age in global self-worth, physical appearance, and social acceptance. Results: Mean global self-worth showed little change over ages 9–14 years in blacks ( p = 0.09) but decreased in whites ( p p p p p p values, ≤ 0.002). Adjustment for maturation stage, BMI, and household income did not alter the significance or direction of racial differences in the changes with age in global self-worth and physical appearance scores. Self-worth, physical appearance, and social acceptance scores decreased with increasing BMI. Decreases in physical appearance and social acceptance scores with increasing BMI were smaller in blacks than in whites ( p p p = 0.08). Conclusions: This article reports the first data on self-esteem scores by age for a large population of black girls aged 9 and 14 years and concludes that self-esteem does not follow the same developmental pattern in black as in white girls. A reason for black girls' higher and more stable self-worth and their greater satisfaction with their physical appearance compared to white girls may be racial differences in attitudes toward physical appearance and obesity.

We determined the prevalence of herpes simplex virus (HSV) and cytomegalovirus (CMV) antibodies in a cohort of adolescents 12 to 22 years of age in anticipation of the development of vaccines to control HSV and CMV infections. For the overall study population, we found that 62% were seropositive for HSV type 1 (HSV-1), 12% were seropositive for HSV type 2 (HSV-2), and 65% were seropositive for CMV. Race was not related to HSV-1 seropositivity, but African-American adolescents were more likely than Caucasian adolescents to be seropositive for HSV-2 and CMV. Girls also were more likely than boys to be seropositive for HSV-2 and CMV. For boys, history of a sexually transmitted disease was identified as a risk factor for HSV-2 seropositivity; for girls, a greater number of sexual partners increased the risk of being seropositive for HSV-2. Our data demonstrating a high prevalence of infection during adolescence suggest that immunization for HSV-1, HSV-2, and CMV may need to occur in childhood.

Objectives: The objectives of this study were to determine which factors in early pubertal girls might be predictive of later, severe facial acne. Study design: The study was a 5-year longitudinal cohort study, with yearly visits from 1987 through 1991, in a volunteer sample of 439 black and 432 white fourth- and fifth-grade girls with consent from their legal guardians. The subjects were recruited from public and parochial schools in Cincinnati, Ohio. The degree of facial acne was classified annually as mild, moderate, or severe. Blood samples were obtained at the first, third, and fifth years of the study. Using the acne status during the fifth year of the study as the outcome variable, we determined the contributions from the prior acne status and the serum levels of dehydroepiandrosterone sulfate (DHEAS), testosterone, free testosterone (FT), estradiol (E 2 ), progesterone, and testosterone-estrogen binding globulin (TEBG) and compared the results at various ages and at times before and after menarche. Results: No racial differences in acne or hormone levels were found. There was a progressive increase in the number of acne lesions with age and maturation. The girls exhibited many more comedonal than inflammatory acne lesions, regardless of age. The girls in whom severe acne developed by the fifth year of the study had significantly more comedones and inflammatory lesions than girls with mild or moderate acne, as early as age 10 years, approximately 2 ½ years before menarche, a time when their degree of acne was mild. Girls with mild comedonal acne had significantly later onset of menarche (12.5 compared with 12.2 years) than girls with severe comedonal acne. Girls in whom severe comedonal acne developed had significantly higher levels of serum DHEAS and, in a longitudinal analysis, somewhat higher levels of testosterone and FT in comparison with girls who had mild or moderate comedonal acne. Serum E 2 , testosterone/E 2 , progesterone, and TEBG values were no different in girls with severe compared with mild or moderate comedonal acne. Conclusions: The early development of comedonal acne may be one of the best predictors of later, more severe disease. The adrenal hormone DHEAS appears to play an important role in the initiation of acne. DHEAS, testosterone, and FT are associated with the perpetuation of severe comedonal acne. Early recognition of young girls at risk of having severe comedonal acne may enable the clinician to intervene and thus prevent unwanted sequelae. J Pediatr 1997;130:30-9

Studies comparing physical activity levels in children with and without asthma have had mixed results. Our objective was to investigate the association between asthma diagnosis and physical activity and to examine differences in these associations by race/ethnicity, weight status and caregiver education.We investigated the association between asthma (defined as report of physician-diagnosed asthma with at least one asthma related symptom) and measures of physical and sedentary activity in a study of 6- to 8-year-old girls in the Breast Cancer and the Environment Research Project. We compared reported activity and pedometer measurements among girls with and without asthma, and examined modification of these associations by race/ethnicity, weight status and caregiver education.Girls (n = 1182) were included with 33.5% White, 4.8% Asian, 30.6% non Hispanic Black and 30.7% Hispanic. Asthma was present in 16.2% of girls. Overall, 38% of girls reported no participation in organized recreational activities and 58% had2 h/day of television, video game and computer time combined. Girls with asthma whose parents were less educated reported fewer pedometer steps and less non-scheduled activity than girls without asthma with similar caregiver education level. Among girls with asthma, those on a controller medication had higher levels of sedentary activity and more structured physical activity but were less likely to report high intensity physical activity.Among girls whose parents are less educated, girls with asthma may have lower physical activity levels than girls without asthma. Use of a controller medication may be related to physical and sedentary activity.

Lignans and flavonols are dietary phytoestrogens found at high concentrations in the Western Diet. They have potential to influence the timing of puberty. We hypothesized that greater consumption of these 2 phytoestrogens would be related to later age at pubertal onset among girls. Pubertal assessment and 24-hour diet recall data were available for 1178 girls, ages 6 to 8 years (mean 7.3 years) in the Breast Cancer and Environment Research Project Puberty Study. Lignan and flavonol intakes were mainly derived from fruit and vegetable consumption. Average consumption was 6.5 mg/d for flavonols and 0.6 mg/d for lignans. Highest flavonol consumption (>5 mg/d) was associated with later breast development (adjusted hazards ratio [HR]: 0.74, 95% CI: [0.61-0.91]) compared to 2 to 5 mg/d (adjusted HR: 0.84, 95% CI: [0.70-1.0]) and

Study objective: We compared the cost-effectiveness of two single-dose treatment strategies for adolescents with uncomplicated Neisseria gonorrhoeae cervicitis. Methods: We used a cost-effectiveness decision-analysis model to compare the two methods: the standard, ceftriaxone 125 mg given by IM injection; and an alternative, cefixime 400 mg given orally. The effect of the costs associated with the risk of accidental needlestick during IM administration was also evaluated. Key baseline assumptions (with ranges, when tested) were from the literature or costs to our hospital. These included ceftriaxone, $8.60 per dose; cefixime, $4.67 per dose; ceftriaxone efficacy, 98% (range, 94.9% to 100%); cefixime efficacy, 97% (94.1% to 100%); and a 15% probability of pelvic inflammatory disease (PID) related to failed treatment. We included costs for PID necessitating hospitalization, disseminated gonococcal infection, infertility, and ectopic pregnancy. Assumptions related to accidental needlestick included the rate of needlesticks with the disposable syringe, 6.9 per 100,000 injections (range, 0 to 69); cost of accidental needlestick to hospital; risk of HIV seroconversion after needlestick exposure to HIV-infected blood, .36% (range, 0% to .86%); rate of HIV infection in 15- to 19-year-olds attending sexually transmitted diseases clinics, .4% (range, 0 to 5); and lifetime treatment costs for a person with HIV. Results: At baseline values the model favored ceftriaxone ($45 per patient) over cefixime ($59 per patient). However, over the range of efficacy of both drugs, two-way sensitivity analysis revealed no consistent cost advantage for either drug. The model was also insensitive to the economic effects associated with the risk of accidental needlestick during IM injection. Conclusion: Over the range of efficacy defined by the 95% confidence intervals of both drugs, our analysis demonstrated no clear cost advantage for either. The economic effects of accidental needlestick do not change this conclusion. Compared with the IM alternative, oral cefixime is painless to the patient and simpler for the practitioner to administer. Oral cefixime also eliminates the psychologic effects associated with needlesticks in health care workers. For these reasons, we favor the use of oral cefixime for uncomplicated gonococcal cervicitis in adolescents. [Friedland LR, Kulick RM, Biro FM, Patterson A: Cost-effectiveness decision analysis of intramuscular ceftriaxone versus oral cefixime for adolescents with gonococcal cervicitis. Ann Emerg Med March 1996;27:299-304.]

Several studies have noted contemporary girls are undergoing pubertal maturation at younger ages. During this same time period many Western nations have experienced an obesity epidemic, prompting investigators and public health officials to consider the association of these two events, and if other exposures might impact this relationship. There are several potential mechanisms that could impact the relationship of pubertal timing in girls with greater body mass, including direct effects of obesity on pubertal timing as well underlying exposures that impact body mass as well as timing of pubertal maturation. These underlying conditions include chemical compounds that could impact synthesis or action of sex hormones, called endocrine disrupting chemicals (EDs). This paper will examine the decline in the age of breast development and potential genetic and environmental influences, the obesity epidemic in the US and other nations, and potential mechanisms to explain the relationship between greater body mass index with earlier puberty in girls.

Background: This study examined the relationships of pubertal maturation and sex steroid hormones to the development of acne in young girls. Black (n=317) and white (n=306) premenarchal girls with a mean age of 9.97±0.62 years were evaluated for acne prevalence and severity, pubic hair and areolar maturation, and sex steroid hormone levels. Results: Overall, 77.8% of the girls had some acne; of the whole group, 48.3% had only comedonal acne, 2.2% had only inflammatory acne, and 27.3% had both types. Although black girls matured at an earlier age than white girls, racial differences in acne were minimal when adjusted for pubertal maturation. Acne increased with advancing maturation; at Tanner pubic hair stages 1, 2, and 3, the prevalence of acne rose from 73.1% to 84.0% and to 90.6%, respectively. Acne lesion counts at seven facial locations revealed a predominance of midfacial acne on the middle aspect of the forehead, nose, and chin. Sex steroid hormone levels measured in 365 of the girls were found to increase significantly during maturation from prepuberty to early puberty. Testosterone-estrogen—binding globulin and the ratio of testosterone to estradiol decreased. In 118 prepubertal girls, estradiol, total and free testosterone, progesterone, testosterone to estradiol ratio, and testosterone-estrogen—bindingglobulin levels were no different whether in subjects with acne or without acne. However, the level of dehydroepiandrosterone sulfate, an androgen of adrenal origin, was significantly higher in prepubertal girls with acne. Conclusion: Acne, especially the comedonal type, can be the first sign of pubertal maturation in girls, even preceding pubic hair and areolar development. Concentration of dehydroepiandrosterone sulfate is significantly and specifically associated with the initiation of acne in young girls. (Arch Dermatol. 1994;130:308-314)

Recent studies have begun to address the relationship between environmental exposures to pubertal development and to later risk of breast cancer. This chapter will review how physiologic changes could define puberty as a window of susceptibility. For example, although many studies have reported the relationship between age of menarche and breast cancer, the underlying physiologic mechanism may be related to pubertal growth characteristics, such as timing of or degree of peak height velocity. The maturing breast also contains cells that might be ­especially susceptible to toxic exogenous agents. The chapter will also discuss how environmental exposures, including dietary factors, could impact timing of puberty or ­subsequent risk of breast cancer.

A group of 46 women attending an adolescent dysplasia clinic were surveyed regarding the reported impact of cervical dysplasia on sexual beliefs and behaviors. The adolescents reported being concerned about their future health and having changed their sexual practices. There were no clear relationships between demographic variables or sexual attitudes and changes. The adolescents' self-reports of their behavior were not consistent; those adolescents who reported safer sex practices did not have lower rates of sexually transmitted diseases postbiopsy. The results of this study indicate the important but complex impact of sexually transmitted disease on adolescents and suggests that this impact on adolescents may be different from that on adults.