Data from the Avon Longitudinal Study of Parents and Children were used to describe initiation of secondary sexual characteristic development of girls. Tanner stages of breast and pubic hair and menarche status were self-reported via mailed questionnaires, administered from ages 8–14. Initiation pathway was categorized as breast [thelarche] or pubic hair [pubarche] development alone, or synchronous. Average ages at beginning breast and pubic hair development were estimated using survival analysis. Factors associated with initiation pathway were assessed using logistic regression. Among the 3938 participants, the median ages at beginning breast and pubic hair development were 10.19 (95% CI: 10.14–10.24) and 10.95 (95% CI: 10.90–11.00) years. Synchronous initiation was the most commonly reported pathway (46.3%), followed by thelarche (42.1%). Girls in the pubarche pathway were less likely to be obese or overweight at age 8 or have an overweight or obese mother. Girls in the thelarche pathway were less likely to be of nonwhite race or be the third born or later child. 1. Introduction In females, the first visible signs of pubertal development are breast and pubic hair development [1, 2]. These processes are governed by two separate physiologic systems (the hypothalamic pituitary gonadal axis and hypothalamic pituitary adrenal axis, resp.), so breast and pubic hair development does not necessarily occur at the same time, or at the same rate of progression. A majority of girls are thought to experience relatively synchronous pubarche and thelarche, with the first appearance of pubic hair and breast budding occurring within a few months of each other (or observed at the same clinic visit). However, some girls will begin pubarche without corresponding thelarche and vice versa [3–6]; this is often referred to as asynchronous development. Different initiation pathways may reflect differential exposures, both external environmental exposures and exposure to endogenous hormones, and timing of pubertal milestones may impact future health outcomes including risk for overweight/obesity and breast cancer [5, 7–9]. Despite the importance of the initiation of puberty, the process and factors which impact pathway and timing have not been well described in a contemporary cohort. Among participants in the Fels longitudinal study in the United States (1948), the majority of girls (85.8%) experienced asynchronous development, with over half of girls entering breast development before pubarche [10]. A Swedish study (1976) found that while 47% of girls experienced synchronous
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