Pubertal Timing as a Determinant of Lifelong Bone Health in Females: A Longitudinal Evidence Review

Abstract

Background: Peak bone mass acquired during adolescence determines lifelong fracture risk, yet the predictive value of pubertal timing for skeletal trajectories remains under-exploited clinically.

Objective: To synthesize longitudinal evidence linking pubertal timing to bone mineral density trajectories across the lifespan and identify clinical applications for fracture prevention.

Methods: We conducted a systematic review of longitudinal cohort studies examining the relationships between pubertal timing and bone mineral density. Major cohorts included the Bone Mineral Density in Childhood Study, the Avon Longitudinal Study of Parents and Children, the British 1946 Birth Cohort, and the National Health and Nutrition Examination Survey, spanning 1946-2024 and encompassing over 70,000 individuals with follow-up periods exceeding 40 years.

Results: Earlier pubertal onset consistently predicted higher bone mineral density throughout life (r = −0.31, P < 0.0001), accounting for 10% of the variance in bone mineral density, independent of other factors. Women with menarche at ≥16 years demonstrated 8% to 10% lower trabecular bone mineral density persisting into their eighth decade and 40% to 60% increased osteoporotic fracture risk. Approximately 40% of lifelong bone mineral content accumulates within the 4 years surrounding peak height velocity, with 95% of adult bone mass established by age 20.

Conclusions: Pubertal timing serves as a powerful predictor of lifelong skeletal health, with delayed development programming decades of fracture vulnerability. These findings support the integration of pubertal assessment into bone health risk stratification, shifting osteoporosis prevention from reactive treatment to proactive adolescent optimization