Introduction:
Menarche is a milestone in female’s reproductive life which marks their sexual maturation. It happens abruptly, unlike other pubertal changes. Various biological and socio-economic factors affect it, therefore, it has also been stated as an indicant of quality of life. (1) It is considered as the most accurately recalled indicator of puberty among girls. (2)
Menarche usually happens one year after growth spurt, and differs between individuals and populations. (3) Reasons of this variation are not specifically known, but it is said to be determined by genetics, fat composition of the body, chronic illness, nutritional status, environmental conditions, socio-economic status and education. (4-6). The initial scientific accounts on menarcheal age are 150 years old. (7) Previous records on studies conducted in 67 countries published between the period of 1960-1990, reported the mean menarche age as 13.53 years. (8) A large secular trend in menarcheal age have been noted since the 19th century when AAM was approximately 17 years. (9) Although, there have been reports that the ongoing downward trend in age at menarche has slowed down, or even completely stopped in few European countries, (7) but, it was still occurring in the US and Asia. (10) Decline in age at menarche has been reported from both developed (11) and developing nations. (12)
Early menarche has been proved to be associated with many health problems among teenagers like overweight, (13) depression and eating disorders. (14) Some of the severe problems might pop up later in adult life which may not seem to be having anything to do with menarcheal age but researches have found that early menarcheal age is accountable for greater risk of breast cancer, (15) diabetes, (16) metabolic syndrome (17) and cardiovascular diseases. (18)
Materials and Methods
The present cross-sectional study was conducted on 276 adolescent girls with age ranging from 13+ to 18+ years and belonging to Tibetan community. Sample was collected using stratified random sampling from three residential schools of Kangra district: Tibetan children’s village (TCV) Gopalpur, TCV lower Dharamsala and Mewoen Tsuglag Petoen School, Dharamsala. The present study was approved from departmental ethical committee. Written consent was taken from necessary authorities before interacting with respondents. Oral consents were taken from the respondents.
Inclusion and exclusion criteria: Subjects who falls in the age group of 13 years to 18 years were taken who are healthy and already had their first periods. Subjects who falls in the inclusion criteria but have any kind of menstrual disorder were excluded from the study.
Socio-demographic data was collected using a pre-formed proforma consisting of questions regarding their name, age, AAM, monthly income of parents and so on. Data on physical activity was collected using physical activity questionnaire for adolescents (PAQ-A). (19) The scoring for PAQ-A was done based on a previous study. (20) Data on AAM was collected using recall method. It was then, categorized into early, medium and delayed AAM by subtracting and adding the standard deviation from mean AAM. Early AAM was considered the age less then mean AAM, Medium AAM as the Mean AAM and Delayed AAM as age greater then mean AAM as done by a previous study. (10) Socio-economic status was assessed on the basis of monthly income using the modified BG Prasad scale. (21) For convenience purpose, lower and lower middle class was combined into lower class and middle and upper middle class into middle class. Data was entered in MS- Excel and was analyzed for statistical tests in SPSS 20.0.
Results
The analysis of data obtained from 276 girls in the present study shows that a majority of 79.7% belonged to upper SES, 13.4% belonged to middle SES and only 6.9% belonged to lower SES (Figure 1).
Figure 2 shows the physical activity level of Tibetan adolescent girls. It was found that 45.3% were doing high levels of physical activity, 31.88% were doing moderate level of physical activity and 22.82% girls were either not physically active or were doing very low levels of physical activity.
| Table 1: Mean and standard deviation of AAM among Tibetan adolescent girls. |
| Age |
N |
Age at menarche |
Mean±SD |
13+ |
45 |
12.07±0.89 |
14+ |
45 |
12.47±1.20 |
15+ |
42 |
12.48±0.99 |
16+ |
52 |
12.79±1.07 |
17+ |
45 |
13.51±1.27 |
18+ |
47 |
13.14±1.41 |
The mean values of AAM shows a forward trend except some fluctuation in 18 year age group. Highest mean value was observed in 17 year age group and lowest in 13 year age group (Table 1).
Distribution according to onset of AAM and the age of participants is shown in table 2, which reveals that the most common age of onset of menarche is 13 years (33.7%) followed by 12 and 14 years. Highest AAM was found to be 17 years and lowest to be 9 years.
| Table 2: Distribution according to AAM and age of studied Tibetan adolescent girls |
| Age |
Age at menarche |
Total |
|
9+ |
10+ |
11+ |
12+ |
13+ |
14+ |
15+ |
16+ |
17+ |
|
13+ |
1
(2.2) |
1
(2.2) |
7
(15.6) |
21
(46.7) |
15
(33.3) |
0
(0) |
0
(0) |
0
(0) |
0
(0) |
45
(100) |
14+ |
1
(2.2) |
2
(4.4) |
5
(11.1) |
12
(26.7) |
16
(35.6) |
9
(20) |
0(0) |
0
(0) |
0
(0) |
45
(100) |
15+ |
0
(0) |
1
(2.39) |
6
(14.28) |
12
(28.57) |
19
(45.23) |
3
(7.14) |
1
(2.39) |
0
(0) |
0
(0) |
42
(100) |
16+ |
0
(0) |
0
(0) |
8
(15.39) |
11
(21.16) |
18
(34.61) |
14
(26.92) |
1
(1.92) |
0
(0) |
0
(0) |
52
(100) |
17+ |
0
(0) |
0
(0) |
2
(4.4) |
10
(22.2) |
9
(20) |
12
(26.67) |
11
(24.45) |
1
(2.2) |
0
(0) |
45
(100) |
18+ |
1
(2.12) |
0
(0) |
3
(6.4) |
10
(21.28) |
16
(34.05) |
10
(21.28) |
5
(10.63) |
1
(2.12) |
1
(2.12) |
47
(100) |
Total |
3
(1.1) |
4
(1.44) |
31
(11.23) |
76
(27.53) |
93
(33.7) |
48
(17.4) |
18
(6.52) |
2
(0.72) |
1
(0.36) |
276
(100) |
| Percentages are given in parentheses. |
Table 3 shows the distribution of girls in onset of AAM categories. Majority of girls were in early menarche (41.30%), 33.7% falls in medium menarche and 25% falls in delayed menarche category. A significant difference of AAM categories was found with SES and physical activity categories (Table 4).
| Table 3: Distribution of Tibetan adolescent girls in Onset of menarche categories |
| Age |
N |
Early menarche |
Medium menarche |
Delayed menarche |
13+ |
45 |
30 (67) |
15 (33) |
0 (0) |
14+ |
45 |
20 (44) |
16 (36) |
9 (20) |
15+ |
42 |
19 (45.24) |
19 (45.24) |
4 (9.52) |
16+ |
52 |
19 (36.55) |
18 (34.6) |
15 (28.85) |
17+ |
45 |
12 (27) |
9 (20) |
24 (53) |
18+ |
47 |
14 (29.78) |
16 (34.05) |
17 (36.17) |
Total |
276 |
114 (41.3) |
93 (33.7) |
69 (25) |
| Percentages are given in parentheses. |
| Table 4: Cross-tabulation analysis of SES and physical activity with AAM categories |
| Variables |
Early menarche |
Medium menarche |
Delayed menarche |
Chi-square value |
Physical activity |
High |
92(33.33) |
26(9.42) |
7(2.53) |
183.9394** |
Moderate |
17(6.15) |
57(20.65) |
14(5.09) |
Low |
5(1.81) |
10(3.62) |
49(7.4) |
Socio-economic status |
Upper |
99(35.9) |
82(29.7) |
39(14.13) |
31.4672** |
Middle |
10(3.62) |
6(2.17) |
21(7.6) |
Lower |
5(1.81) |
5(1.81) |
9(3.26) |
| **P<0.01, Percentages are given in parentheses. |
Discussion
Onset of menarche is a crucial sexual maturation process which has a huge role in reproductive cycle of a woman’s life. A downward trend in AAM has been noticed worldwide (11-12,22) which is a matter of concern as early menarche has been associated with many health problems. The mean AAM for the present data is 12.75 years which is in accordance with the previous studies (23-26) and is in disagreement with Adolescent and Youth Health survey Himachal Pradesh, which reported age at menarche to be 14.46 years which is high in comparison to the the present study. (27) A case control study reported the mean age at menarche of cases to be 10.82 and of controls 14.26. (28) Many other studies were found with contrasting results from the present study. (29-30) The variation in reporting of age at menarche may be attributed due to differences in socio-economic status, environmental conditions, nutritional status in different regions of world and even within India. In the present study, minimum and maximum AAM was observed to be 9 years and 17 years respectively. Thus, no case of precocious puberty was seen which is in contradiction to a study conducted among adolescent girls of Lucknow. (26)
In this study, age at menarche is divided into three categories: Early, Medium and Delayed menarche. According to which, majority of girls (41.3%) had early menarche, 33.7% had medium menarche and 25% had delayed menarche. Many studies have established that early onset of menarche is associated with increased risk for breast cancer, (15) obesity, (31) and endometrial cancer. (32)
In another study, it was found that girls who come from higher socio-economic status attain menarche at an early age in comparison to their lower socio-economic counterparts. (33) Similarly, in the present study, cross tabulation analysis showed that girls who belong to upper class reached menarche at an earlier age then girls from middle and lower class. Chi-square analysis showed that a significant relationship exists between socio-economic status and age at menarche, which is in accordance with previous studies conducted among adolescent girls in Rajasthan, (34) in central India (35) and in West Bengal. (36)
Many studies have showed that vigorous physical exercises particularly in athletes or sports persons may delay age at menarche. (37-38) In this study though majority of girls were reported to be doing high level of physical activity but they were not doing strenuous exercises like athletes do. In the present study, a significant relationship is found between age at menarche and physical activity levels. Girls doing more physical activity were observed to have attained their menarche earlier and girls who were less physically activity were observed to have delayed menarche. Girls who were doing moderate physical activity were observed to have mean AAM.
Conclusion
Menarche marks the beginning of new chapter in female’s reproductive cycle, it is abrupt and generally occurs 6 months after the achievement of peak height velocity. Various genetic and environmental factors affects the onset of AAM. Present study shows that girls who were in better socio-economic category and were physically more active attained menarche at an earlier age in comparison to others. Many other factors such as mother’s menarche age, education, housing situation, place of origin also play a role in the attainment of menarche.
Financial Support: UGC-NET-JRF
Conflict of Interest: There are no conflict of interest.
Acknowledgement: We acknowledge all the participants and the school authorities. We thank the Department of Anthropology for providing technical support.
Ethical Clearance: The ethical clearance was taken prior to the study from ethical committee of Department of Anthropology, University of Delhi.
References
- Prado C, Martinez R, Pérez-Landazábal E, Marrodán MD, Sánchez-Andrés A, Nielsen AH. Menarcheal age as an indicator of socio-economic level in emigrants. J Hum Ecol. 1995;4:157-71.
- Cole TJ. The secular trend in human physical growth: a biological view. Economics & Human Biology. 2003 Jun 1;1(2):161-8.
- Fujii K, Demura S. Relationship between change in BMI with age and delayed menarche in female athletes. Journal of Physiological Anthropology and Applied Human Science. 2003;22(2):97-104.
- Kliegman RM, Behrman RE, Jenson HB, Stanton BM. Nelson textbook of pediatrics e-book. Elsevier Health Sciences; 2007 Aug 15.
- Gong EJ, Heald FP. Diet, nutrition and adolescence. In: Shils ME, Olson JA, Shike M, eds. Modern nutrition in health and disease. Philadelphia: Lea & Febiger; 1994.
- Gaudineau A, Ehlinger V, Vayssiere C, Jouret B, Arnaud C, Godeau E. Factors associated with early menarche: results from the French Health Behaviour in School-aged Children (HBSC) study. BMC Public Health. 2010 Dec 1;10(1):175.
- Ong KK, Ahmed ML, Dunger DB. Lessons from large population studies on timing and tempo of puberty (secular trends and relation to body size): the European trend. Molecular and Cellular Endocrinology. 2006 Jul 25;254:8-12.
- Thomas F, Renaud F, Benefice E, De Meeüs T, Guegan JF. International variability of ages at menarche and menopause: patterns and main determinants. Human Biology. 2001 Apr 1:271-90.
- Mishra GD, Cooper R, Tom SE, Kuh D. Early life circumstances and their impact on menarche and menopause. Women’s Health. 2009 Mar;5(2):175-90.
- Adair LS. Size at birth predicts age at menarche. Pediatrics. 2001 Apr 1;107(4):e59-.
- Anderson SE, Must A. Interpreting the continued decline in the average age at menarche: results from two nationally representative surveys of US girls studied 10 years apart. The Journal of Pediatrics. 2005 Dec 1;147(6):753-60.
- Hwang JY, Shin C, Frongillo EA, Shin KR, Jo I. Secular trend in age at menarche for South Korean women born between 1920 and 1986: the Ansan Study. Annals of Human Biology. 2003 Jan 1;30(4):434-42.
- Adair LS, Gordon-Larsen P. Maturational timing and overweight prevalence in US adolescent girls. American Journal of Public Health. 2001 Apr;91(4):642.
- Posner RB. Early menarche: A review of research on trends in timing, racial differences, etiology and psychosocial consequences. Sex Roles. 2006 Mar 1;54(5-6):315-22.
- Collaborative Group on Hormonal Factors in Breast Cancer. Menarche, menopause, and breast cancer risk: individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies. Lancet Oncol. 2012; 13:1141-1151.
- Mueller NT, Duncan BB, Barreto SM, Chor D, Bessel M, Aquino EM, Pereira MA, Schmidt MI. Earlier age at menarche is associated with higher diabetes risk and cardiometabolic disease risk factors in Brazilian adults: Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cardiovascular Diabetology. 2014 Dec 1;13(1):22.
- Stöckl D, Meisinger C, Peters A, Thorand B, Huth C, Heier M, Rathmann W, Kowall B, Stöckl H, Döring A. Age at menarche and its association with the metabolic syndrome and its components: results from the KORA F4 study. PloS One. 2011;6(10).
- Lakshman R, Forouhi NG, Sharp SJ, Luben R, Bingham SA, Khaw KT, Wareham NJ, Ong KK. Early age at menarche associated with cardiovascular disease and mortality. The Journal of Clinical Endocrinology & Metabolism. 2009 Dec 1;94(12):4953-60.
- Kowalski KC, Crocker PR, Donen RM. The physical activity questionnaire for older children (PAQ-C) and adolescents (PAQ-A) manual. College of Kinesiology, University of Saskatchewan. 2004 Aug;87(1):1-38.
- Chen SR, Lee YJ, Chiu HW, Jeng C. Impact of physical activity on heart rate variability in children with type 1 diabetes. Child's Nervous System. 2008 Jun 1;24(6):741-7.
- Pandey VK, Pradeep A, Rakesh K. Modified BG Prasad's socio-economic classification-2018: the need of an update in the present scenario. Indian Journal of Community Health. 2018;30(1):82-4.
- Hosny LA, El-Ruby MO, Zaki ME, Aglan MS, Zaki MS, El Gammal MA, Mazen IM. Assessment of pubertal development in Egyptian girls. Journal of Pediatric Endocrinology and Metabolism. 2005;18(6):577-84.
- Purushotham GR. A Study on Some Demographic Aspects of Balija and Sugali Populations in Chittoor and Cuddapah Districts, Andhra Pradesh (Doctoral dissertation, M. Sc., Dissertation, SV University, Tirupati).
- Bagga A, Kulkarni S. Age at menarche and secular trend in Maharashtrian (Indian) girls. Acta Biologica Szegediensis. 2000 Jan 1;44(1-4):53-7.
- Al-Sahab B, Ardern CI, Hamadeh MJ, Tamim H. Age at menarche in Canada: results from the National Longitudinal Survey of Children & Youth. BMC Public Health. 2010 Dec 1;10(1):736.
- Khatoon T, Verma AK, Kumari R, Rupani R, Singh M, Rizvi A. Age at menarche and affecting bio-social factors among the girls of Lucknow, Uttar Pradesh. Journal of Indian Academy of Forensic Medicine. 2011;33(3):221-3.
- National Institute of Mental Health and Neuro Sciences. Adolescent and Health Youth Survey Himachal Pradesh Report. 2015. Available at http://nimhans.ac.in/wp-content/uploads/2019/02/HP-Youth-Health-Survey-
Report_3rd-Draft_15-05-2015.pdf
- Bhattarai S, Subedi S, Acharya SR. Factors Associated with Early Menarche among Adolescents Girls: A Study from Nepal. SM J Community Med. 2018;4(1):1028-39.
- Chakravartti MR, Renuka Y. The trend of age at menarche in India. J Soc Res. 1970;13:82-9.
- Rakshit S. Reproductive life of some Maharashtrian Brahman women. Man in India. 1962 Jan 1;42(2):138-58.
- van Lenthe FJ, Kemper CG, van Mechelen W. Rapid maturation in adolescence results in greater obesity in adulthood: the Amsterdam Growth and Health Study. The American Journal of Clinical Nutrition. 1996 Jul 1;64(1):18-24.
- McPherson CP, Sellers TA, Potter JD, Bostick RM, Folsom AR. Reproductive Factors and Risk of Endometrial Cancer The Iowa Women's Health Study. American Journal of Epidemiology. 1996 Jun 15;143(12):1195-202.
- Abioye-Kuteyi EA, Ojofeitimi EO, Aina OI, Kio F, Aluko Y, Mosuro O. The influence of socioeconomic and nutritional status on menarche in Nigerian school girls. Nutrition and Health. 1997 Jan;11(3):185-95.
- Hada R, Shete S, Hamid M. Study to determine the menarcheal age of school going girls at Jhalawar district, Rajasthan. International Journal of Medical Science and Public Health. 2014 Sep 1;3(9):1115-9.
- Dambhare DG, Wagh SV, Dudhe JY. Age at menarche and menstrual cycle pattern among school adolescent girls in Central India. Global Journal of Health Science. 2012 Jan;4(1):105.
- Ray S, Mishra SK, Roy AG, Das BM. Menstrual characteristics: a study of the adolescents of rural and urban West Bengal, India. Annals of Human Biology. 2010 Oct 1;37(5):668-81.
- Sidhu LS, Grewal R. Age of menarche in various categories of Indian sportswomen. British Journal of Sports Medicine. 1980 Dec 1;14(4):199-203.
- Merzenich H, Boeing H, Wahrendorf J. Dietary fat and sports activity as determinants for age at menarche. American Journal of Epidemiology. 1993 Aug 15;138(4):217-24.
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