Acta Pdiatrica ISSN 08035253

REGULAR ARTICLE

Age at menarche in contemporary Greek girls: evidence for levelling-off of the secular trend
Anastasios Papadimitriou (anpapad@med.uoa.gr)1 , Grigorios Fytanidis1 , Konstandinos Douros1 , Chryssa Bakoula2 , Polyxeni Nicolaidou1 , Andreas Fretzayas1
1.Third Department of Pediatrics, University of Athens School of Medicine, Attikon University Hospital, Athens, Greece 2.First Department of Pediatrics, University of Athens School of Medicine, Aghia Sophia Childrens Hospital, Athens, Greece

Keywords Age at menarche, Greek girls, Obesity, Secular trend Correspondence Anastasios Papadimitriou, M.D., Third Department of Pediatrics, University of Athens School of Medicine, Attikon University Hospital, Rimini 1 Street, Athens 124 64, Greece. Tel: +30-210-5832046 | Fax: +30-210-5832229 | Email: anpapad@med.uoa.gr Received 23 December 2007; revised 28 February 2008; accepted 20 March 2008. DOI:10.1111/j.1651-2227.2008.00806.x

Abstract Aim: To examine the secular trend of menarcheal age in Greek girls during the last decade. Methods: Seven hundred and fty senior high schoolgirls were asked through a questionnaire to report their date of menarche, participation in physical activities and their weight status at menarche. The data were compared with those of a study of 1996. Results: Mean age at menarche (SD) in 2006 was 12.29 (1.19) and in 1996 it was 12.27 (1.13) years, p = 0.73. Maternal menarcheal age was 13.02 (1.32). There was a signicant correlation between age at menarche of the schoolgirls and their mothers, p < 0.0001. There was a signicant difference in the age at menarche according to the schoolgirls perceived weight status. Menarcheal age of obese girls (n = 56) was 11.73 (1.21) years, of normal weight girls (n = 474) was 12.29 (1.21) years and of lean girls (n = 220) was 12.42 (1.14) years, p < 0.001. There was no signicant difference in the age at menarche between the girls that participated, 12.23 (1.19), and those that did not participate in sporting activities, 12.32 (1.19), p = 0.31. Conclusion: Levelling-off of the age at menarche over the last 10 years occurred in Greek girls living in Athens. Menarcheal age is inuenced by the weight status and maternal menarcheal age.

INTRODUCTION Menarche is a milestone in the somatic development of females, as it signals an advanced stage of pubertal maturation. Furthermore, it marks the possibility of reproductive competence of the female. During the 20th century the dramatic improvement of socioeconomic conditions and general health of the populations in the industrialized countries resulted in an earlier onset of puberty in children (1). The most reliable marker of the positive secular changes in pubertal development was the fall of the age at menarche. It has been estimated that during most of the 20th century age at menarche has been falling by about 3 months per decade (2). However, there have also been reports from industrialized countries that the age at menarche has been levelling-off or that it shows an upward trend (3,4). In the last 30 years, two studies have been performed in Greek girls showing a secular trend for earlier menarche (5,6). The aim of this study was to examine if, during the last 10 years, a secular trend in the age at menarche in Greek girls is taking place by comparing these data with those of a study we performed in 1996. METHODS For comparison reasons, in this study we used the same methodology to the one in the study of 1996. Physicians from our group visited six senior high schools in various districts of the Greater Athens area some days prior to the

study, out of the eight schools we had visited in the previous study, in order to inform the female students about the study. All the schools were public (state owned), attended mainly by children that belong to the middle social class. The schoolgirls were asked through a questionnaire to report the exact date of their menarche, aided by their mothers, and that of their mothers. If they were not sure about the exact date that menarche occurred, they were asked to report the month and the year. Also, they were asked to report their country of origin; in the last 10 years significant social changes have occurred in Greece, so a substantial number of schoolchildren are migrant children, mostly from Albania. Furthermore, they were asked about parental educational level, participation in sports or other physical activities at the time of or preceding menarche, the duration of their involvement in sporting activities and whether at the time of menarche they considered themselves to be obese, of normal weight or lean. They were also asked about the frequency of their menstrual cycle and the duration of the menses. The questionnaires were filled at home and were collected by members of our group a couple of days later. Age at menarche was calculated as exact decimal age. However, most girls did not report the exact date of menarche but the month and the year, so for the calculations we used the 15th day of the corresponding month. Statistical analysis Values are expressed as mean (SD). In order to explore any correlations of age of menarche with weight status

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(lean, normal and obese), sporting activities duration (in years, until menarche) and frequency of menstrual cycle (in days), we used Pearsons coefficient (r). The independent samples t-test or one-way ANOVA with Bonferroni multiplecomparison test was used for comparing mean age of menarche between different groups. We conducted power analysis prior to our study with significance level 0.05 and effect size 0.15 (characterized as small on Cohens definitions of effect sizes (7)). All reported p-values are based on two-sided tests and are compared with a significance level of 5%. RESULTS In order to achieve a power of 0.9 for our analysis we needed a sample of 771 girls. The number of questionnaires that were given was 1229 and the number of the completed questionnaires was 808 (66%). Fifty-eight questionnaires were filled by non-Greek schoolgirls, therefore 750 schoolgirls participated in the study. The age range of the schoolgirls that filled the questionnaires was 14.8 to 18.2 years. There was no significant difference in the mean (SD) age at menarche between the year 2006, that it was 12.29 (1.19) and 1996 that it was 12.27 (1.13) years (p = 0.73) (Table 1). In this study the age range of menarche was 8.9 to 16.7 years and the ages that corresponded to the 3rd and 97th centile were 10.2 and 14.5 years, quite similar to the ones reported in 1996. Mean menarcheal age of the mothers was 13.02 (1.32). There was a significant correlation between age at menarche of the schoolgirls and their mothers, r = 0.28, p < 0.001. There was a statistically significant difference in the age at menarche according to the schoolgirls perceived weight status at the time of menarche. The girls who considered themselves as obese (n = 56) had a menarcheal age of 11.73 (1.21) years, girls who considered that were of normal weight (n = 474) had a menarcheal age of 12.29 (1.21) years and the girls who considered themselves as lean (n = 220) had menarche at the age of 12.42 (1.14) years, p < 0.001 (Table 2). Significant differences were found to exist between obese and girls of normal weight, p = 0.004 and between obese and lean girls, p < 0.001. There was no correlation between weight status and duration of menses or frequency of menstrual cycles.

A substantial percentage of the girls reported no participation in any sporting activities, that is, 477 girls (63.6%). Thirteen percent reported involvement in ballet dancing or martial arts, whereas 23.3% of the girls reported involvement in sports with intense physical training (basketball, volleyball etc.). However, only a small number of these girls (n = 7) were training at least 5 days a week as part of an athletic team. There was no significant difference in the age at menarche between the girls that participated, 12.23 (1.19), and those girls that did not participate in sporting activities, 12.32 (1.19), p = 0.31. Moreover, there was no statistical difference in the age at menarche in relation to the duration of involvement in sporting activities. There was also no significant difference between age at menarche and parental educational level or whether their mothers were working outside the house or not (data not shown). DISCUSSION Although the recall method for the estimation of the age of menarche has several methodological problems regarding the accuracy of recall (8), we used the same methodology as in the previous study in order for the results to be comparable. Our data provide evidence for arrest in the secular trend in the age of menarche in girls living in Athens, Greece. We had previously shown that during the 20th century a dramatic decrease in the age at menarche had taken place in Greece, as in every other country in the industrialized world. For example, in the first report on menarcheal age that we were able to find in the Greek scientific literature, Malaspina, in her study of 6203 girls from all over Greece performed in 1935, found that menarche occurred in 37.1% of the girls at the ages of 13.013.99 years, in 26.5% at the ages of 14.014.99 and only in 18.6% menarche occurred at the ages of 12.012.99 years (9). In 1979 the mean age at menarche of Athenian girls was found to be 12.4 (1.02) years (6), which is significantly greater than the mean age reported in 1996 (p = 0.004). The mean ages at menarche of Greek schoolgirls found in this study and the studies in 1979 and 1996 are shown in Table 1. It is of historical interest that according to Aristotle, in a thriving ancient Greek society, menarche occurred at the 14th year of age (10). The timing of menarche is known to be determined by factors including body mass index (BMI), socioeconomic status, physical activity, nutritional status and genetic influences. The influence of genetics is estimated to be half of the variance in menarcheal timing (11). In our study the only variables that were found to influence age at menarche were obesity and maternal menarcheal age, whereas an association between age at menarche and schoolgirls physical activities or parental educational level could not be established. It has become common knowledge that overweight girls tend to mature earlier than lean girls. In 1974 Frisch suggested that the degree of body fatness may act as a trigger for the neuroendocrine events that lead to the onset of menses (12). Since then several researchers addressed the hypothesis

Table 1 Mean (SD) age at menarche in Greek girls Year n x (SD)

1979 1366 12.40 (1.02)

1996 1134 12.27 (1.13)

2006 750 12.29 (1.19)

p = 0.004.

Table 2 Mean (SD) age at menarche in relation to the perceived weight status Weight status n x (SD) Lean 220 12.42 (1.14) Normal 474 12.29 (1.21) Obese 54 11.73 (1.13) p

<0.0001

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that increasing obesity may be a significant cause of earlier onset of puberty. In a study of the relation between age at menarche and overweight in U.S. adolescent it was found that early maturing girls were twice as likely to be overweight than average maturers and this was true for all racialethnic groups (13). It has also been shown that in 6- to 9-year-old U.S. girls BMI-Z scores were higher in pubertal than prepubertal white girls, whereas in black girls the difference was significant only for the 9-year-old girls (14). However, Himes et al., in a study of African-American girls showed that pubertal girls were more than six times as likely to be classified as overweight and more than eight times as likely to be obese than their prepubertal counterparts (15). Self-perception of weight status is frequently incorrect especially among overweight children (16). We recently reported that in girls the prevalence of obesity was 9.9% and of overweight 26.5% (17). In this study 7.5% (56 out of 750) of the girls considered themselves as obese. Therefore, these data suggest that overweight girls perceive themselves as of normal weight, whereas most obese girls perceive themselves as such. The positive association between age at menarche and maternal menarcheal age found in our study has also been reported by other researchers (18), highlighting the influence of genetics on menarche. It is known that in female gymnasts pubertal development is delayed as a result of the intense physical training and the psychological stress that accompanies the training and the participation in athletic competitions (19). The lack of an association between age at menarche and sporting activities in our study may be due to the fact that only a small number of girls of the population under study was regularly involved in intense physical training. Although higher socioeconomic status has been reported to be associated with earlier menarcheal age (20), we found no correlation between parental educational level (a proxy of socioeconomic status) and age at menarche. This suggests that in highly urbanized populations, like the one of our study, socioeconomic status is not significant determinant of the age at menarche. Although for the most part of the 20th century a secular trend for earlier menarche was evident in Greek girls, our data suggest that in the last 10 years a levelling-off of the age at menarche has taken place at least in Athenian girls. In U.S. girls it was reported that menarche had remained stable in white girls over the last 45 years (21), and also for U.K. women born from 1950 to 1986 no appreciable decrease in menarcheal age was reported (22). However for U.S. girls several other studies have shown a decline of the menarcheal age over the last 20 years (23,24). A trend towards earlier menarche is still observed in several European countries (25), however in some this trend seems to have come to an arrest (4). It is interesting that there is a north to south gradient in the age at menarche. South European girls have on average earlier menarche than North European girls. This suggests that the difference in menarcheal age may be related to environmental, for example, climate, or to genetic factors.

In conclusion, a levelling-off of the age at menarche over the last 10 years occurred in Greek girls living in Athens. Menarcheal age is influenced by the weight status and maternal menarcheal age.

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