European Journal of Cardiovascular Medicine

The Age at menarche is a significant milestone in a woman's health. The timing of menarche is crucial as it is associated with physiological, behavioural, and social changes that can have dramatic consequences in a girl's life like sexual maturation, adulthood and fertility. It varies among individuals due to several influencing factors, including biological and socio-economic factors, nutrition, physical activity, psychological factors, body mass index (BMI), and physical stress[1].

Research shows that early menarche will increase risk of reproductive health outcomes like breast cancer, endometrial cancer, spontaneous abortion, eating disorder and lack of self-esteem[2]. On other hand late menarche result in osteoporosis, anxiety and depression[2].Some studies have reported a significant correlation between the age of menarche in mothers and their daughters[3,4].

A declining trend in menarcheal age has been observed in both developed and developing countries since the 20th century[5].Studies have documented this trend in various regions, including England, Israel, China, India, Korea, Ghana, Mexico, Thailand, and the USA[5–13]. For instance, in Europe, the menarcheal age decreased from 16-17 years in the mid-19th century to 13 years in the mid-20th century[14]. Similarly, among Chinese girls, the age at menarche declined from 14.25 in those born before 1976 to 12.60 in those born after 2000, indicating a decline of 0.51 years per decade[7].

In India, the average age of menarche was 14 years in 1955, with evidence suggesting a reduction of nearly one month per decade[15,16]. A study in India reported a mean age of menarche of 14 years in 1955[16], while another study conducted in West Bengal in 2018 found the mean age to be 12.8 years[9]. Increased socioeconomic status is associated with a declining age at menarche[17]. Studies in the Philippines, Colombia, Mexico, Egypt, India, Peru, and Vietnam have shown that girls in urban areas and those with higher socioeconomic status tend to experience earlier menarche[12]. Maternal education and family wealth have also been correlated with menarcheal age. Better nutrition and improved public health are linked to a decline in menarcheal age. Factors such as increased wealth and fattier diets also play a role. Sedentary lifestyles and increased consumption of outside food are significantly associated with early menarche.

While numerous studies have explored the trends and determinants of menarcheal age, there remains a gap in understanding the intergenerational changes and the specific factors contributing to these shifts. Most studies focus on nutritional and biological determinants, often neglecting the broader socioeconomic and psychological factors. There is a need for studies that systematically examine these trends across time and countries, giving greater focus to socioeconomic backgrounds and other factors simultaneously.  Few recent studies have been conducted in Andhra Pradesh that focus on determining the mean age of menarche and the associated factors by comparing mothers and daughters.

Therefore, the present study aimed to estimate the mean age at menarche and identify associative factors among female medical undergraduate students and their mothers, while drawing comparisons between the two groups. Results of the study will help in understanding these trends and factors is crucial for developing targeted interventions and health programs to promote adolescent health and prevent potential long-term health consequences associated with early menarche. Furthermore, for designing and implementing programs related to women's reproductive health, stress relief activities, healthy life style activities, family planning, sex education, and establishing laws regarding the legal age of marriage.

An Analytical Cross sectional study was conducted in Government Medical College, Prakasam district. The study was carried out over a period of three months, from May to July 2025, allowing enough time for procuring data. Study was conducted among medical undergraduate female students aged 17- 20 years on voluntary basis. Individuals who are sick and unwilling for participation are excluded from study. The required sample size was estimated using the formula: n = 4pq/L². Based on related literature proportion of individuals with Age at menarche between 14- 15 years was assumed as 57% (p = 0.57)[18] and relative precision of 20% of p (L = 0.114), the calculation was as follows: n=4×0.57×0.43/ (0.114)2 = 75.4, to account for a 10% non-response rate, the final sample size was adjusted to 100participants. The pretested semi-structural questionnaire was administered before which girls were briefly explained about the study and questionnaire. During interviews with mothers, it was explicitly clarified that responses should reflect their experiences and activities during adolescence, rather than their current lifestyle. All participants recalled their adolescent years and provided answers accordingly, as the questions primarily focused on their lifestyle and living conditions during that period.

The questionnaire comprised six sections: First section consists of socioeconomic characteristics, Second section consists of menstrual health, Third section consists of dietary and lifestyle behaviours, Fourth section consists of medical history, Fifth and Sixth section includes stress assessment, and anthropometric measurements. Comprehensive data were collected from adolescent girls and their mothers to evaluate family socioeconomic status; menstrual health parameters, including age at menarche for both the girl and her mother, cycle regularity, flow intensity, and associated discomfort; dietary and lifestyle factors, such as daily meal frequency, consumption patterns of vegetables, animal-based foods, and snacks, physical activity levels, and sleep duration; health conditions, including hypothyroidism, diabetes, hypertension, polycystic ovary syndrome (PCOS) and cancer; stress levels are assessed through the presence of familial stressors and physical metrics, such as body weight and height. The questionnaire was pilot-tested for reliability and clarity; data from the pilot study were not included in the final analysis. The study’s purpose and objectives were explained to each participant, and written informed consent was obtained prior to participation.

ETHICAL CONSIDERATION:

Permission from institution head and Institutional Ethics Committee approval was obtained for the study. Confidentiality and anonymity of all participants were strictly maintained throughout the study.

STATISTICAL ANALYSIS:

 The collected data was being entered in MS excel sheets. Statistical analyses was done to summarize the entirety of study data in SPSS software. Percentages, mean and standard deviation was used for variables and was represented with suitable graphs and tables. The association between age at menarche and related factors among medical undergraduate students and their mothers will be analysed by using chi-square.

The study included 200 participants, comprising 100 medical students and 100 mothers. The average age of the students was 19.13 years (SD ±0.812), while the mothers had a mean age of 42.98 years (SD ±4.292). Body Mass Index (BMI) was assessed for all participants, students recording a mean BMI of 21.79 (SD ±4.11) while in mothers a mean BMI of 26.02 (SD ±4.17). (Table: 1)

Comparison of Mean age of menarche among students and their mothers:

 The mean age at menarche was 12.96 years (SD ±1.145) for students and 13.82 years (SD ±1.487) for mothers. (Table: 1). Among the 100 student participants, 35% experienced menarche between 10–12 years, 62% between ages 13–15 (the predominant range), and 3% between 16–18 age group. The earliest recorded menarche age was 10 years, observed among mothers (Figure-1). Of the mothers, 19% attained menarche between 10–12 age groups, 66% between 13–15years which has the maximum numbers, and 15% of them between 16–18 years.

Comparison of menstruation history, habitual factors and lifestyle among adolescent girls and their mother:

A statistically significant difference was observed in the menstrual histories of students compared to their mothers. Regular menstrual cycles were observed in 80% of students, notably lower than their mothers (92%) (p = 0.014). The average duration of menstrual cycles showed a similar distribution between students and their mothers, with statistical significance (p = 0.041). Additionally, white discharge was more prevalent among students (82%) compared to their mothers (63%), with a p-value of 0.003 indicating statistical significance. 

Coming to the dietary habits significant differences were observed between students and their mothers concerning animal-based and snack food consumption patterns, both with a p-value of 0.000. However, no statistically significant difference was found in vegetable consumption patterns. Regarding lifestyle, a sedentary lifestyle was notably more prevalent among students (91%) compared to their mothers (39%), with a statistically significant p-value of 0.000. Body Mass Index (BMI) was assessed shows that students recording heavy weight (62%) more compare to their mothers (49%). Additionally, a higher prevalence of stress was reported among students (85%) compared to their mothers (48%), with a statistically significant p-value of 0.000.

 Based on the data presented in Table 2, significant differences were observed in the menstrual history of adolescent girls compared to their mothers, particularly in factors such as age at menarche, average days of cycle, white discharge and cycle regularity. Regarding habitual and lifestyle factors, significant differences were identified in the consumption of animal food pattern, snack food pattern, the prevalence of active versus sedentary lifestyles and experience stress.

Association of factors influencing the change in the menarcheal pattern:

The mean menarcheal age for adolescent girls was 12.96 years, compared to 13.82 years for their mothers, indicating a downward trend in menarcheal age. To investigate the factors driving this shift, the mean menarcheal age of mothers (13 years) was used as a reference point to evaluate the lifestyle and behavioural factors contributing to this change.

 A sedentary lifestyle was significantly associated with an earlier age of menarche (≤13 years), with a p-value of 0.002. Among total of 200 participates 70(35%) have active lifestyle and 130 (65%) leads sedentary lifestyle of which 83(41%) of them attain menarche at ≤ 13 years and 47(24%) at > 13 years. (Figure-2).

Furthermore, frequent consumption of animal-based foods (≥3 times per week) was linked to menarche ≤ 13 years, while less frequent vegetable-based food consumption (<3 times per week) was associated with menarche >13 years, with statistically significant p-values of 0.000 and 0.009, respectively. On the other hand, socio economic class, number of days of bleeding, hours of sleep, snack food pattern and stress experience doesn’t seem to have any statistical significance. (Table: 3)

The median menarche age was 13 years for students and 14 years for mothers. The distribution of menarche age among daughters showed a higher prevalence in earlier age groups, decreasing toward later ages, whereas mothers exhibited a more balanced distribution, with the highest frequency occurring between 13–15 years. The duration of menstrual bleeding ranged from 3 to 5 days in 69% of students and 74% of mothers, a difference that was also statistically significant (p = 0.027). Menstrual characteristics such as pain and blood flow volume, did not demonstrate statistically significant differences, with p-values of 0.073 and 0.108, respectively.

The analysis revealed a marked difference in sedentary behaviour, with 91% of students exhibiting sedentary lifestyle compared to 39% of their mothers (p < 0.001). The higher prevalence of sedentary behaviour among students aligns with increased access to electronic devices and academic demands, which may limit opportunities for physical activity. Mothers, conversely, reported more active leisure time, potentially influenced by domestic responsibilities like household chores or greater awareness of health benefits. Regarding BMI, 62% of students were classified as having a higher weight status compared to 49% of their mothers. This difference suggests an increased weight among the younger generation. The elevated BMI among students emphasize the need for interventions promoting active lifestyles in educational settings.                  

The mean menarche age of 12.96 years was recorded for daughters, compared to 13.82 years for their mothers, suggesting a decrease in menarche age across generations. This pattern is similar with the results of a study by Balaji Ramraj et al. and Secular Trends in Menarche Age in India-Evidence.[18]. Likewise, in Chinese females, the age at menarche declined from 14.25 years of 1976 to 12.60 years for those born after 2000, reflecting a reduction of nearly 0.51 years per decade[7]. Age of menarche distribution of daughter was high in the earlier period of life compare to their mothers. In contrast to the present study, a similar study conducted in Tamil Nadu reported a lower mean age of menarche in daughters (12.5 years) and a higher mean age in their mothers (14 years).[18]

A statistically significant difference was observed in the reported sedentary lifestyle patterns between current study and the similar study done in south india by Balaji Ramraj et al.[18].Specifically, 91% of daughters in the current study reported a sedentary lifestyle, compared to 73% in the comparison study[18]. Conversely, 100% of mothers in the comparison study reported an active lifestyle, contrasting with the findings of the present study[18]. A modest increase in PCOS prevalence was observed among daughters in the current study (20%) compared to a similar study reporting 18%. In contrast, the maternal PCOS prevalence (3%) remained consistent with observations from a study conducted in Tamil Nadu[18]. The current study also found there a significant role of sedentary life style and consumption of animal food pattern for > 3 weeks a day in decreased age of menarche which is similar to the study done in south india [18].

 Sedentary lifestyle is drastically increasing in younger generation compare to their mother or earlier generation due to increased technology, machinery, and electronic devices for household works, gadgets, television, following social media, an era of influencers where physical activities are much decreased among the population. Few studies done on relation of physical activity and endogenous oestrogen stated that increased physical activity will decrease endogenous oestrogen and the sedentary lifestyle will decrease the oestrogen metabolism and excretion which in turn will increase endogenous oestrogen which leads to decrease in menarcheal age[18,19] .

This study demonstrated a generational shift towards earlier menarche, with adolescent girls exhibiting a lower mean age of menarche compared to their mothers. In contrast, mothers reported greater menstrual cycle regularity than their daughters. Significant differences in habitual and lifestyle patterns and consumption of animal food pattern were also evident between mothers and adolescent girls. Analysis revealed that lifestyle patterns, specifically the presence of active or sedentary habits and dietary habits, play a significant role in the observed decrease in menarcheal age.

To address this, it is crucial to establish health programs that enhance education aimed at increasing knowledge and awareness about associated risk factors and preventative healthy habits contribute valuable insights into the changing patterns of menarcheal age and its determinants in the Indian context, providing a foundation for future research and public health initiative.

Acknowledgement:

We express our heartfelt appreciation to all participants for their willingness and involvement in this study. We are privileged to extend our gratitude to Dr.G.Aswan, Assistant professor in community medicine department for his innovative thoughts and contribution for preparing the questionnaire of the study we also extend our sincere thanks to Dr. A. Yedukondala Rao, Principal of the institution, for his unwavering encouragement and support throughout our research endeavour.

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