Early Life Circumstances and Their Impact on Menarche and Menopause

Gita D. Mishra; Rachel Cooper; Sarah E. Tom; Diana Kuh


Women's Health. 2009;5(2):175-190. 

In This Article

Age of Menarche

Menarche marks the commencement of the reproductive phase of a woman's life. Records suggest that there was a secular decline in the average age at menarche in developed countries across the 19th and 20th Centuries until the 1950s,[17] with an average age at menarche of 15-17 years reported in the mid-19th Century.[18,19] It has been suggested that pubertal timing may then have plateaued in the 1950s, although further small declines have subsequently been reported.[17] While recent estimates of the median age of menarche vary between 13 to 16 years, recent data suggest that the age of 15 years represents the 95-98th percentile for menarche.[17] A review of family and twin studies has highlighted the key role of genetic factors in determining the timing of menarche, with heritability estimates ranging from 0.44 to 0.72.[20,21] In examining early life predictors of age at menarche, three major themes have emerged, namely the effects of body size, social circumstances and exposure to unfavorable psychological circumstances. The effects of these environmental influences on the timing of menarche can be explained, from an evolutionary-development perspective, in terms of life history theories.

Life History Theory Perspectives on the Timing of Menarche

The main life history theories have been elaborated by Ellis[22] as the energetics theory, and the four psychosocial models of pubertal timing: psychosocial acceleration, parental investment, stress suppression and child development theory. However, the theories differ in their conceptualization of the nature, extent and direction of environmental influences on the age of menarche, and the effect that the timing of menarche has on subsequent reproductive characteristics.[22]

The energetics theory suggests that energy availability during childhood influences the timing of menarche. It hypothesizes that girls who were exposed to a chronically poor nutritional environment will grow more slowly, experience later pubertal development (relative to their genetic potential), and reach relatively small adult size compared with those children who were exposed to greater food availability. This is consistent with an earlier idea regarding the impact of relative fatness that follows from the close relationship of average critical bodyweight on age at menarche.[23] The psychosocial acceleration theory posits that the experience of high levels of emotional stress in and around a girl's family leads to earlier menarche in order that she can maximize her chance of leaving descendents.[24,25] Based on the same logic, the parental-investment theory hypothesizes a special role for the father and other men in influencing the timing of menarche. The stress-suppression theory[26] proposes that early adversity, whether it is by adverse physical or social conditions or psychosocial stress, causes a delay in pubertal development until better times. Last, Ellis describes child-development theory as reconceptualizing 'the age at menarche as the end point of a developmental strategy that conditionally alters the length of childhood in response to the composition and quality of family environments'.[22]

Birthweight and Childhood Growth

Several studies have examined birth size and infant growth in relation to age at menarche ( Table 1 ).[27,28,29,30,31] In a study investigating Filipino girls, long and thin infants had earlier menarche and this effect was strongest for girls with higher growth rates from 0-6 months.[31] The Medical Research Council (MRC) National Survey of Health and Development (NSHD) found, in a group of 2547 British girls, that rapid growth in infancy was associated with an earlier menarche. After adjusting for growth in infancy, higher birthweight was also predictive of an earlier menarche;[29] however, adjustment for growth later in childhood attenuated both of these associations. In another study, Swiss girls who were small for gestational age had earlier menarche than those of normal size for gestational age.[28] As in the previous study, the results were no longer significant when adjusted for childhood growth. A Polish study also found that girls born small for gestational age were more likely to have reached menarche by the age of 14 years, compared with other girls, but the authors were unable to adjust for childhood growth.[32] These results suggest that while age at menarche may be determined, in part, by factors in utero or in infancy, perhaps by programmed release of gonadotrophin,[29] such effects are mediated through early childhood growth.

Other studies have found that rapid prepubertal weight gain and childhood obesity are associated with an earlier menarche.[33] Using the growth status at birth as denoted by the expected birthweight ratio (EBW; a ratio of observed birthweight over median birthweight appropriate for the maternal age, weight, height, infant sex and gestational age), an Australian study found that earlier menarche was predicted by lower EBW combined with higher BMI during childhood.[34] Findings from the UK Newcastle One Thousand Families study support the notion of an interaction between birthweight and weight much later in childhood; specifically, girls who were large for gestational age and heavy at the age of 9 years had the earliest menarche.[35] From a life history perspective, results from the above studies appear to support the energetics theory for timing of menarche. While improvements in childhood nutritional status over time are thought to underlie the secular declines in age at menarche, the precise role of dietary composition in childhood remains unclear.[36] It is also worth noting that a recent study found no evidence to support a link between the secular rise in the prevalence of childhood obesity and the decline in average age at menarche.[37]

Childhood Socioeconomic Position

Numerous studies have investigated the relationship between childhood socioeconomic characteristics (e.g., urbanization, education, parental occupational class and family size) and age at menarche ( Table 1 ).[38,39,40] In general, studies from both developed and developing countries have found that living in urban areas,[40,41,42,43,44] having a father of higher occupational class[24,40,45,46,47] and having parents with higher educational levels[40,48] are associated with earlier menarche. Only a few studies have not found an association with area of residence.[47,49] One explanation postulated for the delayed menarche that is found among girls in rural areas is their increased levels of physical activity compared with those from urban areas.[49] Results from studies of the relationship between family size and pubertal timing have been inconsistent,[50] with some finding a positive association[39,42,47,51] and others not.[40,50]

Since socioeconomic circumstances often act as proxies for many factors, including the quality and quantity of food intake, energy expenditure, family structure and access to healthcare, few studies are able to separate out the effects of specific factors underlying the observed relationships between socioeconomic circumstances and timing of menarche. For instance, socioeconomic differences established in early childhood may be related to maternal efficiency during pregnancy (i.e., the ability of the mother to cope with and care for her unborn child), the duration of breastfeeding and the quality of the diet immediately after being weaned.[48] Associations between socioeconomic conditions and menarche may also be mediated by childhood growth; however, few studies have tested this hypothesis. Again, as socioeconomic circumstances influence nutritional environment in childhood, its relationship with the timing of menarche is consistent with the energetics theory of life history.

Psychosocial Factors: Childhood Experiences

Role of Family Structure and Relationships. While a mother's age at menarche appears to be a better predictor of the daughter's age at menarche than other external factors,[52] research supports the role of family structure in determining pubertal timing. Paternal affection, positive family relationships and paternal involvement in child rearing are related to a comparatively later age of menarche,[53,54] while increased family conflict, divorce and longer durations of paternal absence are correlated with earlier menarche.[55,56,57] It is also found that stepfathering predicts menarcheal age better than absence of a biological father and a longer presence of a stepfather correlates with earlier ages of menarche.[58]

Exposure to External Stressors/Trauma. Results from the 1934-1944 Helsinki Birth Cohort have found that the 396 evacuees who were sent by their parents, unaccompanied, to temporary foster families in Sweden and Denmark because of the Soviet-Finnish wars, had earlier menarche than other girls.[59] Similarly, other studies examining the effect of migration have found increased occurrence of early sexual development, indicated through precocious puberty, in adopted children in cohort studies from European countries.[60] For example, a recent Danish study found that internationally adopted children were more likely (~15-20-times) to develop precocious puberty compared with the Danish reference group.[61] In addition, children migrating with their families had no increased risk of precocious puberty.[61] Exposure to other types of stressors in childhood, such as sexual abuse, have also been shown to be associated with the early onset of menarche.[57,62] These results concur with the studies associating childhood adversities, lack of paternal investment and father's absence with earlier onset of menarche.[22,53,63]

Studies have also found that age at menarche is delayed during periods of war. Authors working on the 1944-1945 Dutch Famine Study attributed this to the effect of food rationing.[64] In another study, it was found that girls living in besieged Srebrenica during the Balkan War had delayed age at menarche.[65] However, the author concluded that psychological trauma, physical injury and low socioeconomic conditions, as a result of war, may have been the causes. A study of girls living in the city of Šibenik, Croatia where the menarcheal status of girls was surveyed three-times in 1981, 1985 and 1996, found that there was a significant increase in mean menarcheal age of approximately 3 months between 1985 and 1996. This increase over time was dependent on the nature of the stress experienced with those girls who had experienced personal tragedies during the Balkan war, demonstrating an even greater delay in menarche of almost 11 months.[50]

Research based on observational studies has also demonstrated delayed pubertal development following childhood adversity.[50,64] The effects of adversity may vary depending on the timing of exposure to the stressors.[59] For example, it has been shown that exposure to stress in early childhood is associated with earlier menarche,[22] whereas exposure during or shortly before puberty has been associated with later onset of menarche.[50,64]

Each of the three psychosocial models of pubertal timing within life history theory, namely psychosocial acceleration theory, parental investment theory and stress-suppression theory, can be invoked to explain the differing effects on age at menarche of each adverse condition in childhood identified previously. As an alternative, Boyce and Ellis have suggested the stress reactivity theory to account for both the delaying and accelerating effects of psychosocial stress on the timing of menarche.[66] They propose the notion that both highly protective and acutely stressful childhood environments trigger stress reactivity systems. If this triggering inhibits maturation of the hypothalamic- pituitary-gonodal axis, then this should produce a U-shaped relationship with age at menarche, whereby high social resources and support levels as well as high psychosocial stress and adversity are both correlated with later timing of menarche.


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