Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Age at menarche in contemporary Greek girls: evidence for levelling-offof the secular trendAnastasios 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, Greece2.First Department of Pediatrics, University of Athens School of Medicine, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece

KeywordsAge at menarche, Greek girls, Obesity, Secular trend

CorrespondenceAnastasios Papadimitriou, M.D., Third Departmentof Pediatrics, University of Athens School ofMedicine, ‘Attikon’ University Hospital, Rimini 1Street, Athens 124 64, Greece.Tel: +30-210-5832046 |Fax: +30-210-5832229 |Email: anpapad@med.uoa.gr

Received23 December 2007; revised 28 February 2008;accepted 20 March 2008.

DOI:10.1111/j.1651-2227.2008.00806.x

AbstractAim: To examine the secular trend of menarcheal age in Greek girls during the last decade.

Methods: Seven hundred and fifty 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 significant

correlation between age at menarche of the schoolgirls and their mothers, p < 0.0001. There was a

significant 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 significant 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 influenced by the weight status and maternal menarcheal age.

INTRODUCTIONMenarche is a milestone in the somatic development of fe-males, as it signals an advanced stage of pubertal maturation.Furthermore, it marks the possibility of reproductive com-petence of the female.

During the 20th century the dramatic improvement of so-cioeconomic conditions and general health of the popula-tions in the industrialized countries resulted in an earlieronset of puberty in children (1). The most reliable markerof the positive secular changes in pubertal development wasthe fall of the age at menarche. It has been estimated thatduring most of the 20th century age at menarche has beenfalling by about 3 months per decade (2). However, therehave also been reports from industrialized countries that theage at menarche has been levelling-off or that it shows anupward trend (3,4). In the last 30 years, two studies havebeen performed in Greek girls showing a secular trend forearlier menarche (5,6).

The aim of this study was to examine if, during the last10 years, a secular trend in the age at menarche in Greekgirls is taking place by comparing these data with those of astudy we performed in 1996.

METHODSFor comparison reasons, in this study we used the samemethodology to the one in the study of 1996. Physiciansfrom our group visited six senior high schools in variousdistricts of the Greater Athens area some days prior to the

study, out of the eight schools we had visited in the previ-ous study, in order to inform the female students about thestudy. All the schools were public (state owned), attendedmainly by children that belong to the middle social class.The schoolgirls were asked through a questionnaire to re-port the exact date of their menarche, aided by their moth-ers, and that of their mothers. If they were not sure about theexact date that menarche occurred, they were asked to re-port the month and the year. Also, they were asked to reporttheir country of origin; in the last 10 years significant socialchanges have occurred in Greece, so a substantial number ofschoolchildren are migrant children, mostly from Albania.Furthermore, they were asked about parental educationallevel, participation in sports or other physical activities atthe time of or preceding menarche, the duration of their in-volvement in sporting activities and whether at the time ofmenarche they considered themselves to be obese, of normalweight or lean. They were also asked about the frequency oftheir menstrual cycle and the duration of the menses. Thequestionnaires were filled at home and were collected bymembers 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 menar-che but the month and the year, so for the calculations weused the 15th day of the corresponding month.

Statistical analysisValues are expressed as mean (SD). In order to exploreany correlations of age of menarche with weight status

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(lean, normal and obese), sporting activities duration (inyears, until menarche) and frequency of menstrual cycle (indays), we used Pearson’s coefficient (r). The independentsamples t-test or one-way ANOVA with Bonferroni multiple-comparison test was used for comparing mean age of menar-che between different groups. We conducted power analysisprior to our study with significance level 0.05 and effect size0.15 (characterized as small on Cohen’s definitions of effectsizes (7)). All reported p-values are based on two-sided testsand are compared with a significance level of 5%.

RESULTSIn order to achieve a power of 0.9 for our analysis we neededa sample of 771 girls. The number of questionnaires that weregiven was 1229 and the number of the completed question-naires was 808 (66%). Fifty-eight questionnaires were filledby non-Greek schoolgirls, therefore 750 schoolgirls partic-ipated in the study. The age range of the schoolgirls thatfilled the questionnaires was 14.8 to 18.2 years. There wasno significant difference in the mean (SD) age at menarchebetween the year 2006, that it was 12.29 (1.19) and 1996that it was 12.27 (1.13) years (p = 0.73) (Table 1). In thisstudy the age range of menarche was 8.9 to 16.7 years andthe ages that corresponded to the 3rd and 97th centile were10.2 and 14.5 years, quite similar to the ones reported in1996. Mean menarcheal age of the mothers was 13.02 (1.32).There was a significant correlation between age at menarcheof the schoolgirls and their mothers, r = 0.28, p < 0.001.

There was a statistically significant difference in the ageat menarche according to the schoolgirls’ perceived weightstatus at the time of menarche. The girls who consideredthemselves 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 andthe girls who considered themselves as lean (n = 220) hadmenarche at the age of 12.42 (1.14) years, p < 0.001 (Table 2).Significant differences were found to exist between obeseand girls of normal weight, p = 0.004 and between obeseand lean girls, p < 0.001.

There was no correlation between weight status and du-ration of menses or frequency of menstrual cycles.

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

Year 1979 1996 2006

n 1366 1134 750x (SD) 12.40 (1.02)∗ 12.27 (1.13)∗ 12.29 (1.19)

∗p = 0.004.

Table 2 Mean (SD) age at menarche in relation to the perceived weight status

Weight status Lean Normal Obese p

n 220 474 54x (SD) 12.42 (1.14) 12.29 (1.21) 11.73 (1.13) <0.0001

A substantial percentage of the girls reported no partic-ipation in any sporting activities, that is, 477 girls (63.6%).Thirteen percent reported involvement in ballet dancing ormartial arts, whereas 23.3% of the girls reported involvementin sports with intense physical training (basketball, volley-ball etc.). However, only a small number of these girls (n =7) were training at least 5 days a week as part of an ath-letic team. There was no significant difference in the age atmenarche 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 dif-ference in the age at menarche in relation to the duration ofinvolvement in sporting activities.

There was also no significant difference between age atmenarche and parental educational level or whether theirmothers were working outside the house or not (data notshown).

DISCUSSIONAlthough the recall method for the estimation of the ageof menarche has several methodological problems regard-ing the accuracy of recall (8), we used the same methodol-ogy as in the previous study in order for the results to becomparable.

Our data provide evidence for arrest in the secular trendin the age of menarche in girls living in Athens, Greece.

We had previously shown that during the 20th century adramatic decrease in the age at menarche had taken placein Greece, as in every other country in the industrializedworld. For example, in the first report on menarcheal agethat we were able to find in the Greek scientific literature,Malaspina, in her study of 6203 girls from all over Greeceperformed in 1935, found that menarche occurred in 37.1%of the girls at the ages of 13.0–13.99 years, in 26.5% at theages of 14.0–14.99 and only in 18.6% menarche occurredat the ages of 12.0–12.99 years (9). In 1979 the mean age atmenarche of Athenian girls was found to be 12.4 (1.02) years(6), which is significantly greater than the mean age reportedin 1996 (p = 0.004). The mean ages at menarche of Greekschoolgirls found in this study and the studies in 1979 and1996 are shown in Table 1. It is of historical interest thataccording 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 byfactors including body mass index (BMI), socioeconomicstatus, physical activity, nutritional status and genetic influ-ences. The influence of genetics is estimated to be half of thevariance in menarcheal timing (11).

In our study the only variables that were found to influ-ence age at menarche were obesity and maternal menarchealage, whereas an association between age at menarche andschoolgirls’ physical activities or parental educational levelcould not be established.

It has become common knowledge that overweight girlstend to mature earlier than lean girls. In 1974 Frisch sug-gested that the degree of body fatness may act as a trigger forthe neuroendocrine events that lead to the onset of menses(12). Since then several researchers addressed the hypothesis

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Age at menarche in Greek girls Papadimitriou et al.

that increasing obesity may be a significant cause of earlieronset of puberty. In a study of the relation between age atmenarche and overweight in U.S. adolescent it was foundthat early maturing girls were twice as likely to be overweightthan average maturers and this was true for all racial–ethnicgroups (13). It has also been shown that in 6- to 9-year-oldU.S. girls BMI-Z scores were higher in pubertal than prepu-bertal white girls, whereas in black girls the difference wassignificant only for the 9-year-old girls (14). However, Himeset al., in a study of African-American girls showed that pu-bertal girls were more than six times as likely to be classifiedas overweight and more than eight times as likely to be obesethan their prepubertal counterparts (15).

Self-perception of weight status is frequently incorrect es-pecially among overweight children (16). We recently re-ported that in girls the prevalence of obesity was 9.9% andof overweight 26.5% (17). In this study 7.5% (56 out of 750)of the girls considered themselves as obese. Therefore, thesedata suggest that overweight girls perceive themselves as ofnormal weight, whereas most obese girls perceive themselvesas such.

The positive association between age at menarche and ma-ternal menarcheal age found in our study has also been re-ported by other researchers (18), highlighting the influenceof genetics on menarche.

It is known that in female gymnasts pubertal developmentis delayed as a result of the intense physical training and thepsychological stress that accompanies the training and theparticipation in athletic competitions (19). The lack of anassociation between age at menarche and sporting activitiesin our study may be due to the fact that only a small numberof girls of the population under study was regularly involvedin intense physical training.

Although higher socioeconomic status has been reportedto be associated with earlier menarcheal age (20), we foundno correlation between parental educational level (a proxyof socioeconomic status) and age at menarche. This suggeststhat in highly urbanized populations, like the one of ourstudy, socioeconomic status is not significant determinantof the age at menarche.

Although for the most part of the 20th century a seculartrend for earlier menarche was evident in Greek girls, ourdata suggest that in the last 10 years a levelling-off of the ageat menarche has taken place at least in Athenian girls. InU.S. girls it was reported that menarche had remained stablein white girls over the last 45 years (21), and also for U.K.women born from 1950 to 1986 no appreciable decreasein menarcheal age was reported (22). However for U.S. girlsseveral other studies have shown a decline of the menarchealage over the last 20 years (23,24).

A trend towards earlier menarche is still observed in sev-eral European countries (25), however in some this trendseems to have come to an arrest (4). It is interesting thatthere is a north to south gradient in the age at menarche.South European girls have on average earlier menarche thanNorth European girls. This suggests that the difference inmenarcheal age may be related to environmental, for exam-ple, climate, or to genetic factors.

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

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