Acta Obstet Gynecol Scand 2005: 84: 645--649

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Copyright # Acta Obstet Gynecol Scand 2005

Acta Obstetricia et
Gynecologica Scandinavica

ORIGINAL ARTICLE

The effect of gynecologic age, body mass

index and psychosocial environment on
menstrual regularity among teenaged
females
MARI JARVELAID
From the Department of Policlinic and Family Medicine, University of Tartu, Estonia

Acta Obstet Gynecol Scand 2005; 84: 645649.

Acta Obstet Gynecol Scand 84 2005

Background. The aim was to study the prevalence of menstrual irregularity at an early
postmenarcheal age and various biopsychosocial factors associated with menstrual
irregularity.
Methods. The study was conducted in Tartu, Estonia. The 70-item questionnaire and the
21-item Beck Depression Inventory (BDI) were completed by 580 female students of grades
912 in four high schools. Their height and weight were measured and body mass index
(BMI) calculated. The effects associated with regularity of the menstrual cycle were studied.
Results. Irregularity of the menstrual cycle was reported by 40% of respondents at an early
postmenarcheal age. The risks for irregular menstrual cycles (IRM) were BMI <17.5 kg/m2
[odds ratio (OR) 2.06; 95% confidence interval (95% CI) 1.064.00], low economic status
IRM [OR 1.77 (95% CI 1.412.20)], insufficient communication with parents [OR 1.46 (95%
CI 1.022.09)], and never pleased to go to school [OR 1.27 (95% CI 1.031.56)]. Comparison
of the answers to the BDI with the regularity of periods revealed a difference in the total
score [OR 1.54 (95% CI 1.211.97)], with a mean score of 8.3
0.4 for the respondents with
regular menstrual cycles (RM) vs. 10.6
0.5 for the respondents with IRM.
Conclusion. Menstrual irregularity at an early postmenarcheal age can be considered as an
indicator of difficulties in psychosocial adaptability of teenaged females.
Key words: menarche; adolescents; gynecologic age; menstrual regularity; body mass
index
Submitted 5 March, 2003
Accepted 13 August, 2003

Menstrual irregularity is a common disorder in

early postmenarcheal age. It has been observed
that exercise, psychological stress and nutritional
status, and, more precisely, sufficient adipose tissue are the factors associated with menarche as
well as with the regularity of adolescent menstrual
cycles (17). Variability in cycle length among
Abbreviations:
RM: regular menstrual cycles; IRM: irregular menstrual cycles;
BDI: Beck Depression Inventory; BMI: body mass index; OR:
odds ratio; CI: confidence interval.

females is in principle due to the varying number

of days required for follicular growth and development in the follicular phase. In a study of more
than 250 000 menstrual cycles of 2700 women, it
was found that at the second gynecologic year the
central 90% intervals would fall between 20.2 and
53.5 days (median 29.2 days), and at the sixth
gynecologic year between 21.8 and 39.2 days (median
at 28.0 days) (8).
The aim was to study the prevalence of menstrual
irregularity at an early postmenarcheal age and
the effects of various associated biopsychosocial
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Acta Obstet Gynecol Scand 84 (2005)

646

M. Jarvelaid

factors on menstrual regularity among teenaged

females.

Materials and methods

Four schools in different parts of the town of Tartu were
chosen. A 70-item questionnaire and the 21-item Beck
Depression Inventory (BDI) were completed by schoolgirls
from grades 9 to 12 in their classrooms during a regular
class. Their height and weight were measured and body
mass index (BMI) was calculated. The sample included 580
females, and comprised 22% of all female students in grades
912 in Tartu.
The questionnaire contained items on socioeconomic and
health status, emotional and physical welfare and menstrual
patterns. The respondents were asked about their parents
education and whether they lived together with their mother
and/or father, as well as about number of siblings, and
engagement in sports in addition to physical education at
school. They were also asked about communication with
their parents and school achievement. These questions were
to be answered on a 5-point Likert scale ranging from
always to never.
Menstrual regularity was assessed on the basis of the
question: How many days do you usually have from the
first day of one bleeding until the first day of the next one?
The periods were defined as regular if the overall range was
within 20 to 40 days or the difference between the shortest
and the longest cycle was less than 15 days. The respondents
were divided into two groups: those with regular menstrual
cycles (RM) and those with irregular menstrual cycles
(IRM).
The 21-item BDI was used to measure depressive feelings.
The scores of the single items of the BDI were added up for all
respondents. The summed score of the BDI was considered
normal with 09 points, slightly depressed with 1015 points,
moderately depressed with 1629 points, and severely
depressed with more than 29 points (9,10).
Statistical analysis used the
2-test, with 0.05 as the level
of significance. Binomial logistic regression analysis was
performed, and odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. The dependent variables were
regularity of menstrual cycles and gynecologic age up to
2 years. The covariables were all other items explored in
the questionnaire. The analysis was performed using the
statistical program Statistical Package for Social Sciences
(SPSS) version 10.0 for Windows.

Results

Regularity of periods
The RM group consisted of 311 respondents and
the IRM group 209. The mean (
standard deviation) age in the RM group was 15.7
1.0 years
and in the IRM group 15.6
1.0 years. A gynecologic age less than 2 years was associated with a
statistically higher risk for IRM [OR 1.91 (95%
CI 1.332.72)]. The prevalence of RM increased
linearly with gynecologic age (Table II).
Although at the age of 6 and 7 gynecologic
years all respondents reported RM, this group
was too small for any conclusions to be drawn
(1% of the total sample, n 6) (Table II).
Body mass index
The RM group had a mean weight of 57.5
7.9 kg
and the IRM group 56.2
7.6 kg, the mean height
being 1.68 m in both groups. The RM group had a
mean BMI of 20.5
2.6 kg/m2 and the IRM group
20.0
2.3 kg/m2 (p 0.03). BMI was lowest
(16.6 kg/m2) among the premenarcheal respondents (Table II). A BMI lower than 17.5 kg/m2
was associated with risk of IRM [OR 2.06 (95%
CI 1.064.00)]. A correlation between higher BMI
and RM was found at a gynecologic age of up to
2 years, whereas a similar correlation was not
found among the respondents at a gynecologic
age more than 2 years (Fig. 1).
Psychosocial environment
Low economic status was a risk for IRM
[OR 1.77 (95% CI 1.412.20)]. An 82% prevalence
of RM was noted for those with high economic
status within the group of gynecologic age up to
2 years vs. a 41% prevalence of RM for those at a
higher gynecologic age than 2 years.
No statistically significant difference was
found between the groups for the items chronic
disorder, number of siblings, living together with
mother and/or father, and level of parents education. Although whether or not the respondent
lived with the father had no influence on RM,

Population
In total, 580 female students took part in the
study, of whom 99.1% were ethnic Estonians.
Thirty-two respondents (5.5%) reported using
oral contraceptives and 11 (1.9%) gave no
answers to the questions about the characteristics
of their periods; these 43 respondents were
excluded from further analysis. The mean age
was 15.7 years (range 13.218.4 years) and the
mean age at menarche was 13.0 years (range
917 years). Seventeen respondents (2.9%) were
in premenarche (see Tables I and II).
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Acta Obstet Gynecol Scand 84 (2005)

Table I. Gynecologic age, height, weight, body mass index (BMI) and
prevalence of regular menstrual cyclicity (RM) by age of respondents
Age
(years) N

Mean gynecologic Mean height Mean weight BMI

% of
age (years)
(m)
(kg)
(kg/m2) RM

13
14
15
16
17
18
Total

1.0
2.4
2.7
3.0
4.0
4.4
3.1

1
61
166
168
117
7
520

1.68
1.65
1.68
1.68
1.68
1.70
1.68

53.0
53.0
55.6
57.7
58.3
63.0
56.7

18.8
19.4
19.8
20.5
20.5
21.6
20.2

0
56
57
63
64
29
60

Menstrual regularity among teenaged females

Table II. Age, body mass index (BMI), weight, height and prevalence of regular
menstrual cyclicity (RM) by gynecologic age of respondents
Gynecologic age
(years)
N

Mean age BMI

Weight Height
(m)
% of RM
(years)
(kg/m2) (kg)

Premenarcheal
<1
1
2
3
4
5
6
7
Mean
N
SD

14.8
14.6
14.9
15.4
15.9
16.4
16.7
16.7
18.0
15.7

17
28
76
142
124
96
47
6
1

16.6
18.9
19.4
19.8
20.6
21.1
20.9
21.9
18.4
20.17

45.2
51.3
54.6
55.7
58.2
59.9
58.8
62.0
47.0
57.0

1.65
1.64
1.67
1.68
1.68
1.68
1.68
1.68
1.60
1.68

537

43
52
54
66
66
72
100
100
312

1.01

2.47

2.95

0.06

communication with the father seemed to be

essential for regularity of periods. The respondents who could always talk to their fathers
about their problems reported RM in 77% of
the cases (respondents at a gynecologic age of
more than 2 years in 80% of the cases) [OR 1.18
(95% CI 1.032.09)]. The lowest prevalence of
RM (35%) was revealed in the group of respondents who sometimes could, but sometimes could
not, talk to their father about their problems. The
prevalence of RM in the group of respondents
who had no such opportunity was 47%. Communication with the mother did not reveal such an
effect, but the respondents who could always talk
to both parents about their own problems had the
highest prevalence of RM in the total sample
[OR 1.46 (95% CI 1.022.09)]. Thus in the group
of respondents at a gynecologic age of more than
2 years, the respondents who could always talk to
both parents about their own problems had 94%
of RM compared with 50% for those who
reported having poor communication with their
parents.

647

The respondents who always thought of

attending school with pleasure showed a prevalence of RM of 53% for gynecologic age up to
2 years and 78% for those over 2 years vs. 20% for
respondents who were never pleased to go to
school [OR 1.27 (95% CI 1.031.56)]. Respondents who always gained good marks at school
had the lowest prevalence of RM, 36% vs. 60%
for those who mostly gained good marks, and
75% for those who never gained good marks.
The group of respondents engaged in sports
showed a slightly higher, statistically insignificant
prevalence of RM; 62% vs. 57% for respondents
who did not go in for sports.
Beck Depression Inventory
Comparison of the answers to the BDI with the
regularity of periods revealed a difference in the
total score [OR 1.54 (95% CI 1.211.97)], with a
mean score of 8.3
0.4 for the RM group vs.
10.6
0.5 for the IRM group. Regarding individual questions the IRM group showed a higher
prevalence of guilt [OR 1.35 (95% 1.031.77)],
self-dislike [OR 1.33 (95% CI 1.051.69)], selfaccusation [OR 1.30 (95% CI 1.021.65)], suicidal
thoughts [OR 1.72 (95% CI 1.242.40)], anorexia
[OR 1.75 (95% CI 1.232.49)] and somatic preoccupation [OR 1.79 (95% CI 1.262.53)].
Discussion

It is known that menstrual cycles are often irregular in early postmenarcheal years, although this
irregularity shows a great variability in different
countries (4,8,11,12). A World Health Organization Multicenter Study showed that during the
two postmenarcheal years 71% of girls menstruated at 20- to 40-day intervals (12). In another

90
80
02
gynecological
years

70
60
50
%
40

37
gynecological
years

30
20
10

Fig. 1. Percentage
prevalence
of
regular
menstrual
cyclicity
by
gynecologic age and body mass index
(BMI).

0
<17.5

17.519

1924

2427.5

>27.5

Body mass index (kg/m2)

#

Acta Obstet Gynecol Scand 84 (2005)

M. Jarvelaid

study, menstrual irregularity was reported by

43% at the second gynecologic year, but by only
24% at gynecologic age 4 or more years (4).
In the current study 46% of respondents at the
second gynecologic year and 33% of respondents
with gynecologic age more than 2 years had irregular menstrual cycles.
One of the principal factors for the cycle regularity is bodyweight. The average weight of teenaged females in Estonia has declined in the past
decade. In 1989 the BMI of 18-year-olds was
23.2 kg/m2, while in 1996 it was 21.2 kg/m2 (13).
The smaller BMI is due to a decline in bodyweight. The extremely rapid decline in bodyweight (see Figs 24) among Estonian teenaged
females seems to be exceptional in an international context, where so many countries have
a secular trend toward an increasing prevalence
of childhood obesity (6,14,15). The cutoff point for
the desired body shape, expressed by 1518-yearold Estonian females, is to have a BMI less than
19 kg/m2 (16).
According to the critical weight or body fat
theory, sufficient body stature must be reached
for menarche to be triggered as well as to maintain menstrual regularity (37). This was supported by the present data because the
respondents in premenarche clearly exhibited
the lowest BMI. Moreover, a positive correlation
between BMI and cycle regularity was observed
for up to 2 postmenarcheal years, but not later
(see Table II). Thus it seems possible that factors
other than adequate BMI become more important for the cycle control in later postmenarcheal
years. This is in line with previous data (4).
A good family relationship was a significant
factor for RM in the current study. The fact
that prevalence of menstrual regularity was
higher when teenaged females had a better relationship with the father may reflect the general

65
19261927
Weight in kilograms

648

19561967
55
1978
50
1989
45
1996
40
14

15

16
17
Age in years

18

Fig. 3. Average weight of Estonian females in 192627, 195667,

1978, 1989 and 1996.

good emotional welfare of these families.

Another important determinant appeared to be
the desire to go to school. With this as the background, it may seem surprising that the prevalence of RM was as low as 36% among female
students with the highest marks at school, but
this must reflect the impact of mental stress on
menstrual function.
This study demonstrated an association
between depressive mood, negative self-esteem,
somatic preoccupation and menstrual irregularity. The presence of IRM was more common in
female students with loneliness, guilt, self-dislike,
suicidal thoughts and dissatisfaction with life, but
also with anorexia, weight loss and somatic preoccupation. This confirms that factors other than
only BMI are crucial for menstrual regularity.
To sum up, the irregularity of menstrual cycles
among teenaged females is associated with a
number of indexes reflecting psychosocial distress. Thus, cycle irregularity in adolescent
females appears to be one indicator of the general
distress and poor adaptability in daily life.

24

170

19261927

19261927
165

19561967

160

1978

23
19561967
BMI kg/m2

Height in centimetres

60

22
1978
21
1989

1989

155

20
1996

1996
150

19
14

15

16

17

18

Age in years

Fig. 2. Average height of Estonian females in 192627, 195667,

1978, 1989 and 1996.
#

Acta Obstet Gynecol Scand 84 (2005)

14

15

16

17

18

Age in years

Fig. 4. Average body mass index (BMI) of Estonian females in

192627, 195667, 1978, 1989 and 1996.

Menstrual regularity among teenaged females

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Address for correspondence:

Mari Jarvelaid
Department of Policlinic and Family Medicine
University of Tartu
Gonsiori 34-4
Tallinn
Estonia EE 10128
e-mail: Mari.Jarvelaid@tervisekaitse.ee

Acta Obstet Gynecol Scand 84 (2005)