Original Study

Differences in Anthropometric and Ultrasonographic Parameters between

Adolescent Girls with Regular and Irregular Menstrual Cycles: A Case-Study
of 835 Cases
Ubavka D. Radivojevic MSc 1,*, Gordana B. Lazovic PhD 2,3, Tamara K. Kravic-Stevovic PhD 4,
Zarko D. Puzigaca PhD 1, Fadil M. Canovic MD 5, Rajko R. Nikolic PhD 1, Srboljub M. Milicevic PhD 2,3
1
Department of Human Reproduction, Mother and Child Healthcare Institute “Dr Vukan Cupic,” Belgrade, Serbia
2
Institute of Gynecology and Obstetrics, Clinical Centre of Serbia, Belgrade, Serbia
3
School of Medicine, University of Belgrade, Belgrade, Serbia
4
Institute of Histology and Embryology, School of Medicine, University of Belgrade, Belgrade, Serbia
5
Outpatient Gynecological Department Zemun, Belgrade, Serbia

a b s t r a c t
Study Objective: Exploring the relation between the age, time since menarche, anthropometric parameters and the growth of the uterus
and ovaries in postmenarcheal girls.
Design: Cross sectional.
Setting: Department of Human reproduction at a tertiary pediatric referral center.
Participants: Eight hundred thirty-five adolescent girls.
Interventions: Postmenarcheal girls were classified according to the regularity of their menstrual cycles in 2 groups (regular and irregular
cycles) and compared. Anthropometric measurements and ultrasonographic examination of the pelvis was conducted with all participants.
Main Outcome Measures: Anthropometric and ultrasonographic parameters were evaluated.
Results: Results of our study showed that girls with regular and irregular cycles differed in height, weight, body mass index, percentage of
body fat and ovarian volumes. The size of the ovaries decreases in the group of girls with regular cycles (r 5 0.14; P ! .005), while it
increases in girls with irregular cycles (r 5 0.15; P ! .001) with advancing age. Uterine volume in all patients increases gradually with age
reaching consistent values at 16 years (r 5 0.5; P ! .001). Age at menarche, the time elapsed since menarche, the height, weight, body
mass index and percentage of body fat in patients correlated with uterine volume. Ovarian volume correlated with patients' weight, BMI
and percentage of fat.
Conclusion: Uterus continues to grow in postmenarcheal years, with increasing height and weight of girls, regardless of the regularity of
cycles. Postmenarcheal girls with irregular cycles were found to have heavier figures and larger ovaries.
Key Words: Adolescents, Uterus, Ovary, Growth, Anthropometry, Menstrual cycles, Body composition, Ultrasonography

Introduction regularity of menstrual bleeding, regularity of ovulation and

Adequate pubertal growth of the genital organs is essen-
tial for reproductive health of a girl.1 The development of the
female reproductive system from birth until menarche is well
documented.2,3 On the other hand, fewer data are available
on morphologic changes and growth patterns of the uterus
and ovaries during the first few years after menarche.1,4
It has been suggested that after the menarche uterus
continues to grow and gradually reaches the adult size and
form.1 This process is thought to be completed by the age of
16.4,5 An ovary, in the immediate premenarchal period, en-
larges rapidly and attains, by menarche, the adult appear-
ance.5 After menarche, the ovarian/uterine ratio decreases
with increasing gynecologic age.1 Among the reproductive
hormones, estradiol seems to be the main agent stimulating
uterine growth. Other reproductive parameters, such as the
progesterone levels, do not appear to be related to uterine
size and growth rate.1
The imaging technique of choice for studying the pelvic
organs in adolescent girls is real-time ultrasonography (US)
because it is noninvasive, painless and free of ionizing ra-
diation.1 Transabdominal US is the approach of choice for
non sexually active adolescents2 and provides an optimal
overview of the anatomy, shape, size, and echogenicity of
the pelvic organs.
The aim of this study was to explore postmenarcheal
development of the uterus and ovaries. We studied the
relation between age, time since menarche, antrophometric
parameters and the volume and size of the uterus and ovaries
in a population of girls with regular and irregular menstrual
cycles.
Methods

The authors indicate no conflicts of interest. Study Design and Participants

* Address correspondence to: Ubavka D. Radivojevic, MSc, Department of Human
Reproduction, Mother and Child Healthcare Institute “Dr Vukan Cupic,” Radoja A cross sectional study on 857 postmenarcheal patients
Dakica 6 St, 11000 Belgrade, Serbia; Phone: þ 381 60 550 30 33; fax: þ 381 11 667
14 81 (postmenarcheal period ranged from 6-72 months) was
E-mail address: radivojevic.ubavka@gmail.com (U.D. Radivojevic). conducted from July 2008 to January 2013.
1083-3188/$ - see front matter Ó 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpag.2013.11.007
2 U.D. Radivojevic et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e5

Adolescents were selected based on the following crite- Table 1

Baseline Data: Age, Age at Menarche, Time Elapsed Since Menarche and a Summary
rion: the ultrasonographic presence of the uterus and both of Anthropometric Characteristics and Ultrasonographic Findings
ovaries. The exclusion criteria were: endocrinopathies (hypo/
Adolescents Adolescents Total P
hyperthireoidism, hyperprolactinemia, diabetes mellitus); with with
evidence of congenital adrenal hyperplasia or androgen- Irregular Regular
secreting tumors; cardiovascular or other systemic diseases; Cycles Cycles

chromosomopathies; ovarian cysts and tumors; suspicion of N 5 428 N 5 407 N 5 835

ovarian torsion; malformations of the internal genital organs; Mean SD Mean SD Mean SD
nutrition disorders and current use of medications known to Age (years) 15.77 2.18 15.58 2.08 15.68 2.14 NS
alter reproductive hormones (hormonal contraceptives, Time elapsed since 2.94 1.77 2.86 1.76 2.89 1.76 NS
progesterone therapy, insulin sensitizers and antihyperten- menarche (years)
Age at menarche (years) 12.81 1.30 12.70 1.29 12.76 1.29 NS
sive medications). Height (m) 1.65 0.07 1.66 0.07 1.65 0.07 !.05
Menstrual cycles were defined as either (1) regular, if Weight (kg) 57.85 11.36 54.92 8.27 56.43 10.08 !.001
their length was 22-35 days, or (2) irregular, when they were BMI (kg/m2) 21.28 3.83 19.88 2.44 20.61 3.31 !.001
Fat (%) 23.91 4.96 22.10 3.38 23.04 4.36 !.001
less than 22 or more than 35 days long.6 Uterus volume (cm3) 49.54 20.47 48.67 22.72 49.10 21.61 NS
The study protocol was approved by the Ethic Committee Right ovary volume (cm3) 8.57 4.11 6.35 2.58 7.42 3.57 !.001
Left ovary volume (cm3) 8.28 3.82 6.74 4.64 7.48 4.33 !.001
of the Mother and Child Healthcare Institute. Signed in-
Mean ovarian volume (cm3) 8.44 3.61 6.52 2.99 7.46 3.45 !0.001
formed consent was obtained from all participants and/or
P, Statistical differences between parameters in the group of adolescents with
their parent or legal guardian before participation in the irregular and regular cycles; NS, Not significant.
study.

Procedures
At the examination each subject had a protocol consist-
ing of anthropometric measurements and ultrasonographic
evaluation of the ovaries and uterus.
Postmenarcheal patients were grouped into 2 distinct
groups. First group consisted of patients with menstrual
irregularities (IC) and the second group comprised of pa-
tients with regular cycles (RC). Data distribution regarding
age and time since menarchae did not show statistically
significant differences, thus our groups had homogenous
distribution.
Ultrasonographic Examination
Transabdominal ultrasonographic examination of the
ovaries and uterus was performed during the early follicular
phase of the cycle (day 1-6), or on a random day of a cycle (at
least 3 months of amenorrhea) for the amenorrheic pa-
tients. The examinations were conducted by 1 sonographer
in all cases, using MyLab 50 Xvision scanner equipped with
CA631 convex probe (8-1 MHz). Transabdominal US was
performed in all the cases, with a patient in dorsal decubitus
and with a full urinary bladder. The uterine and ovarian
volumes were calculated using the formula for ellipsoid
bodies (volume equals to 0.523  length  width  height
of the organ), and expressed in cubic centimeters. The study
included 835 out of 857 patients in whom uterus and both
ovaries were identified. In remaining 22 cases only 1 ovary
was visualized, and we excluded those patients from data
analysis.
Anthropometric Measurements
Patients had a height measurement (in meters) to within
 0.005 m, and weight (in kilograms) was measured  0.1 kg
with minimal clothing on. Body mass index, defined as the
individual's body mass divided by the square of their height,
was calculated. All patients had height and weight and BMI
between the 3rd and the 97th percentiles compared with a
sex- and age-matched normal population. Body fat per-
centage (fat %) was estimated from BMI, using Deurenberg's
prediction formulas.7
Statistical Analysis
Statistical analysis was performed with SPSS for Win-
dows software, version 15.0 (SPSS, Chicago, IL). Most of the
results are expressed as the mean and SD. The scatter plot
was used to compare the volumes of uterus, ovaries and
ovarian/uterine ratio, and construction of estimation curves
using cubic and linear models was done. The inflection
point of the cubic estimated curve was determined as a
point at which second derivative changed sign. Pearson's
correlation was employed to assess the correlations be-
tween considered parameters. A P value of ! .05 was
considered statistically significant. Finally, graphic displays
of uterine volume, mean ovarian volume and ovarian/
uterine volume ratio versus age were generated.
Results
Data are available for 835 patients. Baseline data in-
cluding the age at the time of the study, the age at menarche,
the time elapsed since menarche and a summary of ultra-
sonographic findings and anthropometric characteristics are
reported in Table 1. There are no differences between RC and
IC group of girls regarding the age at the time of the study
and the age at menarche. However, the girls with RC are
taller, with lower weight, lower BMI, and lower percentage
of fat than the girls with IC. Uterine measurements did not
differ significantly between the 2 groups. Girls with IC have
bigger left, right and mean ovarian volumes. The mean
ovarian volume was used for further analysis since the vol-
umes of the right and the left ovary did not differ signifi-
cantly in each individual subject.
The best curve estimation of uterine volume, according
to age for all the patients, was achieved with cubic model. In
 U.D. Radivojevic et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e5
Fig. 1. Scatter plot showing the distribution of uterine volume according to age. The
curves represent the 5th, 50th, and 95th percentiles. The intersection between the
mean uterine volume and the cubic model curve estimation is presented.
the cubic equation y 5 ax3þ bx2 þ cx þ d, y stands for
uterine volume, x stands for age in years; and a, b, c, and
d are constants calculated using the SPSS software for each
of the variables. The following equation was calculated for
all patients:
Uterine volume all patients 5 0. 1303 age3þ6. 5226 age2-
101. 84 ageþ542. 68 (r 5 0. 5; P ! . 001);
The cubic equation reveals a gradual increase in uterine
volume with age (Fig. 1). Further mathematical analysis of
the cubic equation for uterine volume, reveals a falling in-
flection point which corresponds to the point of intersec-
tion between the mean uterine volume and the cubic model
curve estimation. This point of intersection corresponds to
the age in which uterine volume reached consistent values,
and this age is calculated to be 16.69 years.
The best curve estimation of ovarian volume, according
to age, was achieved with linear models. In the linear
equation y 5 ax þ b, y stands for ovarian volume, x stands
for age in years while a and b are calculated constants for
each of the variables. Following equations were calculated:
Fig. 2. Scatter plot showing the distribution of mean ovarian volume according to age.
The curves represent the 5th, 50th, and 95th percentiles.
3
Fig. 3. Scatter plot showing the distribution of mean ovarian volume in the group of
patients with regular cycles according to age. The curves represent the 5th, 50th, and
95th percentiles.
Ovarian volume all patients 5 0. 05 age þ 6. 63 (r 5 0. 03; P
!. 001);
Ovarian volumeirregular cycles 5 0. 2463 age þ 4. 5028
(r 5 0. 15; P !. 001);
Ovarian volumeregular cycles 5 -0. 1979 age þ 9. 4936
(r 5 0. 14; P ! . 005);
The linear equation reveals the decrease in mean ovarian
volume with advancing age (Fig. 2). Mean ovarian volume in
the RC and IC group of patients showed differences pre-
sented in Fig. 3 and Fig. 4, respectively. In the RC group of
patients decrease in mean ovarian volume with age was
noticed, while in the IC group of girls, the increase of mean
ovarian volume was seen.
Correlations between uterine volume, mean ovarian
volume and the age at menarche with age, the time elapsed
since menarche, height, weight, body mass index, and
percentage of body fat are illustrated in Table 2. Uterine
volume correlated with all examined parameters except
BMI. Ovarian volume correlated with weight, BMI, and
percentage of fat.
Fig. 4. Scatter plot showing the distribution of mean ovarian volume in the group of
patients with irregular cycles according to age. The curves represent the 5th, 50th, and
95th percentiles.
4 U.D. Radivojevic et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e5
Table 2
Correlations between Age and Time Elapsed since Menarche, Ultrasonographic, and
Anthropometric Parameters
Uterine Ovarian
Volume (cm3) Volume (cm3)
Age (y) r 5 0.005*
Time elapsed since r 5 0.597*
menarche (years)
r 5 0.176* r 5 0.104z
Weight (kg)
Height (m) r 5 0.309*
BMI r 5 0.132y
y
%fat r 5 0.084 r 5 0.134y
Statistically significant P for all correlations is reported.
* P ! .001.
y
P ! .01.
z
P ! .05.
When we analyzed the same correlations in the RC and IC
groups of girls, we found certain differences. Ovarian vol-
ume inversely correlated with age (r 5 -0. 143, P ! .05) and
the time elapsed since menarche (r 5 -0. 142, P ! . 05) in RC
patients, while in the IC group those correlations were
positive (r 5 0. 147, P ! . 05; r 5 0. 055, P O .05).
Although BMI correlated with ovarian volume and the
age at menarche in all patients, it did not correlate with
those parameters in the RC and IC groups of girls, presum-
ably because of the homogeneity of these 2 groups. The
same was noticed when the percentage of body fat was
analyzed. Percentage of body fat correlated with uterine
and ovarian volume and the age at menarche in all exam-
ined patients, but it did not correlate with those parameters
in the RC and IC groups of girls.
Discussion
Menarche is an important landmark in the process of
growth and maturation of girls.8 Menarche occurs between
12 and 13 years of age in most developed countries.9,10 The
mean age at menarche in girls examined in our study was
12.76 years, which is in accordance with the previously
published data.9,10
Previous studies suggested that maturation of the
hypothalamic-pituitary-ovarian axis takes up to ~5 years
after menarche to be completed.11,12 The period of time
elapsed since menarche in girls included in our study varied
from 6 months till 6 years. It has been proposed that irreg-
ular menstrual cycles in the first 5 years after menarche are
physiological, so no clinical or endocrine evaluation13 is
needed. However, in the peri-menarcheal period the first
symptoms of ovarian dysfunction appear and in the first
years after menarche the clinical picture of polycystic ovary
syndrome (PCOS) may evolve or already be complete.14 Van
Hooff et al concluded that the menstrual cycle pattern in the
first years after menarche is a better predictor for ovulatory
dysfunction in adulthood than androgen or LH concen-
trations.15
There are only a few studies investigating anthropo-
metric features in postmenarchal girls.16,17 From the result
of our research, the postmenarcheal girls with regular cycles
showed taller and slimmer figures than girls with irregular
cycles. The girls with regular cycles also showed lower BMI
and lower percentage of body fat.
The relation between anthropometric parameters and
sonographic findings of the pelvis was further studied.
Ovarian volume in our study correlated with weight, BMI
Age at Menarche (y)
and percentage of fat of postmenarcheal girls. Although we
did not find differences in uterine measures between the
studied groups, postmenarcheal girls with irregular cycles
had higher ovarian volume. This finding is consistent with
previously published data.1
r 5 0.269*
r 5 0.096y We noticed that with age, in the group of girls with
r 5 0.088y regular cycles, the size of ovaries decreases, while in girls
with irregular cycles it increases. Ovaries of healthy girls in
the premenarcheal period enlarge rapidly and attain, by
menarche, the adult appearance.5 From that time on, the
volume of ovaries gradually decreases.1 Porcu stated that
girls with irregular cycles have a mean volume significantly
higher than that of regular ovulatory adolescents.1 This may
be related to the possible development of PCOS later in
adult life in girls with irregular cycles, implying that PCOS
may emerge at or soon after puberty.18 Polycystic ovary
syndrome is characterized by a great diversity in its clinical
presentation and an elevated BMI (O30) is found in 20%-
69% of patients, depending on the studied population,19 but
women who are lean can also have PCOS.20 In the studied
group of girls, BMI was within normal range in all patients,
but the girls with IC had significantly higher BMI than the
RC girls. We propose that increasing ovarian volume and
heavier figure in adolescence could be a finding that may
raise suspicion towards the possible development of PCOS
or irregular cycles in adulthood.
The process of uterine growth continues during post-
menarcheal period and it is thought to be completed by the
age of 16.4,5 In postmenarchal girls, in our study, uterine
volume increases gradually with age, reaching consistent
values at 16.7 years. No differences in uterine volume were
found in between groups of girls with regular and irregular
cycles, implying that cycle regularity does not influence
uterine growth. These findings are in agreement with the
previously published data.1 Porcu stated that height and
weight correlate with uterine volume before menarche but
not afterwards, explaining that at this age they have nearly
exhausted the developmental changes.1 Our results differ
from previous findings1 and demonstrate that postmen-
archeal growth of uterus correlates with height, weight, and
percentage body fat. We propose that the regularity of
the menstrual cycles is not related to the uterine growth
and that uterine volume correlates with growth after the
menarchae.
In conclusion, studies investigating anthropometric fea-
tures and the growth of the uterus and ovaries in post-
menarchal girls are scarce, thus, the results of our study add
to the medical knowledge regarding this specific age group.
Our study shows that uterus continues to grow in post-
menarcheal years, with increasing height and weight of
girls, regardless of the cycle regularity, reaching consistent
volume between 16 and 17 years of age. Postmenarcheal
girls with irregular cycles in our study were found to have
heavier figures and larger ovaries, finding that may raise
suspicion towards developing PCOS or irregular cycles in
adulthood. These patients could benefit from further med-
ical evaluation and weight reduction.
 U.D. Radivojevic et al. / J Pediatr Adolesc Gynecol xxx (2013) 1e5
Acknowledgments
The authors wish to thank the children and the parents
included in this research.
References
1. Porcu E: Imaging in pediatric and adolescent gynecology. Endocr Dev 2004; 7:9
2. Ziereisen F, Guissard G, Damry N, et al: Sonographic imaging of the paediatric
female pelvis. Eur Radiol 2005; 15:1296
3. Razzaghy-Azar M, Ghasemi F, Hallaji F, et al: Sonographic measurement of
uterus and ovaries in premenarcheal healthy girls between 6 and 13 years
old: correlation with age and pubertal status. J Clin Ultrasound 2011; 39:64
4. Hart R, Sloboda DM, Doherty DA, et al: Prenatal determinants of uterine volume
and ovarian reserve in adolescence. J Clin Endocrinol Metab 2009; 94:4931
5. Ivarsson SA, Nilsson K, Persson PH: Ultrasonography of the pelvic organs in
prepubertal and postpubertal girls. Arch Dis Child 1983; 58:352
6. Agarwal A, Venkat A: Questionnaire study on menstrual disorders in adolescent
girls in Singapore. J Pediatr Adolesc Gynecol 2009; 22:365
7. Deurenberg P, Weststrate JA, Seidell JC: Body mass index as a measure of body
fatness: age- and sex-specific prediction formulas. Br J Nutr 1991; 65:105
8. Cooper R, Blell M, Hardy R, et al: Validity of age at menarche self-reported in
adulthood. J Epidemiol Commun Health 2006; 60:993
9. Rigon F, Bianchin L, Bernasconi S, et al: Update on age at menarche in Italy:
toward the leveling off of the secular trend. J Adolesc Health 2010; 46:238
5
10. Whincup PH, Gilg JA, Odoki K, et al: Age of menarche in contemporary British
teenagers: survey of girls born between 1982 and 1986. BMJ 2001; 322:1095
11. Metcalf MG, Skidmore DS, Lowry GF, et al: Incidence of ovulation in the years
after the menarche. J Endocrinol 1983; 97:213
12. Harel Z: Approach to the adolescent girl as she transits from irregular to regular
menstrual cycles. J Pediatr Adolesc Gynecol 2005; 18:193
13. Gardner J: Adolescent menstrual characteristics as predictors of gynaecological
health. Ann Hum Biol 1983; 10:31
14. Burt Solorzano C, McCartney C, Blank S, et al: Hyperandrogenaemia in
adolescent girls: origins of abnormal gonadotropin-releasing hormone secre-
tion. BJOG 2010; 117:143
15. van Hooff MH, Voorhorst FJ, Kaptein MB, et al: Predictive value of menstrual
cycle pattern, body mass index, hormone levels and polycystic ovaries at age
15 years for oligo-amenorrhoea at age 18 years. Hum Reprod 2004; 19:383
16. Zukauskaite S, Seibokaite A, Lasas L, et al: Serum hormone levels and anthro-
pometric characteristics in girls with hyperandrogenism. Medicina (Kaunas)
2005; 41:305
17. Harlow SD, Campbell B, Lin X, et al: Ethnic differences in the length of the
menstrual cycle during the postmenarcheal period. Am J Epidemiol 1997;
146:572
18. Shayya R, Chang R: Reproductive endocrinology of adolescent polycystic ovary
syndrome. BJOG 2010; 117:150
19. Rachon  D, Teede H: Ovarian function and obesityeinterrelationship, impact on
women’s reproductive lifespan and treatment options. Mol Cell Endocrinol
2010; 316:172
20. Stovall DW, Bailey A, Pastore LM: Assessment of insulin resistance and impaired
glucose tolerance in lean women with polycystic ovary syndrome. J Womens
Health (Larchmt) 2011; 20:37