Annals of Human Biology

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Early menarche and premature natural

menopause in Indonesia

Sri Andarini & Sujarwoto Sujarwoto

To cite this article: Sri Andarini & Sujarwoto Sujarwoto (2018) Early menarche and
premature natural menopause in Indonesia, Annals of Human Biology, 45:5, 419-427, DOI:
10.1080/03014460.2018.1523461

To link to this article: https://doi.org/10.1080/03014460.2018.1523461

Published online: 08 Jan 2019.

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ANNALS OF HUMAN BIOLOGY
2018, VOL. 45, NO. 5, 419–427
https://doi.org/10.1080/03014460.2018.1523461

RESEARCH PAPER

Early menarche and premature natural menopause in Indonesia

Sri Andarinia and Sujarwoto Sujarwotob
a
Department of Public Health, Faculty of Medicine, University of Brawijaya, Malang, Indonesia; bPortsmouth Brawijaya Centre for Global
Health, Population and Policy, University of Brawijaya, Malang, Indonesia

ABSTRACT ARTICLE HISTORY

Background: An association has been suggested between early menarche and premature natural Received 6 July 2018
menopause. However, existing studies in developed countries show mixed findings. Revised 6 August 2018
Aim: This study examined whether early menarche (first menstrual period
11 years old) is a factor Accepted 27 August 2018
for premature natural menopause (final menstrual period <40 years old) in the context of a
KEYWORDS
developing country. Women’s health; early
Subjects and methods: Data came from the Indonesia Family Life Survey (IFLS) 2014, which consists menarche; premature
of 1608 post-menopausal women. natural menopause;
Results: Results of hierarchical logistic regression show that women who experienced early menarche Indonesia
(first menstrual period
11 years old) were found to be at higher risk of premature natural meno-
pause (b ¼ 0.94, p < 0.01, CI ¼ 0.24–1.63). The results are robust against potential confounding factors
including individual reproductive history, lifestyle and sociodemographic characteristics, as well as
unobserved factors at the household and community levels.
Conclusion: The findings support early monitoring of women with early menarche, especially those
who have no children, for preventive health interventions aimed at mitigating the risk of adverse
health outcomes associated with premature natural menopause.

Introduction based on studies of women in developed countries (Mishra

Premature natural menopause is defined as the experience
of menopause before the age of 40 (Shuster et al. 2010).
Nippita and Baber (2007) explain that premature natural
menopause occurs in women who have been diagnosed
with premature ovarian failure following extended amenor-
rhoea, hypergonadotropinaemia and oestrogen deficiency.
Studies have widely documented that premature natural
menopause relates to higher risk of early death and chronic
conditions in late life, including cardiovascular disease, Type
2 diabetes and osteoporosis (Harlow and Signorello 2000;
Gaudineau et al. 2010, Gold 2011; Forman et al. 2013; Muka
et al. 2016). Researchers have suggested a relationship
between early menarche and premature natural menopause.
However, studies that have examined the links between
these variables show mixed findings. Using population data
from four developed countries, Mishra et al. (2016) found
early menarche (
11 years) to be a risk factor for both pre-
mature natural menopause (FMP < 40 years) and early meno-
pause (FMP 40–44 years). However, Hardy and Kuh (1999)
found no association between early menarche and early
menopause using British National Cohort data. Gold (2011)
documented a lack of association between age at menarche
and early menopause after adjusting for other reproductive
history factors (i.e. parity, breastfeeding, age at first birth).
Much of the evidence on the relationship between early
menarche and premature natural menopause has been
et al. 2016); some of these studies have failed to adjust for
confounding factors (Gold 2011), and lack of statistical power
remains a key issue (Nippita and Baber 2007; Forman et al.
2013). Furthermore, most studies in this field have used clin-
ical-based rather than population-based samples of women
(Stanford et al. 1987). The current study fills these gaps by
examining the relationship between early menarche
(
11 years old) and premature natural menopause (<40
years old) based on data from women from a middle-income
country context. The data, drawn from the population-based
Indonesian Family Life Survey (IFLS) 2014, were analysed
using three-level logistic regression to account for unob-
served factors in households and communities, while also
considering a range of potential confounding factors includ-
ing respondents’ reproductive histories, handedness, lifestyles
and sociodemographic characteristics.
Prior studies indicate that women’s reproductive histories,
lifestyle factors and sociodemographic characteristics may
relate to premature and early menopause. Parity is one of
the key determinants of the lifetime number of ovulatory
cycles and the effect of null parity on age of natural meno-
pause has been investigated in many studies (see for
example, Mishra et al. 2016). Studies also found that obstet-
ric and gynaecological history, such as the number of still-
births and miscarriages, associate with early menopause
(Mishra et al. 2016). Studies suggest that the tempo of

CONTACT Sujarwoto Sujarwoto sujarwoto@ub.ac.id Portsmouth Brawijaya Centre for Global Health, Population and Policy, University of Brawijaya, JL
Veteran, Malang, 65145 Indonesia
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
420 S. ANDARINI AND S. SUJARWOTO
growth during infancy can potentially be mitigated by
breast-feeding, which is thought to prevent or delay the
tempo of growth during this period (Johnson et al. 2014).
Two recent studies reported evidence suggesting a positive
association between breast-feeding and age at menarche,
while others have not (Morris et al. 2010; Al-Sahab
et al. 2011).
Some studies have investigated the possible association
between handedness and early natural menopause, drawing
on previous findings which link left-handedness to auto-
immune and reproductive disorders (Geschwind and Behan
1982) and the possibility that autoimmune reactions against
hormone receptor sites and/or oocytes may play a role in
the premature onset of menopause (Escobar et al. 1982).
Iron deficiency in women going through menopause is com-
mon (Sokoll and Dawson-Hughes 1992) and, therefore, in
this study we included both women who take iron supple-
ments and those who do not, to control for the effect of
iron pill consumption on premature natural menopause.
One of the strongest and most clearly demonstrated life-
style risk factors for an early menopause is cigarette smoking
(Bromberger et al. 1997; Tawfik et al. 2015). In general,
women who smoke are likely to undergo a natural meno-
pause about 1 year earlier than non-smokers. Researchers
have frequently cited evidence that tobacco smoke contains
polycyclic hydrocarbons that may be toxic to ovarian germ
cells and might lead to oestrogen deficiency related to fol-
licular exhaustion (Mattison and Thorgeirsson 1978). There is
also evidence that the alkaloid components of tobacco
smoke, including nicotine and anabasine, may lower oestro-
gen levels by interfering with its synthesis.
A lifestyle risk factor that is often cited as a risk factor for
early menopause is obesity. Studies have found that obese
women are known to have high concentrations of endogen-
ous oestrogens, coupled with low levels of sex hormone-
binding globulin (Speroff and Fritz 2005). Under this
mechanism, follilucar growth may be constantly stimulated,
leading to more rapid follicular exhaustion. A number of epi-
demiologic studies have investigated increasing body mass
index and earlier natural menopause, with mixed results.
Colditz et al. (1987) found that obese women, as measured
by BMI >25 kg/m2, had a significantly earlier menopause
(about 1 year) than non-obese women. Brambilla and
McKinlay (1989) reported no difference in the median early
natural menopause by quintile of body mass index.
Emotional determinants have been found to affect the
pituitary–ovarian axis at the level of the hypothalamus
(Harlow and Signorello 2000). The best known example is
the link between environmental and endogenous-generated
stress and hypothalamic amenorrhea (Liu 1990), thought to
result from a deficiency in the pulsatile secretion of gonado-
tropin-releasing hormone (GnRH) (Khoury et al. 1987).
However, the mechanism by which depression may affect
early menopause is a bit complicated. One main issue is that
distinguishing the effect of depression from the effect of
pharmacological therapy has yet to be accomplished. Using
sample women with and without an early menopause, a
study found a strong association between depression and
women pharmacologically treated for more than 3 years
(Khoury et al. 1987). Although this finding might support the
theory of an effect of therapy, a long duration of treatment
may also correlate with more severe emotional disturbance.
Some attention has also focused on the role of other
socio-demographic factors as predictors of early natural
menopause, such as education, income, marital status and
urban/rural living environment. The results of these studies
have been largely inconclusive. Some investigations have
found low educational status and income to be a risk factor
for early menopause (Schoenaker et al. 2014). A recent
Indian study documented that women who were less edu-
cated, poor, currently separated or widowed and lived in
urban locations, were more likely to experience an earlier
natural menopause than women who were not
(Pallikadavath et al. 2016). However, other studies have
found no link between educational status, income, marital
status and early natural menopause (Stanford et al. 1987).
Demographic determinants are of arguable aetiologic signifi-
cance since, at best, they are surrogates for other exposures
which may have direct physiological effects on the ovaries.
Methods
Indonesia Family Life Survey (IFLS) 2014
The Indonesian Family Life Survey (IFLS) is a nationally repre-
sentative survey that collects data on various social eco-
nomic, health and demographic indicators of individual
respondents, their families, their households and the com-
munities in which they live in Indonesia. The survey has
been conducted since 1993 (Strauss et al. 2016). The IFLS
dataset is in the public domain and can be accessed via the
RAND Labour and Population website (http://www/rand.org/
labor/FLS/IFLS.html). The sample of households represented
83% of the Indonesian population living in the country’s 13
provinces. In this study, we used data from the fifth (2014)
wave of the IFLS, which is the most recent survey. Overall,
IFLS covers 33,081 individuals aged 14 years and older living
in 297 districts. In this study, the sample was restricted to
those women for whom there was complete information on
menarche status and, thus, includes 12,188 women. From
those, we selected 1608 post-menopausal women living in
808 households and 148 communities or villages. The data
were weighted using cross-sectional person sampling
weights based on age and sex provided in the IFLS datasets
for 2014 (Strauss et al. 2016). The percentage of missing
responses was quite low, at 1%.
Main outcomes and exposure variables
Premature natural menopause is defined as a condition in
which the ovaries stop working and menstrual periods stop
before age 40 where this is not the result of an intervention
(such as surgical menopause due to bilateral oophorectomy
or hysterectomy (Mishra et al. 2016). In the survey, respond-
ents were asked ‘how old were you when you stopped
having menstruation?’ A dummy variable indicating FMP

<40 years old (coding ¼ 1) and FMP 40 years old
(coding ¼ 0) was used to measure premature natural meno-
pause. Early menarche was measured as the first menstrual
period occurring at 11 years or younger (Schoenaker et al.
2014). In the survey, respondents were asked with a question
‘how old were you on your first menstruation?’ A dummy
variable indicating first menstrual period
11 years old
(coding ¼ 1) and first menstrual period >11 years old was
created to measure early onset of menarche. Previous studies
in developed and developing countries showing the validity
of self-reported age at menarche report a moderate-to-high
validity (r ¼ 0.66  0.83) when comparing actual age at
menarche later in life (Cooper et al. 2006).
Covariates
Covariates at an individual level include reproductive history
(i.e. the absence of biological children, the presence of bio-
logical children, the number of stillbirths and miscarriages
and the length of breastfeeding), handedness (left-handed-
ness), lifestyle (obesity (BMI >30), depression (CES-D  16),
chewing tobacco and cigarette consumption, and socio-
demographics (i.e. years of schooling). The covariate at the
household level is log per capita household expenditure,
while urban/rural category was used as the community/vil-
lage level covariate. We prefer to use per capita household
expenditure rather than income to capture household finan-
cial resources: in developing countries such as Indonesia, it is
not income but expenditure measured from consumption
that more accurately captures levels of long-term economic
resources (Deaton and Zaidi 2002; Sujarwoto and
Tampubolon 2015). Appendix 1 describes coding of each of
those covariates.
Statistical analysis
Hierarchical logistic regression was applied to take full
advantage of the household and community clustering infor-
mation available from the IFLS. This regression is able to
account for the clustering of individuals by separating indi-
vidual variances in premature natural menopause from
household and community variances (Snijders and Bosker
1999). Therefore, this regression is more appropriate than
simple logit regression, which ignores the clustering of data
in the household and communities (Snijders and Bosker
1999). For these analyses, the hierarchical logistic regression
can be written as follows, considering an individual i nested
in household j and community/village k:
X had breastfed was 96%, with an average duration of 19
Eijk : ¼ bo þ bjk Wjk þ bijk Xijk þ ljk þ ijk
where: Eijk ¼ logit (P (Eij ¼ 1) is a dummy variable indicating
an individual with premature natural menopause; Wjk is a set
of household variables (j ¼ household expenditure) and com-
munity/village variables (k ¼ urban/rural category); Xij is indi-
vidual variables (i ¼ early menarche, age, number of
biological children, take iron supplements, handedness, BMI,
smoking, etc.); mjk is a random intercept of households and
ANNALS OF HUMAN BIOLOGY 421
communities with mean zero and variance rm2; and eijk is
normally distributed with zero and variance r2.
We estimated hierarchical logit regression using general-
ised linear latent and mixed models commands (GLLAMMs)
(Rabe-Hesketh and Skrondal 2008). Because premature nat-
ural menopause is measured on a nominal scale, we used
GLLAMM with a logit link. We used maximum likelihood esti-
mation to fit all models. Odds ratios were used to compare
the magnitude of various risk factors for the occurrence of
premature natural menopause. We carried out three-level
logistic regression using STATA 14.0 software.
Results
Study characteristics
The total number of women who reported having menarche
was 12,163 individuals. Among them, 1730 women reported
the cessation of menstruation, which divided into 1615
women reaching menopause at 40 years and older and 115
women experiencing premature menopause. The distribution
of each category of the sample is described in Figure 1. The
first figure on the right side in the first panel describes the
distribution of women who reported having menstruation.
The distribution is slightly skewed to the right, indicating
that most of the women experienced menarche between 12
and 15 years old. The second figure on the left side of the
second panel illustrates the distribution of women who
reported the cessation of menstruation. The distribution is
skewed to the left, indicating most women reach menopause
between 45 and 53 years old. The two figures in the bottom
panel describe the distribution of women having normal
menopause and of women having premature menopause.
The first figure on the right shows a relatively normal distri-
bution, while the second figure on the left shows a skewed
pattern to the left, which means most of the premature
menopause women reported menstruation stopping
between 35 and 39 years old.
Table 1 describes the details of sample characteristics in
this study. The mean age at menopause was 52 years
(SD ¼ 4.01, range ¼ 35–57). The percentage of respondents
who experienced premature natural menopause was 6%
(SD ¼ 0.25). The mean age at menarche was 14 years
(SD ¼ 1.75, range ¼ 7–25). The percentage of women having
experienced menarche at age 11 or younger was 7%. The
percentage of respondents without biological children was
similar. Most of the women surveyed had at least two live-
births, and most of them reported not having experienced
miscarriages or stillbirths. The percentage of women who
months. Most of the respondents smoked at least one cigar-
ette per day (SD ¼ 2.07, range ¼ 0–48) or consumed on aver-
age 0.02 grams of tobacco daily (SD ¼ 0.15, range ¼ 0–2).
Only a small percentage of women took iron supplements
(4%, SD ¼ 0.07). Obesity and depression levels were quite
low, at 4% and 3%, respectively. We found that 4% of the
women were left-handed. Most of them were educated to
the junior secondary school level and lived in urban areas.
422 S. ANDARINI AND S. SUJARWOTO

Figure 1. The distribution of age at menarche (AME), age at menopause (AM), age at menopause 40 years old (AM1) and age at menopause <40 years
old (AM2).

Table 1. Sample characteristics and bivariate correlation.

Variables % or mean SD Min Max
Individual (n ¼ 1608)
Premature natural menopause (FMP < 40 years) 7% 0.25 0 1
Age 52 years 4.01 35 57
Divorced 6% 0.23 0 1
Widowed 17% 0.38 0 1
Early menarche (first menstrual period
11 years) 7% 0.25 0 1
Not having biological children 7% 0.25 0 1
Number of live births 2 children 0.76 0 5
Number of stillbirths 2% 0.16 0 2
Number of miscarriages 10% 0.41 0 5
Months of breastfeeding 19.1 months 10.77 0 60
Consumption of iron supplement 4% 0.07 0 1
Number of cigarettes consumed per day 1 cigarette 2.07 0 48
Grams of tobacco consumed per day 0.02 g 0.15 0 2
Obesity (BMI >30) 4% 0.19 0 1
Left-handedness 4% 0.21 0 1
Depression (CES-D  16) 3% 0.18 0 1
Years of schooling 10 years 3.86 1 18
Household (n ¼ 808)
Log household expenditure 13.64 0.64 11.19 16.42
Community (n ¼ 148)
Living in an urban area 55% 0.5 0 1

Figure 2 describes simple bivariate correlation of age at
menopause and its covariates. The correlation between age
at menarche and age at menopause (AM–AME) is not clear.
A positive correlation is shown for women who achieve
menopause at age 46 years and younger. In contrast, a
negative correlation is shown for women who achieve meno-
pause at age 47 years and older. A negative association is
also shown between age at menopause and number of mis-
carriages (AM–NMIS) as well as number of cigarettes
(AM–NCIG). A positive correlation is shown for the
 ANNALS OF HUMAN BIOLOGY 423

Figure 2. Simple correlation between time to early menopause and its factors. AM: age at menopause; AME: age at menarche; NK: number of children; NS: number
of stillbirths; BR: months of breastfeeding; NMIS: number of miscarriages; NCIG: number of cigarettes smoked; BMI: Body Mass Index; CESD: mental health score;
EDU: years of schooling; LPCE: log of household expenditure.

relationships between age at menarche and number of still- of breastfeeding (AM–BR), body mass index (AM–BMI) and
births (AM–NS), number of children (AM–NK), education CES-D (AM–CESD).
(AM–EDU) and economic status (AM–LNPCE). The unclear The simple bivariate correlation showed that there was an
correlation is shown between age at menarche and months unclear correlation between age at menarche and age at
424 S. ANDARINI AND S. SUJARWOTO

Table 2. Three-level logistic regression results for the association between premature natural menopause and early menarche adjusted for covariates (meno-
pause women, n ¼ 1608).
Model 1 Model 2 Model 3
95% CI 95% CI 95% CI
Odds SE Lower Upper Odds SE Lower Upper Odds SE Lower Upper
Individual level
Early menarche (first menstrual period
11 years) 1.86 0.31 0.01 1.23 1.92 0.32 0.02 1.27 2.55 0.35 0.24 1.63
Not having biological children 1.35 0.47 0.44 2.27 2.51 0.54 0.11 1.99
Number of live births 0.66 0.13 0.17 0.67 0.66 0.14 0.18 0.68
Months of breastfeeding 1.00 0.02 0.03 0.03 1.00 0.02 0.03 0.03
Number of stillbirths 1.33 0.53 0.74 1.32 1.73 0.56 0.54 1.64
Number of miscarriages 1.73 0.17 0.41 1.31 1.74 0.18 0.43 1.36
Age 0.77 0.03 0.30 0.20
Divorced 1.14 0.52 0.89 1.14
Widowed 1.29 0.33 0.39 0.91
Consumption of iron supplement 0.87 0.14 0.19 0.68
Number of cigarettes consumed per day 0.86 0.13 0.41 0.11
Grams of tobacco consumed per day 3.09 0.50 0.34 2.28
Obesity (BMI >30) 1.27 0.60 0.93 1.41
Left-handedness 1.46 0.41 0.49 1.04
Depression (CES-D  16) 1.85 0.46 0.48 1.01
Years of schooling 0.94 0.02 0.29 0.21
Household level
Log household expenditure 0.87 0.03 0.31 0.22
Community level
Living in an urban area 0.67 0.23 0.84 0.06
Constant 0.07 0.10 2.91 2.50 0.05 0.13 3.25 2.75 0.05 0.13 3.24 2.74
Variance between households 0.09 0.09
Variance between communities 0.11 0.11
Log likelihood 422.22 408.26 312.94
p < 0.1, p < 0.05, p < 0.01.

menopause, but the results may bias with regard to individ-
ual, household and community characteristics. To eliminate
this bias, multilevel analyses were used to control for the
association between age at menarche and age at menopause
with individual, household, and community level factors.
Table 2 shows the results of multilevel analyses.
Three-level logit regression results
The three-level logit regression results for the association
between premature natural menopause and early menarche
are illustrated in Table 2. The odds of facing early meno-
pause are 2-times greater for women experiencing early
menarche than for women who experience natural menarche
(Odds ¼ 1.86, p < 0.05, CI ¼ 0.01–1.23). When the models
were adjusted for other reproductive history covariates
(Model 2), early menarche was still significantly associated
with premature natural menopause (Odds ¼ 1.92, p < 0.05,
CI ¼ 0.02–1.27). The association became strongly significant
when the model was adjusted to account for other risk fac-
tors (i.e. cigarette consumption, chewing tobacco consump-
tion, obesity, mental depression and iron pill consumption),
left-handedness and sociodemographic factors (i.e. years of
schooling, household expenditure and living in an urban
area) (Odds ¼ 2.55, p < 0.01, CI ¼ 0.24–1.63).
Some potential confounders and sociodemographic char-
acteristics show significant associations with premature nat-
ural menopause. The odds of having early menopause is
2.5-times greater for women who do not have biological
children than for women who do. Women who have a
greater number of livebirths were less likely to experience
early menopause than those who had less livebirths. The
odds of having early menopause is about one time greater
for women who experience a higher number of miscarriages
than those who experience a smaller number of
miscarriages.
Women who reported consuming iron supplements dur-
ing pregnancy were also at lesser odds of having early
menopause than those who did not consume iron supple-
ments. The odds of having early menopause is 3-times
greater for women who consume more tobacco than women
who consume less tobacco. Likewise, the odds of having
early menopause is greater for left-handed women and
depressed women. The odds of years of schooling and log
household expenditure are negative, indicating less risk of
early menopause for more educated and affluent women.
Women living in urban areas had lesser odds of having early
menopause than those living in rural areas. As more covari-
ates are introduced into the model, the likelihood or fit of
the model improves (the log likelihood increases).
Sensitivity analysis
Sensitivity analyses were conducted to check whether some
misclassification had occurred, especially because the data
was self-reported without a clinical indicator. Thus, in this
analysis we treated BMI, CES-D score, age at menarche and
natural menopause as continuous variables. Three level lin-
ear regression was used to estimate the data. Table 3
describes the results. Overall, the results were rela-
tively similar.
 ANNALS OF HUMAN BIOLOGY 425

Table 3. Three-level linear regression results for the association between age of menopause and age of menarche adjusted for covariates (menopause women,
n ¼ 1608).
Model 1 Model 2 Model 3
95% CI 95% CI 95% CI
Coef. SE Lower Upper Coef. SE Lower Upper Coef. SE Lower Upper
Individual level
Age of menarche 0.84 0.03 0.06 0.08 0.62 0.02 0.05 0.07 0.35 0.05 0.04 0.06
Not having biological children 0.37 0.07 0.04 0.07 0.41 0.04 0.01 0.02
Number of live births 0.46 0.13 0.07 0.09 0.56 0.04 0.08 0.09
Months of breastfeeding 0.70 0.82 0.03 0.93 0.90 0.12 0.03 0.99
Number of stillbirths 0.38 0.58 0.67 1.42 0.78 0.58 0.58 1.94
Number of miscarriages 0.73 0.07 0.08 0.10 0.71 0.08 0.03 0.06
Age 0.72 0.03 0.01 0.02
Divorced 0.23 0.55 0.89 2.14
Widowed 0.24 0.33 0.39 3.91
Consumption of iron supplement 0.67 0.03 0.01 0.02
Number of cigarettes consumed per day 0.81 0.13 0.41 1.11
Grams of tobacco consumed per day 0.79 0.05 0.04 0.08
BMI score 0.25 0.61 0.03 1.45
Left-handedness 0.48 0.03 0.09 0.10
CES-D score 0.75 0.06 0.08 0.10
Years of schooling 0.74 0.03 0.09 0.10
Household level
Log household expenditure 0.81 0.02 0.01 0.02
Community level
Living in an urban area 0.57 0.03 0.04 0.06
Constant 0.07 0.10 0.03 0.07 0.05 0.13 0.25 0.27 0.06 0.03 0.24 0.26
Variance between households 0.09 0.09
Variance between communities 0.11 0.11
Log likelihood 422.22 408.26 312.94
p < 0.1, p < 0.05, p < 0.01.

Discussion reproductive history, lifestyle and sociodemographic charac-

Main findings
This study examines the association between early menarche
(first menstrual period
11 years) and premature natural
menopause (FMP <40 years) among women in a developing
country context. Prior studies have shown mixed findings on
the association between early menarche and premature nat-
ural menopause in developed countries (Hardy and Kuh
1999; Gold 2011; Mishra et al. 2016). Gold (2011) and Mishra
et al. (2016) posited that these mixed findings may be due
to differences in study contexts, lack of adjustment for con-
founding factors, lack of statistical power and the fact that
many of these studies used clinically-based rather than
population-based samples of women. In this study, we
employed a population-based survey from the Indonesian
Family Life Survey (IFLS) 2014. Three-level logistic regression
was used to take into account unobserved factors in house-
holds and communities, as well as a range of potential con-
founding factors including the reproductive histories,
lifestyles and sociodemographic characteristics of the
respondents.
Our findings are consistent with prior studies that have
established an association between early menarche and pre-
mature natural menopause in a developed country context
(Gold 2011; Mishra et al. 2016). Our findings contrast with
previous reviews that have found there to be a lack of evi-
dence regarding the relationship between age at menarche
and premature natural menopause both in developing and
developed country contexts (Gold 2011; Farahmand et al.
2013; Forman et al. 2013). Our findings are also robust
against potential confounding factors, including individual
teristics, as well as unobserved factors at the household and
community levels. Sensitivity analysis by treating BMI, CES-D
score, age at menarche and natural menopause as a continu-
ous variable show similar results.
Several mechanisms have been proposed to explain the
relationship between early menarche and premature meno-
pause. Menopause reflects the discontinuation of ovulation
due to the loss of ovarian follicles (Gold 2011). The repro-
ductive span has been associated with follicle pool size in
several studies (Sadrzadeh et al. 2003). A recent study by
Perhar et al. (2017) supports those findings by demonstrating
that younger age at menarche is correlated with abnormally
specific diminished functional ovarian reserve (DFOR). Perhar
et al. (2017) further divided the sample into quartiles and
found a relationship between follicular depletion, also at
very young ages, and reproductive span. However, to attri-
bute ovarian function solely to the follicles may be limiting.
The literature has demonstrated the role of genetics in repro-
ductive life span. For example, Hefler et al. (2005) revealed
various polymorphisms as determinants of age at meno-
pause. Genetic studies have also shown that a number of
menarche-related single-nucleotide polymorphism (SNPs) col-
lectively predict age at natural menopause (Day et al. 2015),
supporting a causal relationship between the timing of these
two reproductive factors. Several studies have shown that
the timing of menarche is influenced by factors in early life,
including maternal weight gain, childhood obesity and psy-
chosocial stress during childhood (e.g. infant–parent attach-
ment insecurity), the findings may reflect an underlying
common cause of poor reproductive health throughout a
woman’s life (Belsky et al. 2010; Forman et al. 2013). More
426 S. ANDARINI AND S. SUJARWOTO
studies are needed to understand the mechanisms by which
the cumulative and interactive effects of genetic and envir-
onmental factors influence the association between early
menarche and premature menopause.
Strengths and limitations
A primary strength of our study is that the population-based
sample enhances the generalisability of the study’s findings
and reduces the potential for selection bias. This study dem-
onstrates the utility of collecting and using menarche and
menopause measures from a population-based sample in a
developing country. Limitations of the study include con-
cerns arising from the use of cross-sectional data to estimate
age at menarche and menopause. Specifically, this survey
relied on retrospectively reported age at final menstruation.
Hence, memory bias may affect results, as older women may
not accurately recall the time of last menstruation (Stanford
et al. 1987). Another limitation is that we are unable to
include genetic covariates of early menarche and menopause
as the survey does not contain genetic information (Gold
2011). Therefore, our results are robust with respect to the
covariates used in this study.
Implications for research and practices
Our findings strengthen the case for utilising early preventive
strategies and clinical surveillance to address the increased
risks of chronic diseases associated with early menarche and
premature natural menarche. Policy-makers and health work-
ers in a developing country need guidelines for the clinical
management of the menopausal transition so that they can
help women access diagnosis and treatment options for pre-
mature ovarian failure/insufficiency.
Disclosure statement
The authors report no conflicts of interest. The authors are responsible
for the content and writing of the paper.
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Appendix 1. Coding structure

Variables Coding structure

Premature natural menopause (FMP <40 years) A dummy variable indicating respondent having premature natural menopause (FMP) <40 years
(Code 1 ¼ having FMP <40 years; code 0 ¼ having FMP 40 years)
Age A continuous variable indicating age of respondent
Divorced A dummy variable indicating respondent was divorced (Code 1 ¼ divorce; code 0 ¼ others)
Widowed A dummy variable indicating respondent was widowed (Code 1 ¼ widow; code 0 ¼ others)
Early menarche (first menstrual period
11 years) A dummy variable indicating respondent having first menstrual period at age
11 years
(Code 1 ¼ first menstrual
11 years; code 0 ¼ first menstrual >11 years)
Not having biological children A dummy variable indicating respondent do not have a biological children (Code 1 ¼ not having
biological children; code 0 ¼ having a biological children)
Number of live births A continuous variable measuring number of respondent’s live births
Number of stillbirths A continuous variable measuring number of respondent’s stillbirths
Number of miscarriages A continuous variable measuring number of respondent’ miscarriages
Months of breastfeeding A continuous variable measuring months of respondent’s giving breastfeeding
Consumption of iron supplement A dummy variable indicating respondent consumes iron supplement (Code 1 ¼ consumes iron
supplement; code 0 ¼ do not consume iron supplement)
Number of cigarettes consumed per day A continuous variable measuring number of cigarettes consumed by respondent per day
Grams of tobacco consumed per day A continuous variable measuring grams of tobacco consumed by respondent per day
Obesity (BMI >30) A dummy variable indicating BMI respondent (Code 1 ¼ BMI >30; code 0 ¼ BMI
30)
Left-handedness A dummy variable indicating respondent is left-handed person (Code 1 ¼ left-handed;
code 0 ¼ right-handed)
Depression (CES-D 16) A dummy variable indicating respondent having CES-D score 16 (Code 1 ¼ having CES-D score 16;
code 0 ¼ having CES-D score <16)
Years of schooling A continuous variable measuring respondent years of schooling based on Indonesian education system
Log household expenditure A continuous variable showing log household expenditure of respondent
Living in an urban area A dummy variable indicating respondent lives in urban area (Code 1¼ live in urban area; code 0 ¼ live
in rural area).