ersoy2004

www.elsevier.com/locate/earlhumdev

Early Human Development 76 (2004) 115–125

Effects of different socioeconomic conditions on

menarche in Turkish female students

B. Ersoy a,*, C. Balkan b, T. Gunay c, A. Onag b, A. Egemen d

aDivision of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine,

Celal Bayar University, Manisa, TurkeybDepartment of Pediatrics, Faculty of Medicine, Celal Bayar University, Manisa, TurkeycDepartment of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey

dDivision of Social Pediatrics, Department of Pediatrics, Faculty of Medicine,

Ege University, Izmir, Turkey

Accepted 12 November 2003

Abstract

Purpose: The aim of this study was to determine the age at menarche, the menarcheal features,

and the association between menarcheal age and socioeconomic status in an urban area in Turkey. In

addition, we tried to assess whether there is a relationship between age at menarche and body

composition. Methods: We asked some questions about menarche of 1017 female adolescent

students in the high schools of Manisa region. Height and weight were measured. The body mass

index (BMI; kg/m2) was used as an index of relative weight. Adolescent girls were grouped into

three socioeconomic status according to the educational and occupational levels of their parents. The

age at menarche and the menarcheal pattern were evaluated according to the socioeconomic status.

Results: The ages of girls involved in the study ranged between 14 and 18 years, with a mean of

15.7F 1.1 years. Although the menarcheal age was found to be lower in girls with higher

socioeconomic status, there was no significant difference between the three different socioeconomic

status. In all of the three groups, menarche was more common in summer and fall than in spring and

winter. Although the mother was an important source of knowledge in all groups, it was significantly

more important in the group with high socioeconomic status. Adolescent girls with low

socioeconomic status had fewer premenstrual complaints. However, there was no significant

difference between the groups. We found an inverse correlation between menarcheal age and

postmenarcheal weight and the BMI (r =� 0.14, p = 0.000). However, there was no correlation

between menarcheal age and postmenarcheal height. Conclusion: These results indicate that as the

social status differences decrease, the difference observed in menarcheal age and pattern disappears

0378-3782/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.earlhumdev.2003.11.001

* Corresponding author. Faculty of Medicine, Department of Pediatrics, Celal Bayar University, 108/35

sokak, No. 51/36, Esendere, Izmir 35350, Turkey.

E-mail address: [email protected] (B. Ersoy).

B. Ersoy et al. / Early Human Development 76 (2004) 115–125116

in urban areas of developing countries. Menarcheal age may be an indicator of socioeconomic

development. It does not influence postmenarcheal height; however, as menarcheal age decreases,

BMI increases.

D 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Menarcheal age; Socioeconomic status; Menarche

1. Introduction

The importance of sexual maturation is generally recognized and emphasized in pediatric

practice, as it is associated with a panorama of changes with far-reaching physical,

physiological, sociological, and clinical effects [1]. According to Bielicki, the age at

menarche serves as a reliable instrument with which the effectiveness of social policies

practiced may be measured. A major part of the large interindividual variation found in the

age at menarche is due to genetic factors. However, changes in the population levels,

together with socioeconomic, urban–rural, and regional differences, would be duemainly to

social factors, especially nutrition [2,3].

During the past centuries, menarcheal age has been decreasing gradually. In the case of

United States and Europe, it has come earlier by 2–3 months per decade [4,5]. The age at

menarche has declined in developed countries, and this decline has also been observed in

developing countries during recent years [6]. Environmental changes, improved nutrition,

and resultant physical development owing to the rapid improvement of social and economic

factors may have caused this change [7]. A secular trend towards an earlier age at menarche

during the last centuries [5,8] has been regarded as a positive indicator of a population’s

status of health [3].

The age of girls who start menstruating is an important factor in health planning and is

known to be influenced by genetic factors, environmental conditions, body size and

physique, socioeconomic variables, and level of education [9–11]. In evaluating the age

at menarche of a population or an individual, it is important to consider these environmental

factors. Genetic, environmental, and socioeconomic factors influence body height and

weight, as well as age at menarche [12]. Cameron [13] has shown a positive secular trend for

height and weight as the age at menarche decreased in London girls. The aim of this study

was to determine the current age at menarche and features of adolescent student girls at

menarche in an urban area of Turkey, and to identify its association with socioeconomic

status. In addition, we investigated whether there was a correlation between age at menarche

and postmenarcheal body composition.

2. Materials and methods

One thousand seventeen female students with periodic menstrual cycles who were

studying in the high schools of Manisa City were included in this study, which was

conducted between September 1999 and September 2001. Manisa is located on the west of

Turkey and is 40 km far from Izmir, which is the third principal city of Turkey. Manisa is an

B. Ersoy et al. / Early Human Development 76 (2004) 115–125 117

industrial city and the cultural status has increased after the foundation of Celal Bayar

University in 1992. The population of the city center is 214,400.

2.1. Sample selection and participants

The current study consists of cross-sectional analyses. At present, no published data are

available on the age at menarche in Manisa. There are 10 public high schools in Manisa.

The total number of the female students in these high schools was 4114 during the 1999–

2000 academic year. The calculated sample size was 571, with 95% confidence interval,

5% deviation, and 50% prevalence. The aim was to reach twice this sample size.

Permission was obtained from the Ministry of Education before the study. Ten public

high schools were numbered and four high schools were selected according to the table of

random numbers. There are two private high schools in Manisa. However, the students in

public schools reflect the Turkish population better than the students in private high

schools. Therefore, students in public schools were included in this study. One thousand

seventeen female students who reached menarche were enrolled in this study. In this study,

first of all, we identified the sociodemographic features of adolescent female students who

live in Manisa. The educational and occupational status of their parents were asked of the

adolescent girls and their answers were confirmed by the school directors.

2.2. Data collection

Two medical doctors (one male and one female) handed out the questionnaires involving

a series of questions about their birthday, duration and period of their menses, age at

menarche, premenstrual complaints, source of knowledge about menarche, chronic illness,

etc. The students filled out the papers by themselves. Additional information about

menarcheal age was obtained through an interview by a doctor. Students were asked to

identify the year of their first period. Probing questions such as ‘‘Do you remember which

grade you were in when you started having period?’’ were used to help respondents

remember the date. All students provided the month and year of their menarche. The age at

menarche was calculated by decimal year according to birthday. Each girl was also asked to

recall the age at which her menstruation began. One year after, the same question was asked

of the students again and the same answers were obtained.

Weight was measured to the nearest 0.5 kg using a balance beam scale and height was

measured to the nearest 0.1 cm with a manual height board. The body mass index (BMI;

kg/m2) was used as an index of relative weight. Height SDS (standard deviation score),

weight SDS, and BMI SDS were estimated according to Turkish standards.

Seventeen girls suffering from chronic illnesses (thalassemia, type I diabetes mellitus,

secondary amenorrhea, etc.) were excluded from the study.

Seasons defined according to the climate condition of our region are as follows: Winter:

December, January, February; Spring: March, April, May; Summer: June, July, August;

and Fall: September, October, November.

Categorization of socioeconomic class was based on the occupation and education

of the parents by applying the Hollingshead index [14] (Table 1). Five educational

levels and five occupational categories were used to identify socioeconomic classes. A

Table 1

Scoring of the educational level and occupation of both parents according to the Hollingshead index of

socioeconomic groups

Educational level Score Occupation Score

No education 0 No occupation 0

Elementary school 1 Workman 1

Junior school 2 Blue collar worker 2

High school 3 White collar worker 3

University 4 Professional 4

Educational and occupational scores of parents: 0–4: I; 5–8: II; 9–12: III; and 13–16: IV.


score of 0 was given to the lowest level of education and occupation, and a score of 4

was given to the highest. Three socioeconomic classes were identified, ranging from

lowest to the highest, on the basis of the sum of scores. Hollingshead scoring was

modified according to national Turkish standards. The first and second socioeconomic

classes in Hollingshead scoring were defined as low and middle socioeconomic classes,

respectively. The third and fourth classes were defined as high socioeconomic class.

2.3. Statistical analyses

Mean values of age at menarche, postmenarcheal height and weight, period of

menses, and duration of menses in groups classified according to socioeconomic status

have been compared by means of analysis of variance (one-way ANOVA). Source of

knowledge about menarche, premenstrual complaints, and reactions to menarche in

each socioeconomic status were compared by means of the v2 test. Pearson correlation

analysis was used to determine the relation between menarcheal age and body

composition. Multiple regression analysis was used to reveal the effects of menarcheal

age and socioeconomic status on BMI.

3. Results

The educational and occupational status of parents in the study group were evaluated.

While 10.7% of the fathers had university degree training, only 3.9% of the mothers had

university degree (Table 2). It was found that most of the mothers had only primary

school training and were housewives. When the structure of the families was evaluated,

it was found that most of them were nuclear families (89.8%). Only 8.1% of the families

were of ‘‘extended family’’ structure, in accordance with old Turkish traditions. Only

22.6% of the adolescent girls owned a room at home. According to the educational and

occupational status of their parents, the students were included either in low (21.3%),

middle (46.6%), or high (32.1%) socioeconomic status.

The ages of the girls involved in the study ranged between 14 and 18 years, with a

mean of 15.7F 1.1 years. In this study, we found that the mean postmenarcheal height

(approximately 3.0F 1.1 years after menarche) was 160.42F 6.14 cm. The mean

postmenarcheal weight was 53.73F 8.87 kg. The mean postmenarcheal BMI was

Table 2

Distribution of adolescent girls according to sociodemographic features

Sociodemographic features (n= 1000) Number Percent

Educational level of mothers

No education 57 5.7

Elementary school 665 66.5

Junior school 97 9.7

High school 142 14.2

University 39 3.9

Educational level of fathers

No education 19 1.9

Elementary school 471 47.1

Junior school 159 15.9

High school 244 24.4

University 107 10.7

Family type

Nuclear family 898 89.8

Extended family 81 8.1

One-parent families 21 2.1

Owned room

Yes 226 22.6

No 774 77.4

Socioeconomic condition

High 213 21.3

Middle 466 46.6

Low 321 32.1


20.82F 3.02 kg/m2. The mean menarcheal age was 12.82F 1.07 years. The mean

period and the mean duration of menses were 29.41F 7.46 and 6.19F 2.23 days,

respectively.

The mean menarcheal age, mean postmenarcheal height and height SDS, weight and

weight SDS, BMI and BMI SDS, and mean period and duration of menses according to

socioeconomic status are shown in Table 3. Although the menarcheal age was found to be

lower in girls with higher socioeconomic status, there was no significant difference

between the three different socioeconomic status ( p>0.05). Postmenarcheal weight in girls

belonging to the low socioeconomic class was significantly lower than those girls

belonging to the middle and high socioeconomic classes ( p < 0.05). Weight SDS values

were not different significantly between the three groups ( p = 0.19). In contrast, post-

menarcheal height was significantly shorter only in girls belonging to the low socioeco-

nomic than the other socioeconomic groups ( p < 0.05). Height SDS value was

significantly lower in low socioeconomic group than the others ( p= 0.036). However,

there were no significant differences between BMI and BMI SDS of girls from different

socioeconomic classes ( p>0.05). The median of the menstrual period was 30 days

(maximum 90 days, minimum 15 days). A total of 22.8% of the girls had irregular

menstrual cycles. The time passed after menarche of girls with irregular cycles was less

Table 3

Mean age of menarche and physique according to socioeconomic statusa

Socioeconomic status

Low Medium High

Postmenarcheal age (years) 15.78F 1.14 15.81F1.12 15.80F 1.11

Postmenarcheal weight (kg) 52.66F 7.90 54.22F 9.57 54.28F 8.57*

Postmenarcheal weight SDS � 0.15F 1.11 � 0.02F 1.34 0.08F 1.33

Postmenarcheal height (cm) 159.47F 5.95 160.61F 6.25 161.43F 5.93*

Postmenarcheal height SDS � 0.08F 1.4* 0.22F 1.0 0.36F 1.0

Postmenarcheal BMI (kg/m2) 20.63F 2.81 20.95F 3.13 20.77F 3.09

Postmenarcheal BMI SDS 0.32F 1.11 0.39F 1.25 0.32F 1.23

Age at menarche (years) 12.87F 1.08 12.83F 1.06 12.73F 1.07

Period of menses (days) 29.95F 7.15 29.58F 6.86 29.95F 7.15

Duration of menses (days) 5.33F 1.31* 5.50F 1.26 5.67F 1.28

a One-way ANOVA.

*p< 0.05.


than 1 year in 8.8%, 1–2 years in 9.6%, and more than 2 years in 11.6%. The median of

the menstrual duration was 5 days (maximum 10 days, minimum 1 day). While the period

of menses was not different significantly, the duration of menses was significantly longer

in the high socioeconomic class than in the low socioeconomic class ( p < 0.05).

The seasonal distribution pattern of menarche in the three socioeconomic groups was

similar. We found two peaks of frequency in the seasonal distribution pattern. In all of the

three groups, menarche was more common in the summer and fall than in the spring and

winter. Menarche was more frequent in the summer among the girls with low and middle

socioeconomic status. However, the difference in seasonal distribution of menarche

between the groups was not significant ( p>0.05) (Fig. 1).

All of the subjects were asked to identify the first-hand source of their knowledge

regarding menarche and menstruation. All of the students were informed about menarche

before its start. The first source of their knowledge was their mother. However, friends,

sisters, journals, and television were also among the sources. Although the mother was an

important source of knowledge in all groups, it was significantly more important in the

high socioeconomic class (Table 4). The girls in the high socioeconomic group had their

mothers as the main source of knowledge.

All of the girls had information about menarche. However, they stated that they showed

reactions such as sadness and fear during menarche. Happiness and neutral feelings at

menarche were accepted as ‘‘no response,’’ while reactions like being afraid, sad, or

confused were accepted as a response. The number of girls who showed responses at

menarche was significantly lower in the high socioeconomic class (Table 4). Premenstrual

complaints are important problems that decrease the productivity of girls and women in

school and at work. Adolescent girls were asked if they had water retention, constipation,

weight gain, nausea, and increase in appetite during premenstrual period. Subjects who

had complaints or no complaints were evaluated according to their socioeconomic classes.

Although adolescent girls belonging to the low socioeconomic class had fewer premen-

strual complaints, there was no significant difference between the three socioeconomic

classes (Table 4).

Fig. 1. The figure depicts the seasonal distribution pattern of menarche in three socioeconomic groups. The

distribution pattern was similar in all groups. There are two peaks of frequency in the seasonal distribution

pattern. The difference in seasonal distribution of menarche between the groups was not significant ( p>0.05).


The age at menarche is suggested to influence the height and body weight in

adolescents and adults. In our study, there was a weak but significant inverse correlation

between BMI (r =� 0.1498, p = 0.000), postmenarcheal weight (r =� 0.1229, p = 0.000),

and mean menarcheal age. However, there was no significant correlation between

postmenarcheal height and menarcheal age (r = 0.063, p= 0.843). When the effect of

Table 4

Distribution of menarcheal features according to socioeconomic status

Features Socioeconomic status (%) p

High (n= 210) Middle (n= 464) Low (n= 318)

Sources of knowledge about menarche

Mother 65.3 58.0 50.5 0.003

Other 34.7 42.0 49.5

Reactions to menarche

Yes 47.1 56.7 45.5 0.045

No 52.9 43.3 54.5

Premenstrual complaints

Yes 50.7 49.8 45.5 0.386

No 49.3 50.2 54.5


menarcheal age and socioeconomic status on BMI was evaluated using the multiple

regression analysis, we found that the socioeconomic status did not have any effect on

BMI. However, there was a strong inverse correlation between menarcheal age and BMI

(B =� 0.416, SEB= 0.090, p = 0.000). Menarcheal ages of the girls over 24.1 kg/m2 of

BMI were 12.52F 1.38 years, and of those under 24.0 kg/m2 of BMI were 12.86F 1.02

years. There was a significant difference between the two groups (t = 2.014, p = 0.046).

4. Discussion

The age at menarche has declined in many countries. In general, these declines have

been attributed to the improvements in nutritional status and general health [13]. In the

literature, there are many studies that show a decrease in menarcheal age regarding the

improvement of socioeconomic conditions in developed and developing countries. In a

number of studies, which investigate the association between socioeconomic status and

age at menarche, the difference in socioeconomic status is shown to influence the age at

menarche [1,3,5,6,15,16]. Other studies have shown that socioeconomic status and age at

menarche are not significantly related [17]. Our findings concur with this study.

We evaluated whether the age at menarche was affected by different socioeconomic

status in adolescent girls who live in urban areas. The students in this study represent a

selected population because they were all from the high schools of Manisa. In our country,

more than 80% of adolescent girls attend high schools in urban areas. Our results have

shown that the age at menarche was not significantly different between the three

socioeconomic status. In our study, different from previous studies, socioeconomic

differences in urban areas were taken into consideration. Urban girls were menstruating

significantly earlier than the girls living in rural areas in China, as reported in other studies

[15]. Similar results have been obtained from studies which were done in Brazil [18,19]. A

study done in Guatemala showed that nutritional supplementation did not affect the age at

menarche, but socioeconomic status was found to be associated with the age at menarche,

which may be due to the influences on general environmental factors [20]. However,

Veronesi and Gueresi [21] reported that as a consequence of the improved living standards

of the Bologna area, the differences observed in the mean menarcheal age between the

classified groups have gradually disappeared. Results of a study from Spain indicated that

as the socioeconomic differences between the urban and rural environments decrease, the

difference observed in the menarcheal age between the rural and urban populations also

decreases [22]. In our study, although the mean menarcheal age in the high socioeconomic

group was earlier than the middle and low socioeconomic groups, the difference was not

significant. In a study by Neyzi et al. [23], the age at menarche was significantly higher in

the low socioeconomic group than in the high socioeconomic group. This study was done

in Istanbul, which is the biggest metropolitan area of Turkey. On the other hand, the mean

menarcheal age of Turkish girls living in Bremen is distinctly lower than the mean age at

menarche of urban German girls living in the same district [24].

The median length of the menstrual cycle is 28 days (range 21–41 days) and there is a

wide variation between women. Menstrual bleeding lasts 2–7 days in 80–90% of

adolescent girls [25]. In our study, period of menses was not different significantly


between the three socioeconomic statuses. However, the duration of menses was

significantly longer in the girls with high socioeconomic status than the girls with low

socioeconomic status. Park et al. had found that seasonal distribution of menarche was

most common during school vacation in Korea. In our study, menarche was most common

in the summer and fall than in the winter and spring. In our country, students have summer

vacation from June to September. There was no significant difference in seasonal

distribution of menarche between the three socioeconomic status. Our seasonal distribu-

tion pattern of menarcheal age was different from that in Europe. The pattern most

frequently reported in Europe shows two frequency peaks. They are in the winter and

summer [26]. In an examined sample from many countries, the rhythm in schoolwork

activity is reflected in the rhythm of menarche occurrence, which is more frequent during

vacation and less frequent during school attendance. Sexual maturation could be inhibited

by excessive psychophysical load, and triggered by relaxation in correspondence to the

period of school vacation.

Mothers were found to be the most important source of knowledge about menarche.

Vicdan et al. [27] have found that girlfriends were the most important source of sexual

knowledge in Turkey. In our study, mothers were a significantly more important source of

sexual knowledge, especially in girls belonging to the high socioeconomic group. The

explanation for this observation may be that the mothers of these girls had higher

educational level. In our neighbor, Iran, mothers and health teachers were identified as

the first-hand sources of menstrual knowledge [16]. In girls with high socioeconomic

status, the reaction to the onset of menarche was significantly fewer than the girls in other

groups. This may be because they were informed about menarche by their mothers.

Results of the study from Iran have not concurred with our study. Consistent with the

study of Fisher et al. [28], water retention was the most frequent premenstrual symptom

and premenstrual symptoms were more frequent in girls who have enough knowledge

about menarche. A number of studies have found that women with a high level of formal

education report a more negative effect during premenstruum [29].

In general, improvement in nutritional status results in earlier onset of puberty and

menarche [5,6]. In postmenarcheal period, the girls with high socioeconomic status were

taller and heavier than those with low socioeconomic status in this study. Mean

menarcheal age was lower in these girls, but it was not significant. Similar results had

been obtained in other developing countries [30,31]. Overall results were consistent with

the hypothesis that nutritional factors influence the age at menarche mainly through their

effects on the accumulation of adipose tissues [32,33]. We also determined that post-

menarcheal weight and BMI increased as menarcheal age declined. However, we did not

find a relation between menarcheal age and postmenarcheal height. Other studies have

reported that adult height was significantly related to menarcheal age [9,34].

5. Conclusion

Socioeconomic differences have decreased in urban areas in developing countries.

Although the educational status among the parents is still very low in our region, the

improvement of cultural and economic status caused the difference seen in menarcheal age


between the socioeconomic classes to disappear. Menarcheal age may be an indicator of

the socioeconomic improvement observed in an area. However, changes observed in

environmental and socioeconomic factors have resulted in a progressive decrease of

menarcheal age and an increase in body weight in urban areas. Depending on our results,

we can conclude that the differences observed in socioeconomic status do not influence the

age at menarche, and that the age at menarche does not influence adult height. However,

early menarcheal age may result in increased BMI. However, increased BMI can cause

early menarche and persist in the postmenarcheal period.

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