Background:
Menarche, the onset of menstrual cycles in females, marks a milestone in the journey of reproductive development. It can be defined as the first occurrence of menstruation, typically between the ages of 9 and 16; menarche represents the activation of the hypothalamic-pituitary-ovary axis and the maturation of the reproductive system.
The timing of menarche is influenced by a complex interplay of genetic, nutritional, hormonal, and environmental factors. Understanding the average age range for menarche and its variability across populations is essential for ensuring reproductive health. Beyond its biological significance, timely menarche often signifies the attainment of fertility and the potential for childbearing.
The Overview of Delayed Menarche:
Most girls experience their first menstrual period or menarche within a specific age range. However, some may not get their period until later, beyond the expected age, also known as delayed menarche. This can occur due to various factors, including genetics, insufficient nutrients, hormonal imbalances, or environmental factors.
Delayed menarche is essential to consider because it might indicate not just fertility concerns but also potential health issues. Hormonal imbalances or chronic illnesses could be at play. There’s also a social and emotional side to it, as it may affect how people perceive themselves and others.
So, looking into the reasons behind delayed menarche helps us understand its different aspects, guiding healthcare professionals and individuals toward better reproductive health.
Normal Menarcheal Age:
Every girl goes through the time of menarche when she gets her first period. It usually happens within a specific age range. On average, most girls experience menarche between the ages of 9 and 16. However, it’s essential to know that there’s a difference. Some may start earlier, and some may start a bit later.
Several studies suggested that the menarcheal age in Asian countries ranges between 12.0 to 13.0 years. Similarly, the average age of menarche in the United States is 12.4 years.
This variety is entirely normal. The age at which menarche happens can also be influenced by where you come from and your family, family history, and nutritional values.
Signs and Symptoms of delayed menarche:
The primary sign indicating delayed menarche is the absence of a menstrual cycle, which means that the girl has not experienced uterine bleeding yet, compared to her other age fellows. Some other signs and symptoms which are also significant in identifying delayed menarche include:
- Absence of breast development.
- Slower growth rate.
- Weak bones.
- Absence of pubic and axillary hairs.
- The uterus does not begin to develop.
Causes/Factors Affecting Menarcheal Timing:
A. Nutritional Factors:
1. Impact of Malnutrition:
Malnutrition means not getting the proper nutrients (protein, vitamins) the body needs to maintain the organ’s physiology. It can delay menarche. A balanced and healthy diet is key to supporting the body’s natural processes and ensuring it matures.
It is proven that the initial stages of sexual maturity in girls are delayed by 2.1 years concerning the onset of menarche in those who live in village areas. So, paying attention to what we eat is crucial for overall health and can also influence essential events like menarche.
2. Role of Body Mass Index (BMI)
Another important factor influencing the timing of menarche is the Body Mass Index (BMI). BMI measures the balance between weight and height. Girls who have a low BMI, meaning they are underweight, may experience delayed menarche.
Simultaneously, girls with higher BMI, indicating overweight or obesity, may also face delays. Some studies suggested that pubertal development (from thelarche to menarche) is delayed during obesity.
It might be due to a disruption in the body’s hormonal balance, (you can check your BMI by clicking here) affecting the timing of menarche. Maintaining a healthy weight through proper nutrition and regular exercise is essential for ensuring the body is in the right conditions for menarche to occur at the expected time.
B. Hormonal Influences
1. Hypothalamic-Pituitary-Ovary Axis:
The Hypothalamic-Pituitary-Gonadal (HPG) Axis is a complex communication system that involves three key players:
- The Hypothalamus,
- The Pituitary Gland and
- The Gonads (ovaries in females).
The hypothalamus, a vital region in the brain, releases gonadotropin-releasing hormone (GnRH), signaling the pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones then travel to the ovaries, stimulating the production of estrogen and progesterone, essential for regulating the menstrual cycle.
Any disruptions in this delicate HPG Axis can profoundly affect reproductive milestones such as menarche. Factors like chronic stress, nutritional imbalances, and environmental toxins can interfere with the smooth functioning of this axis, leading to hormonal irregularities.
Stress, for instance, can suppress GnRH secretion, creating a domino effect that ripples through the entire system. Such disruptions may result in delayed menarche.
2. Thyroid Function and Menarche:
The thyroid, a butterfly-shaped gland in the neck, secretes hormones that regulate various bodily functions, including metabolism and growth. Thyroid hormones, particularly thyroxine (T4) and triiodothyronine (T3), play a crucial role in the development and functioning of the reproductive system.
Thyroid dysfunction, characterized by an underactive (hypothyroidism) or overactive (hyperthyroidism) thyroid, can impact the delicate balance required for timely menarche.
In cases of hypothyroidism (Hashimoto’s thyroiditis), where the thyroid produces insufficient hormones as a consequence of an autoimmune reaction toward the thyroid-hormone-producing cells, causes a delay in thelarche as well as the development of internal genital parts, specifically in females, which eventually leads to delayed menarche.
On the other hand, hyperthyroidism, an excess of thyroid hormones, and its impact on pubertal development and menarche is still debatable.
C. Psychological Stress:
1. Cortisol and Its Effects:
In the intricate chemistry of factors influencing menarche, the role of psychological stress cannot be overstated. Stress, particularly chronic stress, can impact the body’s hormonal balance, with cortisol taking center stage.
Cortisol, also called the “stress hormone,” is produced through adrenal glands in response to stressors. In menarche, elevated cortisol levels can disrupt the finely tuned dance of hormones orchestrated by the Hypothalamic-Pituitary-Gonadal (HPG) Axis.
Chronic stress can lead to dysregulation of the HPG Axis, affecting the release of essential reproductive hormones like gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
This eventually leads to a decline in the body’s estrogen levels. Estrogen is produced by the ovary’s follicular cells and is responsible for puberty-associated physical changes. A decline in estrogen leads to delayed puberty and, thus, menarche.
D. Chronic Illnesses and Delayed Menarche:
1. Diabetes and Insulin Resistance:
Now, let’s talk about how specific long-term health issues, like chronic illnesses, can play a part in delaying a girl’s first period. One such condition is diabetes, and a related concern is insulin resistance.
When someone has diabetes, their body has trouble managing blood sugar levels, and insulin, an important hormone, doesn’t work as well as it should. Insulin resistance is when the body doesn’t respond to insulin like it should. These conditions can impact the delicate balance of hormones that regulate the menstrual cycle.
In the case of diabetes and insulin resistance, irregular insulin levels can affect other hormones involved in getting a period. This disruption may lead to delayed menarche.
Type-l diabetes occurs when the immune system mistakenly attacks the beta cells of the pancreas, which produce insulin. In patients with type-1 diabetes, there is a high chance of slowing down the first menstruation. Lack of insulin also disrupts GnRH neuronal transmission, which eventually causes delayed puberty and the menstrual cycle.
2. Chronic Kidney Disease:
Another chronic illness that can influence the timing of a girl’s first period is chronic kidney disease (CKD) and end-stage renal disease (ESRD). When someone has CKD or ESRD, their kidneys are unable to perform the filtration process accurately.
It is assumed that about 50% of patients who require renal replacement therapy have delayed puberty and low height as compared to the normal range.
The onset of puberty and the first periods are delayed by 2 years in the patients with CKD compared to the control ones. This delay in the menstrual cycle and genital maturation is associated with declining levels of GnRH from the hypothalamus and low levels of the active form of LH in the circulation.
CKD-associated inhibitory factors such as angiotensin-ll are responsible for the decreasing secretion of GnRH and, therefore, affect the whole system and its related physiology.
3. Autoimmune Disorders:
Now, let’s explore how autoimmune disorders, conditions in which the immune system mistakenly destroys the body’s tissues, can be linked to delayed menarche. When the immune system is not working correctly, it can have broader effects on various bodily functions, including the intricate system that regulates the menstrual cycle.
It is proven that there is a strong relation between autoimmune disorders like systemic lupus erythematosus (SLE), scleroderma, Sjögren’s syndrome, rheumatoid arthritis (RA), autoimmune thyroid disease, multiple sclerosis (MS), and late onset of menarche. It is also thought that juvenile SLE is linked with the late periods in girls as well as the incidence of psoriasis.
E. Environmental Toxins and Menarche:
Moving on to another significant factor influencing the timing of a girl’s first period, the impact of environmental toxins, specifically focusing on endocrine disruptors. Endocrine disruptors are substances in the environment that can interfere with the body’s endocrine system, which includes the glands that produce hormones regulating various physiological functions.
These disruptors, often found in everyday products like plastics, pesticides, and certain chemicals, such as phthalates, phenols, metals, smoke substances, and organochlorines, can mimic or block the body’s natural hormones and induce various disorders. When it comes to menarche, exposure to endocrine disruptors can throw off the delicate hormonal balance needed for the menstrual cycle to start at the expected time.
Endocrine disruptors affect hormones like estrogen and progesterone, which are crucial players in the initiation of menstruation. Prolonged or excessive exposure to these substances can potentially lead to delayed menarche.
F. Genetic Predisposition to Delayed Menarche:
1. Familial Patterns:
Observing family history provides valuable insights into understanding delayed menarche. If there are consistent instances of girls experiencing their first period later than average within a family, it suggests a familial pattern. Shared genetic factors among family members can contribute to similarities in the timing of menarche. However, it’s crucial to recognize that genetic predisposition doesn’t act in isolation; it interacts with various environmental influences.
2. Identification of Genetic Markers:
Scientists have been exploring specific genes and markers associated with the timing of menarche. While no single gene solely determines when a girl will have her first period, variations in multiple genes contribute to the overall genetic influence.
3. Interaction with Environmental Factors:
Genetic predisposition doesn’t operate independently; it interacts with environmental factors. While certain genetic factors may influence the potential for delayed menarche, environmental conditions can modulate their effects. For instance, a girl with a genetic predisposition may still experience timely menarche if ecological factors are supportive. On the other hand, unfavorable environmental conditions may exacerbate the impact of genetic factors, leading to delays.
Treatment options:
When addressing delayed menarche, various treatment approaches can be considered to support and optimize reproductive health. It includes:
1. Nutritional Interventions:
- A balanced and nutritious diet provides essential vitamins, minerals, and energy necessary for the body’s optimal functioning. In the context of delayed menarche, ensuring an adequate intake of nutrients is crucial for supporting the body’s natural processes.
- In some cases, nutritional supplements may be prescribed to address specific deficiencies or ensure that the body receives essential nutrients in sufficient quantities. Iron, calcium, vitamin D, and certain B vitamins are integral to reproductive health. However, supplementation should be approached cautiously and under healthcare professionals’ guidance.
2. Hormonal Therapy:
- Hormonal imbalances can be a contributing factor to delayed menarche, and hormonal therapy aims to restore the delicate equilibrium required for reproductive health. In cases where there is insufficient production of reproductive hormones, such as estrogen and progesterone, hormonal therapy may be recommended.
- This can involve administering hormones in specific doses to mimic the natural hormonal fluctuations that facilitate the menstrual cycle. As with any medical intervention, hormonal therapy comes with its own set of risks and benefits. While it can effectively restore hormonal balance and promote menarche, weighing these potential benefits against possible risks is essential.
3. Psychosocial Support:
- Delayed menarche can have psychosocial implications, impacting emotional well-being and self-esteem. Counseling, provided by trained mental health professionals, becomes a crucial component of psychosocial support. It provides a safe space for individuals to express their feelings, thoughts, and experiences related to delayed menarche.
- Recognizing the potential influence of stress on menarcheal timing, stress management techniques are integrated into psychosocial support. Stress management involves learning strategies to cope with and reduce stress levels. These techniques may include mindfulness, relaxation exercises, and lifestyle adjustments, which help handle stress.
Conclusion:
So, when it comes to delayed periods, we’ve learned that there’s not just one thing causing them. Factors like what we eat, our genes, and even stress can play a role. Treating delayed periods involves a team effort. We must focus on good nutrition, consider hormonal therapy when necessary, and provide emotional support through counseling and stress management. It’s like putting together puzzle pieces – each factor is essential, and we must look at everything together.
References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413391/