J Pediatr Endocr Met 2012;25(1-2):57–62 © 2012 by Walter de Gruyter • Berlin • Boston. DOI 10.
1515/jpem-2011-0277
Association of early menarche age and overweight/obesity
Irena Bralić1,*, Husref Tahirović2,3,
Dubravka Matanić4, Ozren Vrdoljak5,
Stanislava Stojanović-Špehar6, Vedran Kovačić7
and Sanja Blažeković-Milaković6
1 Conclusions: Girls who experienced early menarche are
Specialist Office in Pediatrics, School of Medicine,
University of Split, Trogir, Croatia
2 sity may be considered as one of the predictors for the early
Academy of Sciences and Arts of Bosnia and
Herzegovina, Sarajevo, Bosnia and Herzegovina
3
Department for Research and Education, University
Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
4
City of Zagreb, Zagreb, Croatia
5
University Hospital “Sestre Milosrdnice”, Children’s
Hospital Zagreb, Zagreb, Croatia
6
Department of Family Medicine, “Andrija Štampar”
School of Public Health Medical School, University of
Zagreb, Zagreb, Croatia
7 pubertal development in girls. Knowing the menarcheal age
School of Medicine, University of Split, Split, Croatia
Abstract
Aim: The aim of the study is to assess the association of over-
weight/obesity and early menarcheal age.
Patients and methods: The study comprised 2127 healthy
girls aged 9 to 16 years. Menarcheal age was estimated by
status quo method. The girls’ body weight and height were
measured and their body mass index (BMI) calculated. The
diagnostic criteria of the WHO were used to define over-
weight and obesity. Girls with a BMI in the range of 1–2 for
age and sex were considered overweight. Girls with a BMI
>2 standard deviation (SD) for age and sex were considered
obese. Girls with a BMI >1 SD for age and sex were con-
sidered overweight/obese. Social and economic status was
analyzed according to years of education completed, parents’
occupations, and the number of children in the family.
Results: Median menarcheal age was 12.83 years; 25% girls
had menarche before 11.98 years and 75% by 13.69 years.
By 11.21 years, 10% of girls had had menarche, and 95%
by 14.91 years. Girls who had menarche before 11.98 years
had higher body weight values (48.5 vs. 40.2 kg) (p<0.001),
height (159.3 vs. 149.2 cm) (p<0.001), and BMI (18.9 vs.
17.8 kg/m2) (p = 0.003) than their peers without menarche.
Girls with menarche before 11.98 years had significantly
higher BMI values than girls with menarche after 13.69 years
(18.94 vs. 17.84 kg/m2) (p = 0.008). Girls with menarche
*Corresponding author: Irena Bralić, Specialist Office in Pediatrics,
School of Medicine, University of Split, A. Stepinca 17,
21220 Trogir, Croatia
E-mail: irena.bralic@si.t-com.hr
Received May 16, 2011; accepted November 2, 2011; previously
published online January 17, 2012
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before 11.98 years and those after 13.69 years differ signifi-
cantly in distribution of thinness (3.4% vs. 2.54%), normal
weight (85.3% vs. 91.8%), and overweight/obesity (11.2%
vs. 5.7%) (p = 0.002).
significantly more often overweight/obese. Overweight/obe-
occurrence of menarche.
Keywords: body mass index (BMI); menarche; overweight/
obesity.
Introduction
Menarcheal age is still considered one of the best indicators of
in a specific population group is significant from auxological,
biological, pyschosocial, and clinical points of view.
In the literature, various trends in secular changes in
growth and development have been described, including
the menarcheal age. The menarcheal age fell significantly
during the 20th century in developed countries and at the
same time, an increase in the values of body height, mass,
and overweight/obesity was noted (1, 2). From the clinical
aspect, the need to recognize overweight/obesity early in
childhood and adolescence has become important because
its many short- and long-term, direct, and indirect effects
on the health of individuals and the population as a whole
are well known. The attention of experts in different fields,
and society at large, has been drawn to the increasingly
early onset of pubertal changes and menarcheal age due to
their significant influence on the psychosocial and somatic
development of children and also due to the increased risk of
endometrial cancer, menstrual problems, adult obesity, type
2 diabetes, and breast cancer (3–5). The relationship between
menarcheal age and overweight/obesity is the result of the
influence of many individual and mutual factors, including
genetics, as well as a number of environmental influences.
Individual researchers into the lowering of the menarcheal
age link it with an increase in body mass index (BMI) and
frequency of overweight/obesity (6, 7), whereas others (8)
consider “that increases in relative weight are a consequence,
rather than a determinant, of the menarcheal age and that sec-
ular changes in BMI and in the mean menarcheal age could
be independent phenomena”. Physiological and pathogenic
mechanisms that affect the occurrence of overweight/obesity
and also the early onset of pubertal changes, including early
menarche, have not been fully clarified. The effect on occur-
rences during puberty of the circadian rhythm of secreting
leptin, gonadotropins, steroids, and growth hormone is well
known (9).
58 Bralić et al.: Association of early menarche age and overweight/obesity

The aim of this study was to investigate the association of
overweight/obesity [defined as a BMI >1 standard deviation
(SD) for age and sex] with the early occurrence of menarche
in a random group of more than 2000 healthy girls who are
permanently residing in Croatia.
Subjects and methods
Study was carried out during 2009 on a random group of girls in the
Šibenik-Knin County. The Šibenik-Knin County covers an area of
about 2.984 km2 and has a population of 114,000. There are 14,600
children and young people aged between 7 and 19 years. The coun-
ty is in Dalmatia, in the southern part of Croatia, on the Adriatic/
Mediterranean coast. There are two national parks in the area of the
county (Kornati and Krka), and the main economic activities are
tourism and wine and virgin olive oil production.
Study participants
A total of 2429 girls, aged between 9 and 16 years, were included in
the study, representing about 80% of the group under observation.
The criteria for inclusion were healthy girls, all permanent residents
of Šibenik-Knin County, who were regular school attenders, between
the fourth grade of primary and the second grade of secondary school
(n=2127). The criteria for exclusion were the presence of a chronic
illness limiting adequate growth and development in girls (n=119)
(5.6%) and incomplete data on age (n=183) (11.6%).
A questionnaire was compiled for the study, which included date
of birth, sex, presence of chronic illnesses that may limit adequate
growth and development in girls (diabetes, endocrine illnesses, ma-
lign diseases, etc.), social and economic indicators in which they
were growing up, and whether they had experienced menarche.
digital scales and Seca-type height-measuring instruments. Each
girl’s BMI was calculated using the formula BMI=body weight/
height2 (kg/m2). The diagnostic criteria of the WHO were used to
define overweight and obesity (11). Girls with BMI ranging from
1 SD to –2 SD were considered having normal weight. Girls with
a BMI of <2 SD for age and sex were considered thin/undernour-
ished. Girls with a BMI in the range of 1–2 for age and sex were
considered overweight. Girls with a BMI >2 SD for age and sex
were considered obese. Girls with a BMI >1 SD for age and sex
were considered overweight/obese.
Age at menarche
Menarcheal age was estimated using the status quo system and deter-
mined using probit analysis. Girls whose menarcheal age was below
the 25th centile had early menarche, whereas girls whose menarcheal
age was above the 75th centile in the group observed had late menar-
che. Girls whose menarcheal age was from 11.99 to 13.70 years were
considered to have average menarche. The period of early menarche
was defined as menarche occurring before 11.98 years old (<25th
centile) and the period of late menarche occurring after 13.69 years
old (>75th centile) in the group observed.
After the probit analysis, 565 girls younger than 11.98 years com-
prised the early menarche group and 752 girls older than 13.69 years
comprised the late menarche (total 1317 girls).
Social and economic status
Social and economic status was analyzed on the basis of the answers
to questions regarding parental education (years in formal education:
8 years or fewer, 11–12 years, 14 or more years), parental occupation
(manual, blue-collar worker, white-collar worker, administrative),
and the number of children in the family (1–2, 3, or more).

Age of the girls Statistical analysis

The age of each girl was expressed in decimal figures, according to
the decimal calendar (10). The girls were divided into groups accord-
ing to age by periods of 6 months (Table 1).
Anthropometric measurements
Each girl was evaluated, with body weight and height measured
during regular medical examinations. Body weight was measured
in underclothes, to the nearest 0.01 kg, and height was measured
on bare feet, to the nearest 0.05 cm. Anthropometric measurements
were taken by trained medical staff who were recommended to use
The results are shown using the parameters of descriptive statistics:
quantitative variables using arithmetical means and SD, which are
95% reliable, and qualitative variables using absolute and relative
frequencies. The average menarcheal age was established using pro-
bit analysis. Differences in the measured values of quantitative vari-
ables between the girls and the period of early or late menarche were
tested using the Mann-Whitney U-test, and differences in measur-
ing the values of qualitative variables were tested using the χ2-test.
Probability of <5% was considered statistically significant.
Results

Table 1 Distribution of subject in half-year groups. The results of the study showed that the median menar-
cheal age was 12.83 years, with 25% of the girls experi-
Girls younger than 11.98 years Girls older than 13.69 years encing menarche before the age of 11.98 years and 75%
before the age of 13.69 years. The youngest age at which a
Age n % Age n % girl experienced menarche was 9.89 years, and the oldest
9 3 0.5 13.5 57 7.4 15.77 years. Ten percent of the girls experienced menarche
9.5 17 2.7 14 113 14.6 by the age of 11.21 years, and 95% of the group experi-
10 115 18.5 14.5 126 16.3 enced menarche before the age of 14.91 years. Girls who
10.5 152 24.5 15 114 14.7 experienced menarche before the age of 11.98 years had
11 172 27.7 15.5 104 13.5 significantly higher body weight, height, and BMI in com-
11.5 162 26.1 16 259 33.5 parison to their peers who had not experienced menarche
Total 621 100.0 Total 773 100.0 (Table 2).

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 Bralić et al.: Association of early menarche age and overweight/obesity 59

Table 2 Anthropometric characteristics of girls younger than 11.98 years in relation to the occurrence of menarche.

Anthropometric Menarche p-Valuea

characteristics
Yes No
n Mean ± SD 95% CI n Mean ± SD 95% CI

Body weight, kg 41 48.7± 9.1 45.9–51.6 524 39.9 ±7.1 39.2–40.5 < 0.001
Body weight for age Zb 41 – 0.1± 0.8 – 0.3–0.2 524 – 0.9 ± 0.6 –1.0– – 0.8 < 0.001
Height, cm 41 159.3 ±7.4 157.0–161.7 521 149.3 ± 8.9 148.5–150.0 < 0.001
Height for age Zb 41 – 0.1± 0.7 – 0.3–0.1 521 –1.0 ± 0.8 –1.1– – 0.9 < 0.001
BMI, kg/m2 41 19.1± 2.6 18.3–19.9 521 17.8 ± 2.3 17.6–18.0 0.003
BMI for age Zb 41 0.0 ±1.0 – 0.3–0.3 521 – 0.5 ± 0.9 – 0.5– – 0.4 0.003
a
H0, menarche, yes vs. no. Difference equals 0, as assessed by Mann-Whitney U-test. bZ-scores express levels relative to those among children
in studies.

In the group older than 13.69 years, girls who had experi-
enced menarche had statistically higher body weight, height,
and BMI in comparison to their peers who had not yet experi-
enced menarche (Table 3).
Girls who experienced early menarche had a lower body
weight (p < 0.001), height (p < 0.001), and BMI (p = 0.008) than
girls who experienced late menarche (Table 4).
In the entire group observed, 3.0% were considered thin,
88.3% normal in weight, and 8.7% overweight or obese. In
the group of girls who had experienced menarche before the
age of 11.98 years, 3.4% were thin, 85.3% normal in weight,
and 11.2% overweight or obese, whereas in the group of girls
who had experienced menarche after the age of 13.69 years,
2.5% were thin, 91.8% normal in weight, and 5.7% over-
weight or obese (χ2=12.01, p = 0.002).
Body weight for age Z behaves inversely, that is, in the
early menarche group, overweight/obese girl have higher and
positive values (0.1±0.8), but those with normal body weight
have negative, that is, lower values (–0.1±0.6) (Table 5).
The proportion of overweight, obese, and thin girls who
had experienced menarche before 11.98 years and after 13.69
years is shown in Figure 1.
Girls with early or late menarche did not differ signifi-
cantly in terms of parental education or occupation, parental
employment or lack of employment, and the number of chil-
dren in the family (Table 6).
Discussion
Girls who experience early menarche are significantly more
often overweight or obese. Overweight/obesity may be con-
sidered as one of the predictors of the early occurrence of
menarche.
The group of girls observed did not differ significantly in
terms of occurrence of menarche from their peers in devel-
oped countries (12, 13). In the group of girls observed, the
25th centile for menarcheal age was the same as for white
American girls (11.98 vs. 11.9), but the range of average
menarcheal age was somewhat wider (11.99–13.68 vs. 12.0–
13.1), whereas later menarcheal age was higher (13.69 vs.
13.2) (13). By the age of 11.98 years, 25% of the girls in this
study had experienced menarche, which is consistent with the
results obtained by Martínez et al. (14).
According to the results of this study, with 95% confi-
dence, the body weight of girls with early menarche ranges
from 45.9 to 51.6 kg.
The significantly greater body weight, height, and even
BMI in groups of girls who experienced early menarche in
comparison to girls of the same age who had not experienced
menarche can be viewed in the context of the “critical mass”
theory (15). This attitude is supported by the significantly
greater body mass of girls in the group who had experienced
menarche after 13.69 years old, in comparison to their peers

Table 3 Anthropomorphic characteristics of girls older than 13.69 years in relation to the occurrence of menarche.

Anthropometric Menarche p-Valuea

characteristics
Yes No
n Mean ± SD 95% CI n Mean ± SD 95% CI

Body weight, kg 724 57.8 ±7.8 57.3–58.4 28 50.9 ± 9.1 47.4–54.5 < 0.001
Body weight for age Zb 724 0.7± 0.7 0.7–0.8 28 0.1± 0.8 – 0.2–0.4 < 0.001
Height, cm 723 168.8 ± 6.5 168.3–169.3 28 165.3 ± 6.4 162.8–167.7 < 0.001
Height for age Zb 723 0.7± 0.6 0.7–0.8 28 0.4 ± 0.6 0.2–0.6 0.002
BMI, kg/mb 722 20.3 ± 2.4 20.1–20.5 28 18.6 ± 2.4 17.6–19.5 < 0.001
BMI for age Zb 722 0.5 ± 0.9 0.4–0.5 28 – 0.2 ± 0.9 – 0.5–0.2 < 0.001
a
H0, menarche, yes vs. no. Difference equals 0, as assessed by Mann-Whitney U-test. bZ-scores express levels relative to those among children
in studies.

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60 Bralić et al.: Association of early menarche age and overweight/obesity

Table 4 Anthropometric characteristics of girls experiencing the occurrence of early or late menarche (before 11.98 years and after 13.69
years).

Anthropometric Girls younger than 11.98 years Girls older than 13.69 years p-Valuea
characteristics
n Mean ± SD 95% CI n Mean ± SD 95% CI

Body weight, kg 41 48.7± 9.1 45.9–51.6 724 57.8 ±7.8 57.3–58.4 < 0.001
Body weight for age Zb 41 – 0.1± 0.8 – 0.3–0.2 724 0.7± 0.7 0.7–0.8 < 0.001
Height, cm 41 159.3 ±7.4 157.0–161.7 723 168.8 ± 6.5 168.3–169.3 < 0.001
Height for age Zb 41 – 0.1± 0.7 – 0.3–0.1 723 0.7± 0.6 0.7–0.8 < 0.001
BMI 41 19.1± 2.6 18.3–19.9 722 20.3 ± 2.4 20.1–20.5 0.001
BMI for age Zb 41 0.0 ±1.0 – 0.3–0.3 722 0.5 ± 0.9 0.4–0.5 0.001
a
H0: menarche, girls younger than 11.98 years vs. girls older than 13.69 years. Difference equals 0, as assessed by Mann-Whitney U-test.
b
Z-scores express levels relative to those among children in studies. BMI, body mass index.

Table 5 Occurrence of menarche among overweight/obese and normal-weight girls younger than 11.98 years.

Anthropometric Overweight/obese Normal weight p-Valuea

characteristics
n Mean ± SD 95% CI n Mean ± SD 95% CI

Body weight, kg 69 50.8 ± 8.8 48.7–52.9 546 39.1± 6.2 38.6–39.6 0.000
Body weight for age Zb 69 0.1± 0.8 – 0.1–0.3 546 –1.0 ± 0.6 –1.0– – 0.9 0.000
a
H0, girls’ nutritional status, overweight/obese vs. normal. Difference equals 0, as assessed by Mann-Whitney U-test. bZ-scores express levels
relative to those among children in studies.

who had not yet experienced menarche. The greater body
mass and height of girls who experienced menarche after the
age of 13.69 years, in comparison to those in whom menarche
occurred before the age of 11.98 years, can be explained by
their different linear growth.
However, the higher value of BMI in girls experiencing
menarche before the age of 11.98, in comparison to their peers
who experienced menarche after the age of 13.69 years, is wor-
thy of attention (18.94 vs. 17.84 kg/m2). These results support
earlier studies, which significantly correlated BMI not only
to the early onset of puberty but also to the early occurrence
of menarche (16, 17). According to the results obtained by
Bau et al. (18), overweight or obese girls have a significantly
earlier menarcheal age in relation to normal-weight or under-
weight girls (12.5 vs. 12.7 vs. 13.7). In the group observed,
the frequency of overweight/obesity was almost doubled in
the group of girls with a low age at menarche, compared
with those with a high menarcheal age. The differences in the
occurrence of obesity (BMI >2 SD) are even more marked in
girls with a low menarcheal age in comparison to those with a
high menarcheal age (3.09% vs. 0.78%).
The relationship between overweight/obesity and menar-
cheal age is usually seen as a result of the interaction of com-
plex physiological and biological mechanisms, which are
affected significantly by environmental factors. According to
the results of this study, girls with early menarche or are over-
weight/obese can be considered a group at risk and require
increased medical supervision in terms of preventing a num-
ber of conditions that may affect their current and future
health. According to Pierce et al. (19), earlier maturation is
associated with greater BMI and waist circumference in later
life, which results in increased triglycerides and cholesterol
in women.
The relatively rare occurrence of overweight/obesity in the
group of girls older than 13.69 years should be highlighted
in particular. In interpreting the frequency of overweight/

12
Early menarche Late menarche
10
8
6
%

4
2
0
Overweight Overweight Obesity Thinness
/obesity

Figure 1 Difference in overweight/obesity, overweight, obesity, and thinness of girls with early and late occurrence of menarche.

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 Bralić et al.: Association of early menarche age and overweight/obesity 61

Table 6 Overview of social and economic characteristics in girls of potential endocrinal disruptors on the early occurrence
with early or late occurrence of menarche. of menarche. The challenge facing any future study at the
national level will be to analyze the correlation between over-
Occurrence of menarche p-Valuea
weight/obesity and menarcheal age in a larger sample and
Girls Girls older also to explain the relatively rare occurrence of overweight/
younger than 13.69 obesity in relation to the wider European region.
than 11.98 years
years
n % n % Conclusion
Children in family Overweight/obesity in girls is associated with the early occur-
1–2 24 55.8 402 55.98 0.717 rence of menarche. Girls with a lower menarcheal age may
3 or more 16 42.2 319 44.02
be considered a risk group, and programs focussing on the
Working mother
Yes 27 65.8 418 58.21 0.422 prevention of overweight/obesity should be directed at them.
No 14 34.2 300 41.78 Similarly, girls who are overweight/obese have a greater
Working father chance of experiencing early menarche.
Yes 34 85.0 503 72.27 0.114
No 6 15.0 193 27.73
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