Menstruation in adolescents: what's normal, what's not

Overview of infertility

Having a child is an innate trait in animals, including humans, and is required for the continued existence of all animal species. Therefore, for most women, the inability to conceive or to do so in a timely fashion - termed infertility - to enable the continuation of the family line can be emotionally distressing. The definition of infertility is controversial because of its separation into primary and secondary. This is further complicated by the loosely used term subfertility, which relates to couples who have reduced ability because they take longer than the natural time to conceive, as opposed to those who are infertile and are entirely unable to conceive after 6 to 12 months, depending on age. Infertility evaluation requires a thorough male and female history, physical examination of both partners, and targeted investigation to determine the cause of infertility in a particular couple. Various treatments apply to infertile couples depending on the age of the female partner, the results of investigations, the reason for infertility, the presence of inheritance of abnormal genes, the pregnancy rates the couple is happy with, the resources available, how desperate the couple is to achieve a live birth, and how much they want to commit to treatment. Infertility treatment could include counseling and expectant management only, intrauterine insemination in a natural or stimulated cycle, and IVF and or ICSI. Men with azoospermia will need surgical options to retrieve sperm for IVF/ ICSI, but rarely for IUI. This review overviews infertility's etiology, diagnosis, investigations, and treatment.

The genetic architecture of age at menarche and its causal effects on other traits

Age at menarche (AAM) is a sign of puberty of females. It is a heritable trait associated with various adult diseases. However, the genetic mechanism that determines AAM and links it to disease risk is poorly understood. Aiming to uncover the genetic basis for AAM, we conducted a joint association study in up to 438,089 women from 3 genome-wide association studies of European and East Asian ancestries. A series of bioinformatical analyses and causal inference were then followed to explore in-depth annotations at the associated loci and infer the causal relationship between AAM and other complex traits/diseases. This largest meta-analysis identified a total of 21 novel AAM associated loci at the genome wide significance level (P < 5.0  × 10-8), 4 of which were European ancestry-specific loci. Functional annotations prioritized 33 candidate genes at newly identified loci. Significant genetic correlations were observed between AAM and 67 complex traits. Further causal inference demonstrated the effects of AAM on 13 traits, including forced vital capacity (FVC), high blood pressure, age at first live birth, etc, indicating that earlier AAM causes lower FVC, worse lung function, hypertension and earlier age at first (last) live birth. Enrichment analysis identified 5 enriched tissues, including the hypothalamus middle, hypothalamo hypophyseal system, neurosecretory systems, hypothalamus and retina. Our findings may provide useful insights that elucidate the mechanisms determining AAM and the genetic interplay between AAM and some traits of women.

Longitudinal associations of menstrual characteristics with mental health problems among Chinese girls

Cross-sectional studies indicate that menstrual problems are related to poorer mental health; however, longitudinal studies are limited. This longitudinal study aimed to determine whether baseline menstrual characteristics were risk factors for incident and persistent mental health problems. The study was conducted among Chinese adolescent girls. Menstrual characteristics including menarche, menstrual cycle and menstrual pain were assessed at baseline, whereas mental health problems including PTSD, depression, anxiety, ADHD, insomnia, psychotic-like experiences, non-suicidal self-injury, suicide ideation, suicide plan, and suicide attempt were assessed at baseline (n = 1039) and at the 1-year follow-up (n = 946) by self-administered, structured questionnaires. Multiple logistic regressions were performed to examine whether menstrual characteristics were associated with incident (e.g., PTSD at follow-up but not baseline) and persistent (e.g., PTSD at both time points) mental health problems. The results demonstrated that early menarche was related to persistence of psychotic-like experiences; irregular menstruation was associated with higher rates of incident anxiety and insomnia, and persistent depression, anxiety, ADHD, insomnia, non-suicidal self-injury, suicide ideation, and suicide plan; menstrual pain was associated with elevated rates of incident PTSD and depression, and persistent depression, insomnia, psychotic-like experiences, non-suicidal self-injury, suicidal ideation, suicide plan, and suicide attempt. In conclusion, irregular menstruation and menstrual pain specifically contributed to the development of emotional problems and insomnia, and were associated with maintenance of the most mental health problems in early adolescence. The long-term effects of menstrual problems on mental health need further study.

A reanalysis of strontium isotope ratios as indicators of dispersal in South African hominins

Dispersal patterns in primates have major implications for behavior and sociality but are difficult to reconstruct for fossil species. This study applies novel strontium isotope methodologies that have reliably predicted philopatry and dispersal patterns in chimpanzees and other modern primates to previously published strontium isotope ratios (87Sr/86Sr) of two South African hominins, Australopithecus africanus and Australopithecus robustus. In this study, the difference or 'offset' was calculated between the 87Sr/86Sr of each fossil tooth compared to local bioavailable 87Sr/86Sr as defined by cluster analysis of modern plant isotope ratios. Large teeth (presumably belonging to males) have low offsets from local 87Sr/86Sr proxies, while small teeth (presumably from females) have greater offsets from local 87Sr/86Sr proxies. This supports previous conclusions of male philopatry and female dispersal in both A. africanus and A. robustus. Furthermore, A. robustus shows more extreme differences between presumed males and females compared to A. africanus. This is analogous to differences seen in modern olive baboons compared to chimpanzees and suggests that A. africanus may have had a larger home range than A. robustus. Neither hominin species has 87Sr/86Sr consistent with riparian habitat preferences despite the demonstrated presence of riparian habitats in South Africa at the time.

Prevalence and Associated Factors of Premenstrual Syndrome in Chinese Adolescent Girls

Epidemiological data on premenstrual syndrome (PMS) in Chinese adolescents are limited. This study reported the prevalence and associated factors of PMS in a large sample of Chinese adolescents. A total of 5099 adolescent girls who had menarche participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort study in Shandong, China. A self-administered questionnaire was used to ask about PMS, age at menarche, menstrual cycle interval, menstrual flow length, menstrual regularity, period pain, body weight and height, trait anger, stressful life events, and demographics. The mean age of the sample was 15.19 years (SD = 1.32). The overall prevalence of PMS was 24.6%. The prevalence rates of PMS-anxiety, PMS-water retention, PMS-craving, and PMS-depression were 18.9%, 4.0%, 7.9%, and 11.5%, respectively. The most common symptoms were premenstrual irritability (54%) and fatigue (52.5%). Stepwise logistic regression showed that high levels of life stress (OR 2.26), high levels of trait anger (OR 4.65), alcohol consumption (OR 1.28), menstrual cycle interval ≤ 24 days (OR 1.45), and mild (OR 1.50), moderate (OR 2.57) or severe period pain (OR 4.84) were all significantly associated with increased likelihood of PMS. In conclusion, approximately 1 in 4 Chinese adolescent girls suffered from PMS. Multiple psychosocial and menstrual factors were associated with PMS. Further research is needed to understand developmental changes of PMS and its long-term impacts on psychosocial wellbeing in Chinese adolescent girls.

The association between age at menarche and chronic pain outcomes in women: the Tromsø Study, 2007 to 2016

ABSTRACT

Sex differences in chronic pain are well established with documented predominance in women. This study assessed relationships between age at menarche and chronic pain, site-specific chronic pain, pain characteristics, and chronic widespread pain (CWP). We used data from the Tromsø Study conducted in 2007 to 2008 and 2015 to 2016 (Tromsø 6 and Tromsø 7 waves) including participants aged 30 to 99 years. The associations between age at menarche and chronic pain were examined in Tromsø 6 (n = 6449), Tromsø 7 (n = 5681), and the combination of Tromsø 6 and Tromsø 7 (n = 12,130). Tromsø 7 data were used further to examine the associations between age at menarche and site-specific chronic pain, 4 pain characteristics (pain duration, pain intensity, episode duration, and episode frequency), and CWP. All analyses were adjusted for body mass index, age, and economic status of the household in childhood. Lower age at menarche was associated with an increased risk of chronic pain in all 3 samples (risk ratio for each year delay in menarche 0.98, 95% CI [0.97 to 0.99] across samples). Risk differences were -0.014, CI 95% (-0.02 to -0.005) in Tromsø 6, -0.011, CI 95% (-0.02 to -0.02) in Tromsø 7, and -0.012, CI 95% (-0.02 to -0.01) in the combined sample. Age at menarche was significantly associated with chronic pain in the neck, abdomen, and both arms, and CWP. Of the 4 pain characteristics, pain duration was statistically significant. We conclude that early menarche is an independent risk factor for pain across a broad spectrum of pain outcomes.

Teachers' Perceptions and Experiences of Menstrual Cycle Education and Support in UK Schools

The purpose of this study was 2-fold, to (1) explore current education provision in UK schools including barriers to menstrual cycle education and (2) assess the perceived support teachers received to deliver menstrual cycle education. Seven hundred eighty-nine teachers (91% female) from all stages of school education in England (48%), Scotland (24%), Wales (22%) and Northern Ireland (6%) completed an online survey. The survey captured information on menstrual education in schools, teacher's knowledge and confidence of the menstrual cycle, support provided to teachers, provision of menstrual products in school and perceived impact of the menstrual cycle on young people in school. Four hundred ninety-eight teachers reported lessons were provided on the menstrual cycle (63%), predominantly delivered within personal, social, health and economic or science subjects, with over half of the lessons focusing on the biology (56%) or provision of menstrual products (40%) rather than lived experiences (14%). Teachers perceived the menstrual cycle affected participation in PE (88%), pupil confidence (88%), school attendance (82%) and attitude and behavior (82%). Overall, 80% of teachers felt receiving training would be beneficial to improve menstrual education. The results highlight education is scientifically focused, with less education on management of symptoms or lived experiences. Teachers also perceive the menstrual cycle to influence multiple aspects of school attendance and personal performance. There is a need to address menstrual education provided in schools across the UK to help empower girls to manage their menstrual cycle, preventing a negative impact on health and school performance.

Factors Affecting Menstrual Cycle Developmental Trajectory in Adolescents: A Narrative Review

CONTEXT

The time interval between the age at menarche and regulation of menstrual cycles (menstrual cycle developmental trajectory) is considered an indicator of the function of the reproductive system later in life. This study aimed to summarize the factors affecting this trajectory.

EVIDENCE ACQUISITION

A comprehensive literature search in PubMed, Scopus, Google Scholar, and Web of Science was performed to identify studies investigating factors influencing the regularity of the menstrual cycle in adolescents.

RESULTS

The interval between menarche and the onset of the regular menstrual cycle in adolescent girls may vary from several months to several years. Several factors, including genetic, race/ethnicity, intrauterine situation, social factors, geographical factors, lifestyle, and chronic diseases, are considered the predisposing factors for the trajectory.

CONCLUSIONS

Age at menarche and the onset of regular menstrual cycles are directly and indirectly influenced by several genetic, environmental, and lifestyle factors. Understanding these factors may improve our practice in managing irregular menstrual cycles that commonly happen in the first years after menarche.

Chronic Fatigue Syndrome: A Case Report Highlighting Diagnosing and Treatment Challenges and the Possibility of Jarisch-Herxheimer Reactions If High Infectious Loads Are Present

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex multi-system disease with no cure and no FDA-approved treatment. Approximately 25% of patients are house or bedbound, and some are so severe in function that they require tube-feeding and are unable to tolerate light, sound, and human touch. The overall goal of this case report was to (1) describe how past events (e.g., chronic sinusitis, amenorrhea, tick bites, congenital neutropenia, psychogenic polydipsia, food intolerances, and hypothyroidism) may have contributed to the development of severe ME/CFS in a single patient, and (2) the extensive medical interventions that the patient has pursued in an attempt to recover, which enabled her to return to graduate school after becoming bedridden with ME/CFS 4.5 years prior. This paper aims to increase awareness of the harsh reality of ME/CFS and the potential complications following initiation of any level of intervention, some of which may be necessary for long-term healing. Treatments may induce severe paradoxical reactions (Jarisch–Herxheimer reaction) if high infectious loads are present. It is our hope that sharing this case will improve research and treatment options for ME/CFS.

Menstrual distress in females of reproductive age: a literature review

Menstrual-related issues have significant public-health ramifications. Women who are having menstruation troubles should get their mental health checked by healthcare specialists. In young women, a menstrual-related condition has serious health implications. Young females who have menstrual issues miss job and school, and their behavioural and mental development suffers as a result. Depression and anxiety have an impact on women's menstrual periods in adults. Symptoms like as cramps, tiredness, backache, swelling abdomen, and painful breasts have also been described in women with menstrual misery. Menstrual distress has been shown to impair women's daily activities, as well as their reproductive and psychological health, according to research. Menstrual periods are frequently accompanied by a variety of unpleasant symptoms, such as premenstrual syndrome, which includes symptoms such as mild cramping and exhaustion. The severity of these symptoms, on the other hand, differs from woman to woman, depending on their health, food, way of life, and other factors. Women with menstrual-related issues have also reported smoking, alcohol intake, and an increase in hunger. Furthermore, young women experience emotional disturbances such as melancholy, restlessness, and despair. It is a sign of an atypical menstrual cycle if there is no cycle or if the bleeding is atypical or light. As a result, it is critical to maintain contact with a gynaecologist in order to detect any significant changes in a regular menstrual cycle.

Socio-Ecological Challenges as Modulators of Women's Reproductive Trajectories

Amenorrhea, anovulatory cycles, miscarriages, and other reproductive outcomes are often seen as pathological. Life history theory, in contrast, treats those outcomes as adaptations that helped women optimize the timing of reproductive ventures across our evolutionary history. Women's bodies adjust their reproductive strategies in response to socio-ecological conditions, a process mediated by the hypothalamic-pituitary-adrenal axis (HPAA). Here, we review the links between socio-ecological conditions, HPAA activity, and the pace of women's reproductive transitions such as puberty, age at first birth, interbirth interval, and perimenopause. We also discuss the HPAA's role as a modulator of reproductive function: It not only suppresses it but may also prime women's bodies for future reproductive ventures. We conclude by reviewing challenges and opportunities within our subfield, including the need for transdisciplinary teams to develop longitudinal studies to improve our understanding of women's reproductive trajectories and outcomes from the moment they are conceived.

Perception of Menstrual Normality and Abnormality in Spanish Female Nursing Students

Menstrual problems are usually taboo; and often, some, such as dysmenorrhea, are presumed normal. This study seeks to compare the menstrual characteristics and symptoms of female university students reporting self-perceived normality concerning their cycles and menstruation with those who perceive their menstruation as being abnormal. A cross-sectional descriptive study was conducted among 270 nursing students using a self-report questionnaire that included sociodemographic and gynecological issues, together with Visual Analog Scale, the Andersch and Milsom Scale, and the Spanish version of the EuroQol-5 Dimension (EuroQol-5D) to measure self-perceived health status. A bivariate analysis was performed using the chi-square test, linear trend chi-square, and Student's t-test, and a multivariate analysis of stepwise binary logistic regression was performed to predict the perception of cycle abnormality. In total, 77.4% of participants displayed normality; however, in self-reporting of menstrual characteristics, 67.4% identified alterations. Young women suffering from menstrual dizziness were 1.997 (CI95% = 1.010-3.950; p = 0.047) more likely to manifest abnormal menstruation, 4.518 (CI95% = 1.239-16.477; p = 0.022) more likely if they suffered from Grade 3 menstrual pain, and 2.851 (CI95% = 1.399-5.809; p = 0.004) more likely if they perceived that menstruation interfered with their daily lives. Many menstrual changes and symptoms are still considered normal, making it difficult to identify and address these issues. Therefore, it is necessary to develop health policies and strategies to improve menstrual health literacy for increased knowledge and earlier diagnosis.

Developing and trialling a school-based ovulatory-menstrual health literacy programme for adolescent girls: a quasi-experimental mixed-method protocol

INTRODUCTION

A review of international and Australian school-based resources suggests that teaching of the ovulatory-menstrual (OM) cycle is predominantly couched in biology. A whole-person framework that integrates spiritual, intellectual, social and emotional dimensions with the physical changes of the OM cycle is needed to facilitate adolescent OM health literacy. This paper describes the protocol for a study that aims to develop and trial an intervention for adolescent girls aged 13-16 years that enhances positive attitudes towards OM health coupled with developing skills to monitor and self-report OM health. These skills aim to foster acceptance of the OM cycle as a 'vital sign' and facilitate confident communication of common OM disturbances (namely, dysmenorrhoea, abnormal uterine bleeding and premenstrual syndrome), which are known to impact school and social activities.

METHODS AND ANALYSIS

Phase I will comprise a Delphi panel of women's health specialists, public health professionals and curriculum consultants and focus groups with adolescent girls, teachers and school healthcare professionals. This will inform the development of an intervention to facilitate OM health literacy. The Delphi panel will also inform the development of a valid and reliable questionnaire to evaluate OM health literacy. Phase II will trial the intervention with a convenience sample of at least 175 adolescent girls from one single-sex school. The mixed-method evaluation of the intervention will include a pre-intervention and post-intervention questionnaire. One-on-one interviews with teachers and school healthcare professionals will expand the understanding of the barriers, enablers and suitability of implementation of the intervention in a school-based setting. Finally, focus groups with purposively selected trial participants will further refine the intervention.

ETHICS AND DISSEMINATION

The study findings will be disseminated through local community seminars, conferences, peer-review articles and media channels where appropriate. The Curtin University of Human Research Ethics Committee has approved this study (approval HRE2018-0101). This project is registered with the 'Australian and New Zealand Clinical Trials Registry'.

TRIAL REGISTRATION NUMBER

ACTRN12619000031167; Pre-results.

Age at Menarche and Menstrual Abnormalities in Adolescence: Does it Matter? The Evidence from a Large Survey among Italian Secondary Schoolgirls

OBJECTIVE

To explore the independent role of age at menarche on menstrual abnormalities among adolescents.

METHODS

The present study was a multicenter cross-sectional study on a large sample (n = 3782) of Italian girls aged 13-21 y attending secondary school who already had menarche. Girls were asked to fill in a questionnaire on menarcheal age and menstrual features during the latest three menses. The gynecological age was computed as the difference between age at the survey and the age at menarche. Main outcome measures were: prevalence of oligomenorrhea, polymenorrhea, menstrual cycle irregularity, abnormal bleeding length and dysmenorrhea. Irregularity in the recent past and since menarche was also studied. Multiple logistic models were used to identify any independent association between each abnormal feature and age at menarche or gynecological age. Adjusted ORs and 95%CI were performed.

RESULTS

After adjusting for covariates, menarcheal age was not independently associated with polymenorrhea (OR = 0.81; 95%CI 0.63-1.04), oligomenorrhea (OR = 1.16; 95%CI 0.94-1.43), menstrual cycle irregularity (OR = 0.99; 95%CI 0.86-1.14), abnormal bleeding length (OR = 0.96; 95%CI 0.87-1.06) and dysmenorrhea (OR = 1.03; 95%CI 0.85-1.24). The multivariate analysis suggests that the higher prevalence of oligomenorrhea and menstrual cycle irregularity among the girls who were older at menarche might be purely explained by their younger gynecological age.

CONCLUSIONS

No evidence of any independent influence of age at menarche on menstrual abnormalities among young girls was shown by the investigation. The findings suggest that, after menarche, adolescent girls' menstrual health should be checked to monitor the endocrine system maturation and to early intercept latent disorders becoming symptomatic.

Age at Menarche and Risk of Respiratory Diseases

Several studies have suggested a relationship between reproductive history and respiratory health. The present study explores the association between the age at menarche and the risk of respiratory diseases during early adulthood. The anthropometrical and questionnaire research was conducted among 1323 female university graduates. In a subsample of 152 non-allergic women spirometry tests were additionally performed. We found that the prevalence of allergic diseases, on average, was slightly higher among females having early menarche than in those with a later onset of menstruation; the difference failed to reach statistical significance. However, the risk of allergic rhinitis was significantly related with early menarche compared with average-time, taken as a reference, or late menarche (OR = 1.61 vs. OR = 1 (Ref.) vs. OR = 1.23, p = 0.020). The difference remained significant after adjusting for adiposity (p = 0.050) and socio-economic status (p = 0.001). There was no significant relationship between the age at menarche and the incidence of respiratory infections. We noticed a tendency for increased spirometry variables with increasing age at menarche. In conclusion, early menarche is a risk factor for allergic rhinitis in early adulthood.

Association of Height Growth in Puberty with Lung Function. A Longitudinal Study

Rationale: Puberty may influence lung function, but the precise role of pubertal height growth in lung development is unclear.Objectives: To examine associations of timing of puberty and peak velocity of pubertal height growth with lung function in adolescence and early adulthood.Methods: Longitudinal analyses of repeat height measurements from age 5 to 20 years for a British birth cohort with 4,772 males and 4,849 females were conducted to characterize height growth trajectories and to derive pubertal age and peak height velocity using the validated SITAR (SuperImposition by Translation and Rotation) model. Association of these estimates with prebronchodilator and post-bronchodilator spirometry measures: FEV1; FVC; FEV1/FVC; FEF25-75% at age 15 and 24 years were investigated using multivariable regression models adjusted for lung function at age 8 years, height and age at time of outcome measurements, and potential confounders.Measurements and Main Results: Later pubertal age and greater peak velocity were associated with higher FEV1 and FVC at 24 years in both sexes. A 1-year increase in pubertal age was associated with a 263-ml higher FVC (95% confidence interval [CI], 167-360 ml) for males (n = 567) and 100-ml (95% CI, 50-150 ml) higher FVC for females (n = 990). A 1-cm/yr increase in peak velocity was associated with 145-ml (95% CI, 56-234 ml) and 50-ml (95% CI, 2-99 ml) increases in FVC for males and females, respectively. No associations were found with FEV1/FVC.Conclusions: Later onset and greater peak velocity of height growth in puberty are associated with increased FEV1 and FVC in young adults but there was no evidence of dysanapsis of pubertal lung growth.

Menstrual Patterns in the First Gynecological Year: A Systematic Review

STUDY OBJECTIVE

Understanding what constitutes a normal menstrual cycle during the first gynecological year (GY1) is a common concern of adolescents and clinicians. However, limited high-quality evidence exists. We aimed to summarize published literature regarding menstrual and ovulatory patterns in GY1. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Electronic databases (MEDLINE, Pre-MEDLINE, Embase, Web of Science, CINAHL, Cochrane Library) were systematically searched from database inception to 2018. Eligible studies described menstrual cycles, symptoms, or validated ovulatory data in healthy adolescents in GY1. Two authors independently screened studies, extracted data, and assessed methodological quality.

RESULTS

Twenty-two studies involving more than 2000 adolescents were included. Thirteen recorded menstrual cycle and/or symptom data and 14 measured ovulation. Mean cycle length ranged from 32 to 61 days and decreased throughout GY1. Mean menses length was 4.9 to 5.4 days. Frequent menstrual bleeding was reported in up to 23% of participants, infrequent menstrual bleeding in up to one-third, and "irregular menstrual bleeding" in up to 43%. Dysmenorrhea was reported by 30%-89% of participants. Prevalence of ovulatory cycles identified using luteal phase serum or salivary progesterone or urinary pregnanediol was 0 to 45% and increased throughout GY1. However, all used definitions that would be considered subovulatory in clinical practice.

CONCLUSION

Menstrual and ovulatory patterns in GY1 are diverse and differ from those of adults. A transitional phase of menstrual and ovulatory immaturity is common. However, ovulation, irregular cycles, and dysmenorrhea are not uncommon. As such, safe sexual practice should be advocated and prompt medical management should be accessible.

Menarche and menstrual problems are associated with non-suicidal self-injury in adolescent girls

Menstrual problems and non-suicidal self-injury (NSSI) are common in adolescent girls. This study examined whether onset of menstruation and menstrual problems were related to NSSI in Chinese female adolescents. A total of 5696 adolescent girls participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort (SABHC) study in Shandong, China. A structured questionnaire was used to ask about participants' lifetime and last-year NSSI, age at menarche, menstrual cycle interval, menstrual flow length, menstrual irregularity, period pain, body weight and height, and demographics. Impulsivity was assessed by the Eysenck I7 impulsiveness scale. Internalizing and externalizing problems were measured by the Youth Self-Report of Child Behavior Checklist. The mean age of the sample was 15.0 years (SD = 1.4). The prevalence of lifetime and last year NSSI were 28.1% and 21.4% in Chinese adolescent girls. After adjusting for adolescent and family covariates (age, body mass index, impulsivity, internalizing and externalizing problems, paternal education, and family economic status), onset of menstruation was significantly associated with increased risk of lifetime NSSI (OR = 1.62, 95%CI = 1.20-2.20) and last year NSSI (OR = 1.92, 95%CI = 1.37-2.67). Among adolescent girls who had menarche, often irregular menstruation and period pain were significantly and independently associated with lifetime NSSI (OR = 1.36, 95%CI = 1.03-1.79; OR = 1.29, 95%CI = 1.05-1.58) and last year NSSI (OR = 1.46, 95%CI = 1.07-1.98; OR = 1.29, 95%CI = 1.03-1.61). Our findings suggest that onset of menarche, irregular periods, and period pain appear to be associated with increased risk of NSSI. These findings highlight the importance of menstruation hygiene education and treatment of menstrual problems to reduce the risk of NSSI among adolescent girls.

The Unexplored Crossroads of the Female Athlete Triad and Iron Deficiency: A Narrative Review

Despite the severity and prevalence of iron deficiency in exercising women, few published reports have explored how iron deficiency interacts with another prevalent and severe condition in exercising women: the 'female athlete triad.' This review aims to describe how iron deficiency may interact with each component of the female athlete triad, that is, energy status, reproductive function, and bone health. The effects of iron deficiency on energy status are discussed in regards to thyroid function, metabolic fuel availability, eating behaviors, and energy expenditure. The interactions between iron deficiency and reproductive function are explored by discussing the potentially impaired fertility and hyperprolactinemia due to iron deficiency and the alterations in iron metabolism due to menstrual blood loss and estrogen exposure. The interaction of iron deficiency with bone health may occur via dysregulation of the growth hormone/insulin-like growth factor-1 axis, hypoxia, and hypothyroidism. Based on these discussions, several future directions for research are presented.

Age at puberty and risk of asthma: A Mendelian randomisation study

BACKGROUND

Observational studies on pubertal timing and asthma, mainly performed in females, have provided conflicting results about a possible association of early puberty with higher risk of adult asthma, possibly due to residual confounding. To overcome issues of confounding, we used Mendelian randomisation (MR), i.e., genetic variants were used as instrumental variables to estimate causal effects of early puberty on post-pubertal asthma in both females and males.

METHODS AND FINDINGS

MR analyses were performed in UK Biobank on 243,316 women using 254 genetic variants for age at menarche, and on 192,067 men using 46 variants for age at voice breaking. Age at menarche, recorded in years, was categorised as early (<12), normal (12-14), or late (>14); age at voice breaking was recorded and analysed as early (younger than average), normal (about average age), or late (older than average). In females, we found evidence for a causal effect of pubertal timing on asthma, with an 8% increase in asthma risk for early menarche (odds ratio [OR] 1.08; 95% CI 1.04 to 1.12; p = 8.7 × 10(-5)) and an 8% decrease for late menarche (OR 0.92; 95% CI 0.89 to 0.97; p = 3.4 × 10(-4)), suggesting a continuous protective effect of increasing age at puberty. In males, we found very similar estimates of causal effects, although with wider confidence intervals (early voice breaking: OR 1.07; 95% CI 1.00 to 1.16; p = 0.06; late voice breaking: OR 0.93; 95% CI 0.87 to 0.99; p = 0.03). We detected only modest pleiotropy, and our findings showed robustness when different methods to account for pleiotropy were applied. BMI may either introduce pleiotropy or lie on the causal pathway; secondary analyses excluding variants associated with BMI yielded similar results to those of the main analyses. Our study relies on self-reported exposures and outcomes, which may have particularly affected the power of the analyses on age at voice breaking.

CONCLUSIONS

This large MR study provides evidence for a causal detrimental effect of early puberty on asthma, and does not support previous observational findings of a U-shaped relationship between pubertal timing and asthma. Common biological or psychological mechanisms associated with early puberty might explain the similarity of our results in females and males, but further research is needed to investigate this. Taken together with evidence for other detrimental effects of early puberty on health, our study emphasises the need to further investigate and address the causes of the secular shift towards earlier puberty observed worldwide.

Menstrual Characteristics and Related Problems in 9- to 18-Year-Old Turkish School Girls

STUDY OBJECTIVE

To determine the cross-sectional characteristics of menstruating girls, dysmenorrhea, and the frequencies of related problems.

DESIGN

Descriptive, cross-sectional study.

SETTING

Randomly selected primary, junior, and high schools in the city center of Kayseri.

PARTICIPANTS

Two thousand female adolescents of ages between 9 and 18 years.

MAIN OUTCOME MEASURES

We used a questionnaire addressing the epidemiological characteristics of menstruation, such as age at menarche, duration of menstrual intervals, average days of bleeding, and any menstrual problems and their frequencies.

RESULTS

This study consists of a sufficient number of participants from all age groups. Of the participant (n = 2000) girls, 63.7% (n = 1274) had started menstruating. The mean age at menarche was 12.74 (±1.03) years. With a prevalence of 84.8% (n = 1080), dysmenorrhea was the most prevalent menstrual problem and the average pain score was 5.87 (±2.45). Of the menstruating girls, 34% (n = 439) used painkillers, the most commonly used was acetaminophen; during their period the prevalence of nonmedical methods to relieve pain was 35.2%; the rate of seeking medical help for dysmenorrhea was 9.3% (n = 119). In menstruating participants, 90.8% discussed their menstrual problems with their mothers. The rate of school absenteeism in menstruating girls was 15.9% in general and 18% in those with dysmenorrhea.

CONCLUSION

Problems related to menstruation are common in adolescents and these problems affect their social life. In adolescent girls, the most common menstrual problem is dysmenorrhea and it affects school performance and attendance. Girls with menstrual problems showed a low rate of seeking medical help.

Candidate SNP markers of reproductive potential are predicted by a significant change in the affinity of TATA-binding protein for human gene promoters

BACKGROUND

The progress of medicine, science, technology, education, and culture improves, year by year, quality of life and life expectancy of the populace. The modern human has a chance to further improve the quality and duration of his/her life and the lives of his/her loved ones by bringing their lifestyle in line with their sequenced individual genomes. With this in mind, one of genome-based developments at the junction of personalized medicine and bioinformatics will be considered in this work, where we used two Web services: (i) SNP_TATA_Comparator to search for alleles with a single nucleotide polymorphism (SNP) that alters the affinity of TATA-binding protein (TBP) for the TATA boxes of human gene promoters and (ii) PubMed to look for retrospective clinical reviews on changes in physiological indicators of reproductive potential in carriers of these alleles.

RESULTS

A total of 126 SNP markers of female reproductive potential, capable of altering the affinity of TBP for gene promoters, were found using the two above-mentioned Web services. For example, 10 candidate SNP markers of thrombosis (e.g., rs563763767) can cause overproduction of coagulation inducers. In pregnant women, Hughes syndrome provokes thrombosis with a fatal outcome although this syndrome can be diagnosed and eliminated even at the earliest stages of its development. Thus, in women carrying any of the above SNPs, preventive treatment of this syndrome before a planned pregnancy can reduce the risk of death. Similarly, seven SNP markers predicted here (e.g., rs774688955) can elevate the risk of myocardial infarction. In line with Bowles' lifespan theory, women carrying any of these SNPs may modify their lifestyle to improve their longevity if they can take under advisement that risks of myocardial infarction increase with age of the mother, total number of pregnancies, in multiple pregnancies, pregnancies under the age of 20, hypertension, preeclampsia, menstrual cycle irregularity, and in women smokers.

CONCLUSIONS

According to Bowles' lifespan theory-which links reproductive potential, quality of life, and life expectancy-the above information was compiled for those who would like to reduce risks of diseases corresponding to alleles in own sequenced genomes. Candidate SNP markers can focus the clinical analysis of unannotated SNPs, after which they may become useful for people who would like to bring their lifestyle in line with their sequenced individual genomes.

Early Menarche and Menstrual Problems Are Associated with Sleep Disturbance in a Large Sample of Chinese Adolescent Girls

Study Objectives

Little is known about the association between menstruation and sleep disturbance in adolescent girls. This study examined sleep duration, insomnia symptoms, and sleep quality in relation to age at menarche and menstrual problems in a large sample of Chinese adolescent girls.

Methods

This report represents the baseline data of an ongoing longitudinal study of the Shandong Adolescent Behavior & Health Cohort in Shandong, China. A total of 5800 girls aged 12-18 years (mean age = 15.0, standard deviation = 1.4) participated in the baseline survey. A structured questionnaire was used to assess participants' age at menarche, menstrual cycle interval, menstrual flow length, period irregularity, period pain, body weight and height, and demographics. Internalizing and externalizing problems were measured by the Youth-Self Report of Child Behavioral Checklist. Sleep duration, insomnia symptoms, and sleep quality were assessed by the items adapted from the Pittsburgh Sleep Quality Index.

Results

After adjusting for age, school, body mass index, internalizing and externalizing problems, and family covariates, irregular periods (odds ratio [OR] = 1.46, 95% confidence interval [CI] = 1.06-2.02), period pain (OR = 1.99, 95% CI = 1.44-2.76), and menstrual flow length ≥7 days (OR = 1.21, 95% CI = 1.00-1.48) were significantly associated with insomnia symptoms. Irregular periods (OR = 1.72, 95% CI = 1.30-2.27) and period pain (OR = 1.78, 95% CI = 1.34-2.37) were significantly associated with poor sleep quality. Age at menarche ≤11 years (OR = 1.62, 95% CI = 1.05-2.50) was significantly associated with insomnia symptoms in 12- to 14-year-old girls.

Conclusions

Our results suggest that irregular periods and period pain appear to be associated with sleep disturbance and that early menarche may have short-term impact on sleep in adolescent girls.

Age at menarche and lung function: a Mendelian randomization study

A trend towards earlier menarche in women has been associated with childhood factors (e.g. obesity) and hypothesised environmental exposures (e.g. endocrine disruptors present in household products). Observational evidence has shown detrimental effects of early menarche on various health outcomes including adult lung function, but these might represent spurious associations due to confounding. To address this we used Mendelian randomization where genetic variants are used as proxies for age at menarche, since genetic associations are not affected by classical confounding. We estimated the effects of age at menarche on forced vital capacity (FVC), a proxy for restrictive lung impairment, and ratio of forced expiratory volume in one second to FVC (FEV1/FVC), a measure of airway obstruction, in both adulthood and adolescence. We derived SNP-age at menarche association estimates for 122 variants from a published genome-wide meta-analysis (N = 182,416), with SNP-lung function estimates obtained by meta-analysing three studies of adult women (N = 46,944) and two of adolescent girls (N = 3025). We investigated the impact of departures from the assumption of no pleiotropy through sensitivity analyses. In adult women, in line with previous evidence, we found an effect on restrictive lung impairment with a 24.8 mL increase in FVC per year increase in age at menarche (95% CI 1.8-47.9; p = 0.035); evidence was stronger after excluding potential pleiotropic variants (43.6 mL; 17.2-69.9; p = 0.001). In adolescent girls we found an opposite effect (-56.5 mL; -108.3 to -4.7; p = 0.033), suggesting that the detrimental effect in adulthood may be preceded by a short-term post-pubertal benefit. Our secondary analyses showing results in the same direction in men and boys, in whom age at menarche SNPs have also shown association with sexual development, suggest a role for pubertal timing in general rather than menarche specifically. We found no effect on airway obstruction (FEV1/FVC).

Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline

COSPONSORING ASSOCIATIONS

The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.

OBJECTIVE

To formulate clinical practice guidelines for the diagnosis and treatment of functional hypothalamic amenorrhea (FHA).

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of eight experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and cosponsoring organizations reviewed and commented on preliminary drafts of this guideline.

CONCLUSIONS

FHA is a form of chronic anovulation, not due to identifiable organic causes, but often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.

Menstrual Characteristics of Pubertal Girls: A Questionnaire-Based Study in Turkey

OBJECTIVE

Clinicians should show an awareness on the menstrual characteristics of adolescent girls which may differ from adults in some aspects. To define menstrual cycle features among high school girls residing in a city center in southeastern Turkey.

METHODS

A cross-sectional survey was conducted on 1256 girls attending a high school located in the city center of Elazığ, Turkey. Data from 879 girls (median age, 16.2 years; range, 13.6-19.2 years) who agreed to participate in the study and had started to menstruate were evaluated.

RESULTS

Mean age at menarche was 12.7±1.3 years (range, 8.2-17.3 years). The mean cycle duration was 28.7±4.4 days, and the mean menstrual flow lasted 5.9±1.3 days. Severe, moderate, and mild dysmenorrhea was reported in 29%, 43%, and 28% of the girls, respectively, and 52% used analgesics for dysmenorrhea. A total of 34% of the girls defined their menstrual cycle as irregular, and 32% reported school absenteeism due to menstruation-associated complaints (pain and/or heavy bleeding). Menstrual bleeding affected attendance to classes and other school activities, daily work, social, family, and friend relationships, as well as sports/exercise activities in 43%, 49%, 58%, 48%, 44%, and 60% of the participants, respectively. In total, 30% of the responders had a problem with menstruation, and 12% and 17% of these stated that they consulted a primary care physician or specialist, respectively.

CONCLUSION

Dysmenorrhea was found to be common in adolescent Turkish girls and to affect daily life in approximately half of the girls.

Impact of Advertising on Tampon Wear-time Practices

OBJECTIVES

(1) To determine whether advertising nighttime tampon use for up to eight hours was understood to be consistent with label recommendations and (2) to determine whether television and print advertising with this message affected tampon wear times in adults and teens.

METHODS

(1) A comprehension study (online advertising and follow-up questionnaire) among women aged 14-49 years (300 per group) who viewed either the test or a control advertising message; (2) Diary-based surveys of tampon wear times performed prior to (n = 292 adults, 18-49 years, 74 teens, 12-17 years) and after (n = 287 adults, 104 teens) the launch of national advertising.

RESULTS

Significantly more test message viewers than controls stated tampons should be worn less than or equal to eight hours (93.6% vs. 88.6%, respectively, P = 0.049). A directionally higher percentage of test message viewers said they would use a pad if sleeping longer than eight hours (52% vs. 42% of controls). Among the women who used tampons longer than eight hours when sleeping, 52% reported they would wake up and change compared with 45% of controls. No significant difference between baseline and follow-up diary surveys was found among teens or adults in various measures of tampon wear time (mean wear times; usage intervals from less than two hours to more than 10 hours; percentage of tampons used for more than or equal to eight hours; frequency of wearing at least one tampon more than eight hours).

CONCLUSIONS

Advertising nighttime tampon wear for up to eight hours effectively communicated label recommendations but did not alter tampon wear times. The informational intervention had limited impact on established habits.

THE ASSOCIATION BETWEEN MENSTRUAL CYCLE CHARACTERISTICS AND PERCEIVED BODY IMAGE: A CROSS-SECTIONAL SURVEY OF POLISH FEMALE ADOLESCENTS

The increasing prevalence of negative body perceptions among adolescent girls and the tendency towards wishing to be thinner have become a cultural norm in Western culture. Adolescent girls are particularly vulnerable to developing a negative body image due to physical and sexual changes occurring during puberty. This study aimed to evaluate the association between different measures of body image perceptions and different phases of the menstrual cycle after controlling for weight status and other potential confounders in Polish adolescent girls aged 12-18 years. Three-hundred and thirty participants of a cross-sectional survey conducted in 2009, normally cycling and with no eating disorders, completed a background questionnaire and the Stunkard Figure Rating Scale, and their anthropometric measurements were collected. The dependent outcome variables were measures of body image (actual body image, ideal body image and ideal-self discrepancy) and dichotomous body image perception (satisfied versus dissatisfied) adjusted for other predictor factors: socio-demographic variables, menstrual history and cycle phases, and weight status. One-way ANOVA indicated that weight status, age at menarche and menstrual cycle phase were associated with actual body image and rate of ideal-self discrepancy. Ideal body image was associated with weight status and menstrual cycle phase. General logistic regression models were constructed to evaluate associations of body dissatisfaction and all potential predictor variables. The final selected model of the multiple logistic regression analysis using the backward elimination procedure revealed that adjusted for other factors, negative body image was significantly associated with different phases of the menstrual cycle (p trend=0.033) and increasing body weight status (p trend=0.0007). The likelihood of body dissatisfaction was greatest during the premenstrual phase of the menstrual cycle (OR=2.38; 95% CI 1.06, 5.32) and among girls in obesity class I (OR=8.04; 95% CI 2.37, 27.26). The study confirmed the association between body image dissatisfaction in adolescent girls and different phases of the menstrual cycle after controlling for weight status. The issue of negative body self-image is not only of cognitive, but also of practical value as understanding better the factors contributing to the formation of a negative body image may be instrumental in developing preventive health programmes targeted at young people.

Menstrual cycle alterations during adolescence: early expression of metabolic syndrome and polycystic ovary syndrome

STUDY OBJECTIVE

To assess the importance of the menstrual pattern as a marker for clinical and laboratory alterations related to metabolic syndrome (MS) and polycystic ovary syndrome (PCOS) among Brazilian adolescents.

DESIGN

A cross-sectional study.

SETTING

Endocrine Gynecology Outpatient Clinic of the Adolescent Health Studies Center (NESA) at the Pedro Ernesto University Hospital.

PARTICIPANTS

59 girls (12-19 years old) were classified by their menstrual cycles as regular (n = 23) and irregular (n = 36).

INTERVENTION

None.

MAIN OUTCOME MEASURES

Biochemical collections were made of peripheral blood after fasting for 12 hours, and the oral glucose tolerance test with 75 g of anhydrous glucose.

RESULTS

PCOS, MS, and the criteria for MS were significantly more frequent (P < .05) in the subgroup with irregular menstruation. Adolescents with irregular cycles presented a significant increase in waist circumference, glycemia 2 hours after oral glucose overload (2 h), fasting and 2-h insulin, HOMA-IR, and triglycerides. In contrast, the glucose/insulin ratio, quantitative insulin-sensitivity check index, and HDL serum levels were significantly lower among patients with irregular menstruation, compared to those with regular cycles. In the logistic regression, we noted that insulin 2 h ≥ 75 μIU/mL (r = 1.90; P = .018), waist circumference > 95 cm (r = 2.21; P = .006) and diagnosis of PCOS (r = 1.93; P = .023) were significantly correlated to irregular cycles.

CONCLUSIONS

We concluded that close observation of menstrual cycle patterns is an important tool for identifying adolescents at higher risk of developing PCOS and MS.

Use of levonorgestrel intrauterine system for medical indications in adolescents

The levonorgestrel intrauterine system (LNG-IUS) is an underused contraceptive method in adolescent populations. In addition to being a highly effective, reversible, long-acting contraception, the LNG-IUS has many noncontraceptive health benefits including reduced menstrual bleeding, decreased dysmenorrhea and pelvic pain related to endometriosis, and menstruation suppression in teens with physical or developmental disabilities. The LNG-IUS can also provide endometrial protection in teens with chronic anovulation, and may be used to treat endometrial hyperplasia and cancer. This review examines the evidence supporting the use of the LNG-IUS in adolescents for these noncontraceptive benefits.

Menarche in pediatric patients with Crohn's disease

BACKGROUND AND AIMS

The timing of menarche in Crohn's disease (CD) is poorly described. Our objectives were to study age at menarche onset in CD, and factors associated with this.

METHODS

We compared the age at menarche of 34 CD patients with that for 545 controls, using data in the National Health and Nutrition Examination Survey (NHANES).

RESULTS

Mean chronological age (CA) of CD patients (15.6 years) did not differ from that of the NHANES cohort (15.7 years; P = 0.91). The median CA at menarche (13.9 years) in CD was older than in the NHANES sample (12.0 years) (P < 0.00005). In CD patients, the cumulative incidence of menarche was 10 % at CA 12 years, 51 % at CA 14 years, and 100 % at CA 16 years. Sixty-eight percent reached menarche by bone age (BA) 13.5 years and 100 % by BA greater than 14.0 years. Menarche occurred earliest in South Asians, followed by East Asians, and then Caucasians (P = 0.02).

CONCLUSIONS

CA at menarche is delayed in CD compared with the NHANES cohort. BA at menarche in CD is similar to BA at menarche reported for healthy children. CA at menarche in CD differs by race. If menarche has not occurred by BA greater than 14.0 years, endocrinology referral should be considered.

A rational approach to the diagnosis of polycystic ovarian syndrome during adolescence

Polycystic ovarian syndrome (PCOS) is a lifelong disorder characterized by hyperandrogenism and ovulatory dysfunction, with a wide spectrum of clinical symptoms and signs. Three different sets of diagnostic criteria have been established in order to define this disease in adult women, but there is controversy regarding the use of these criteria in adolescence. During puberty, the adult criteria for ovulatory dysfunction does not seem applicable, because an irregular menstrual pattern and a decreased ovulatory rate is a physiologic event during this period of life. Also, a higher prevalence of polycystic ovarian morphology (PCOM) may be observed during this period, so PCOM is not a useful criterion to define PCOS in young women. These findings suggest that a key factor to diagnose to PCOS during adolescence is hyperandrogenism. In addition, since PCOM is not clearly associated with hyperandrogenism during this period of life, the term "polycystic ovarian syndrome" during adolescence creates confusion and may be misleading.

Contraception, and pregnancy in adolescents with type 1 diabetes: a review

Adolescence is a critical period for girls with type 1 diabetes mellitus (T1D). Reproductive issues, such as menstrual abnormalities, risk of an unplanned pregnancy, and contraception, should be addressed during this phase of life. This paper reviews several reproductive issues that are important in the care of adolescents, including pubertal development, menstrual abnormalities, ovulatory function, reproductive problems, the effects of hyperglycemia, contraception, and treatment of an unplanned pregnancy. A review of the literature was conducted. A MEDLINE search January 1966 to March 2011 was performed using the following MESH terms: puberty, menarche, ovary, polycystic ovary syndrome, menstruation, contraception, contraception-barrier, contraceptives-oral-hormonal, sex education, family planning services, and pregnancy in adolescence. This literature search was cross-referenced with an additional search on diabetes mellitus-type 1, diabetes complications, and pregnancy in diabetes. All published studies were searched regardless of the language of origin. Bibliographies were reviewed to extract additional relevant sources.

High prevalence of hirsutism and menstrual disorders in obese adolescent girls and adolescent girls with type 1 diabetes mellitus despite different hormonal profiles

OBJECTIVES

To compare the pubertal development, the hormonal profiles and the prevalence of hirsutism and menstrual disorders in obese adolescent girls and adolescent girls with type 1 diabetes mellitus (T1DM).

METHODS

Data were collected from 96 obese adolescent girls and 78 adolescent girls with T1DM at Tanner stage IV or V, whose ages ranged between 11.9 and 17.9 years.

RESULTS

High prevalence of hirsutism and menstrual disorder was found in the obese adolescent girls (36.5 and 42% respectively) and the adolescent girls with T1DM (21 and 44% respectively). The obese girls were significantly younger at pubarche, thelarche and menarche than the girls with T1DM. Hirsutism in the obese girls and those with T1DM was associated with hyperandrogenaemia and a raised free androgen index (FAI). When the cause of the raised FAI was investigated in both the groups of girls with hirsutism, the raised FAI in the obese girls was due to low serum sex hormone-binding globulin (SHBG) levels. In contrast, the raised FAI of the girls with T1DM and hirsutism was due to hyperandrogenaemia. Menstrual disorders in the T1DM girls were associated also with hyperandrogenaemia unlike obese girls.

CONCLUSIONS

Hirsutism and menstrual disorders are common in obese adolescent girls and adolescent girls with T1DM. Although hyperandrogenaemia is present in both groups of girls, the androgenic profiles of the two groups differ. The hyperandrogenaemia in the obese girls is primarily due to their decreased serum SHBG levels, whereas the hyperandrogenaemia in the girls with T1DM is due to their increased androgen production.

Skeletal health of children and adolescents with inflammatory bowel disease

Current evidence points to suboptimal bone health in children and adolescents with inflammatory bowel disease (IBD) when compared with their healthy peers. This compromise is evident from diagnosis. The clinical consequences and long-term outcome of this finding are still unknown. The mechanism of suboptimal bone health in children and adolescents with IBD lays mainly in reduced bone formation, but also reduced bone resorption, processes necessary for bone growth. Factors contributing to this derangement are inflammation, delayed growth and puberty, lean mass deficits, and use of glucocorticoids. We recognize that evidence is sparse on the topic of bone health in children and adolescents with IBD. In this clinical guideline, based on current evidence, we provide recommendations on screening and monitoring bone health in children and adolescents with IBD, including modalities to achieve this and their limitations; monitoring of parameters of growth, pubertal development, and reasons for concern; evaluation of vitamin D status and vitamin D and calcium intake; exercise; and nutritional support. We also report on the current evidence of the effect of biologics on bone health in children and adolescents with IBD, as well as the role of bone active medications such as bisphosphonates. Finally, we summarize the existing numerous gaps in knowledge and potential subjects for future research endeavors.

Early life circumstances and their impact on menarche and menopause

Ages at menarche and menopause have been shown to be associated with adverse health outcomes in later life. For example, earlier menarche and later menopause have been independently linked to higher risk of breast cancer. Earlier menarche may also be associated with an increased risk of endometrial cancer, menstrual problems and adult obesity. Given the associations of ages at menarche and menopause with future health outcomes, it is important to establish what factors across life, and generations, may influence these. This article examines the associations of early life factors, namely birthweight, bodyweight and growth during childhood, childhood socioeconomic circumstances and psychosocial factors with ages at menarche and menopause. It examines possible explanations of the associations found, including life history theory, and discusses areas for future research.