Introduction

Puberty is defined by the development of secondary sexual characteristics and reproductive capacity. According to Tanner, full reproductive maturity occurs 12 to 18 months after menarche onset [1]. Age at menarche (AAM), marking the first menstruation, is a key indicator of pubertal timing and is influenced by environmental, nutritional, ethnic, socioeconomic, and genetic factors [2, 3]. While menarche before age 12 years is considered early [4–6], treatment is generally not required in girls with pubertal onset after age 8 years and slow progression [7]. However, early menarche may impair final adult height (FAH) by causing premature epiphyseal closure [8]. It is also associated with irregular cycles and dysmenorrhoea [9, 10], as well as long-term metabolic and cardiovascular risks such as insulin resistance, obesity, breast cancer, and ischaemic heart disease [6, 11–13].

This study aimed to evaluate the impact of early menarche on menstrual characteristics, gynaecological and psychiatric outcomes, and FAH in a single-centre study of adolescent girls.

Material and methods

Our study was conducted on 58 female patients aged 9.5–10.75 years who presented to the paediatric endocrinology outpatient clinic with menarche between January 2012 and January 2018. This was a retrospective, single-centre study conducted at Bezmialem Vakıf University Hospital, Istanbul, Turkey. The “age of menarche” is defined as the onset of the first menstrual cycle. Tekgül et al. [14] reported the mean AAM to be 13.11 ±1.18 years in girls. Based on this study, early menarche was defined as menarche occurring before the age of 10.75 years (menarche occurring below –2 SDS).

Baseline data were collected from the medical records, including maternal and paternal heights, AAM, bone age, weight, height, body mass index (BMI), and the use of nutritional supplements such as vitamins, fish oil, and propolis, as part of a general assessment of possible factors affecting growth and development, and family history of early menarche. The presence and type of chronic illnesses or comorbidities were documented both at the time of menarche and at the follow-up visit. In all height measurements, participants were measured in a Harpenden fixed stadiometer (Holtain Ltd., Crosswell, Crymych, Pembrokeshire, UK), which was used to measure standing height (cm) to the nearest 0.1 cm. Weight was determined to the nearest 0.1 kg with the use of a mechanical scale (Seca GmbH & Co. KG., Hamburg, Germany). Based on the measurements, BMI was computed as weight (kg)/height² (m²). Bone age was assessed via the Greulich and Pyle atlas [15]. The same person evaluated bone age during this study. The predicted adult height is calculated by the method of Bayley and Pinneau [16]. Cole’s LMS method (Lambda–Mu–Sigma method) was used to calculate the BMI standard deviation score (BMI-SDS) [17]. Target height (TH) was calculated using Tanner’s formula (maternal height + paternal height)/2 – 6.5 [18].

After at least four years had elapsed since menarche, patients were first contacted by telephone. Following this initial contact, participants were invited to attend a hospital visit for a follow-up clinical assessment, where their height and weight were measured again with the same devices described above. All anthropometric measurements, including FAH, were performed by trained staff at our centre using standardised equipment. During this visit, medical records were reviewed, and diagnoses of iron deficiency anaemia, polycystic ovary syndrome (PCOS), and psychiatric disorders were confirmed using the national electronic health record system, where available. The duration and treatment of chronic diseases, as well as the need for psychological or psychiatric support and medication use, were recorded and confirmed through review of medical records. This process ensured that all diagnoses and relevant laboratory findings were validated through both direct clinical assessment and official electronic health records. A summary of the questionnaire items is provided in Supplementary Table I.

Those who consented to participate in the study completed a questionnaire that included information regarding their menstrual cycle regularity, the existence of abnormal uterine bleeding, the duration required for cycles to normalise post-menarche, the presence of dysmenorrhoea, any chronic illnesses, specific chronic conditions, gynaecological disorders, the need for psychiatric or psychological support, their final height, the socioeconomic status of their families, and their academic performance.

Iron deficiency anaemia was defined as haemoglobin below the age-specific reference threshold accompanied by a serum ferritin concentration < 12 ng/ml, most commonly in association with heavy menstrual bleeding. PCOS diagnosis was established according to international guidelines and confirmed by pelvic ultrasonography when appropriate. The presence of psychiatric disorders and other chronic diseases was also verified using medical documentation.

Menstrual irregularity was defined as cycles occurring either before 21 days or after 45 days. A prolonged menstrual cycle was defined as one lasting longer than seven days. Heavy menstrual bleeding was characterised by the use of more than six pads per day for a duration exceeding seven days or by bleeding that significantly interfered with daily activities [19].

Results

The baseline characteristics of girls included in the study are summarised in Table I. The mean ±SD age of menarche was 10.3 ±0.32 years. The mean height was 147.02 ±4.96 cm, height SDS was 1.0 ±0.81, weight was 43.74 ±7.41 kg, and weight SDS was 1.03 ±0.75; BMI was 20.21 ±3.11, and BMI-SDS was 1.01 ±0.86, respectively.

At the time of the survey, the participants had a mean age of 18.16 ±1.12 years. The average height was 157.71 ±5.19 cm, with a corresponding height SDS of 0.81 ±0.91. The mean weight was 57.31 ±10.09 kg, and the weight SDS was –0.07 ±1.51. The average BMI was 22.9 ±4.08, with a BMI SDS of 0.28 ±1.56.

The mean TH of the patients was 159.27 ±4.52 cm, while the mean FAH was 157.71 ±5.19 cm (p = 0.029). The mean TH SDS and FAH SDS were 0.64 ±0.76 and 0.81 ±0.91 (p = 0.160), respectively. In 11 out of 58 patients, the final height exceeded 1 SDS below their TH. Among these 11 patients, 6 had a coexisting chronic disease, which had already been present at the time of their initial examination. In contrast, none of the patients whose final height exceeded their TH by more than 1 SDS had any associated chronic conditions. Ten patients (17.2%) used medication due to asthma. Three patients had mild scoliosis, one patient had a pituitary adenoma, one patient had a kidney stone, one patient had an osteoid osteoma, one patient had gastritis, one patient had Hashimoto’s thyroiditis, and one patient had Gilbert’s syndrome. None of the patients had any other chronic diseases, such as chronic renal insufficiency, chronic liver disease, chronic heart disease, chronic inflammatory bowel disease, celiac disease, etc., which are capable of affecting growth velocity. Twenty per cent of asthma patients receiving therapy required an escalation in their drug dosage.

Twelve per cent of patients (n = 7) used multivitamins, 13.8% (n = 8) used propolis, and 12% (n = 7) used fish oil supplements. The incidence of early menarche among their relatives was 24.2% (n = 14).

The distribution of the patient’s menstrual cycle characteristics is summarised in Table II. Fifty per cent of the patients (n = 29/58) had dysmenorrhoea. Abnormal uterine bleeding was observed in 9 patients (15.5%). On average, the menstrual cycle lasted 6.13 ±2.11 days, required 3.74 ±0.82 pads per day, and took 9.18 ±9.95 months to become regular. Nearly half of the patients (44.8%) required treatment due to iron deficiency. Fifteen per cent were diagnosed with PCOS and received treatment (Table II).

Psychiatric problems were found in 22.4% (n = 13). Six individuals were diagnosed with anxiety disorders; two experienced panic attacks, and four suffered from depression. Nine individuals, or 15.5% of the total, were on medication for a mental illness. We found that 18 out of the 58 patients performed poorly in school.

Discussion

Several studies have shown that early menarche may have a detrimental effect on FAH [8, 20]. Kang et al. [4] reported that short stature and obesity were more prevalent among girls under the age of 12 years with early menarche compared to those with late menarche. Similarly, in a study conducted by the European Prospective Investigation into Cancer and Nutrition, short stature was found in patients with early menstruation [20]. In our study, while early menarche did not universally impair FAH, its negative impact is significant among girls with chronic illnesses. Although the mean FAH was significantly lower than TH (p = 0.029), the comparison between TH SDS and FAH SDS did not reach significance (p = 0.160). This discrepancy may be attributed to differences in SDS variability or to the influence of chronic illness disproportionately affecting a subset of patients. Therefore, SDS comparisons alone may underestimate the clinical relevance of height loss in specific individuals. This interpretation is further supported by our subgroup analysis, which showed that 19% (11/58) of the patients had an FAH more than 1 SDS below their TH. Over half of these patients had chronic illnesses such as scoliosis or asthma, whereas none of the patients whose FAH exceeded their TH by more than 1 SDS had any chronic disease. It should be noted that all cases of scoliosis in our study were mild and thus are unlikely to have had a significant impact on final height. These findings suggest that the co-occurrence of early menarche and chronic disease may synergistically impair growth, highlighting the importance of individualised assessment.

Recent research indicates that early menarche may be associated with an increased risk of asthma in adolescent girls [21–24]. In our study, the prevalence of asthma was 17.3%, which was notably higher than the reported community prevalence of 8.3%. Furthermore, 20% of these patients required an escalation in their medication dosage. Although the biological mechanisms remain incompletely understood, hormonal changes during puberty have been hypothesised to influence airway function and immune regulation [25–29]. These findings, however, should be interpreted with caution because asthma was not a primary outcome of our study, and the retrospective, survey-based design does not allow causal inference. Future studies employing more rigorous methodologies beyond survey-based designs would be valuable to clarify the potential relationship between early menarche and asthma.

In our study, 24.2% of participants reported a family history of early menarche. This finding is in line with prior evidence demonstrating that both maternal and paternal pubertal timing strongly influence offspring development [30, 31], which similarly reported that maternal AAM was positively correlated with pubertal milestones in daughters and sons, highlighting the importance of parental reproductive history in clinical evaluation. The American Academy of Pediatrics also recommends obtaining a detailed family history when assessing children with signs of early puberty, as it aids in distinguishing normal variants from pathological causes [32].

Familial clustering of pubertal timing has been consistently documented, with heritability estimates for AAM often exceeding 50% [2]. More recent genome-wide association studies have identified numerous loci associated with pubertal onset, underscoring the substantial contribution of inherited factors [3, 33, 34], further emphasising the role of imprinted genes and rare monogenic causes in central precocious puberty. Epidemiological studies also show that daughters of mothers with early menarche are more likely to experience earlier onset themselves, reflecting combined genetic and environmental influences [5]. Together with recent reports demonstrating secular trends toward earlier pubertal onset, including among girls [35], our findings of a relatively high prevalence of early menarche among relatives reinforce the importance of genetic and familial factors in the regulation of pubertal timing.

According to the findings of this study, most of the females had menstrual cycles that were regular. However, 24.1% experienced menstrual bleeding lasting longer than seven days, and 15.5% had irregular cycles. While the prevalence of PCOS in the population is between 6 and 10% [36], in our study it was found to be 15.5% in patients with early menarche. We determined it to be higher than in the general population. Patients with early menarche showed an increased susceptibility to PCOS compared to the general population. A potential biological explanation is that PCOS and early menarche are metabolic illnesses sharing common pathophysiological and genetic traits. In both conditions, irregularities in gonadotropin-releasing hormone (GnRH) secretion are implicated, affecting luteinising hormone secretion [37]. The initiation of pubertal development is controlled by a genetic network that adjusts the pulsatile secretion of GnRH and resulting elevation of circulating pituitary gonadotropins, which stimulate gonadal function [38]. Genetic variants affecting the neuroendocrine axis may lead to the onset of both PCOS and early menarche [37]. For instance, the rs7759938-T variation on chromosome 6 was linked to an earlier onset of menarche in women with PCOS [39]. Furthermore, frameshift mutations in DLK1 have been linked to early menarche, metabolic dysregulation, and PCOS [40].

Dysmenorrhoea was common among our patients, and it has been reported to affect 43% to 93% of adolescents in previous studies [41, 42]. In one study, 83.3% of girls experienced dysmenorrhoea, making it one of the most prevalent complaints among adolescent females [41]. Early onsets of menstruation and irregular menstrual cycles have been identified as risk factors for dysmenorrhoea [43]. The most likely explanation is that girls who begin menstruating at a younger age are more prone to longer and irregular cycles, which are associated with elevated prostaglandin levels that can induce painful uterine contractions during menstruation [44]. Another study suggested that younger AAM may be linked to dysmenorrhoea due to the physical and psychological immaturity of younger girls, who may lack sufficient awareness of menstrual health and self-care practices [45].

Early pubertal onset in girls has also been associated with a range of adverse psychosocial outcomes, including increased risks of depression, anxiety, eating disorders, and antisocial behaviour [46]. Furthermore, early menarche has been suggested as a risk factor for suicidal ideation in adolescent girls [47]. The prevalence of psychiatric disorders in the general adolescent population ranges from 13.4% to 17.5% [48, 49]. In our study, psychiatric problems were reported in 22.4% of the girls, indicating a slightly higher prevalence compared to population-based estimates. Among these, 9 individuals (15.5%) were receiving pharmacological treatment for psychological conditions, such as anxiety disorders (including panic attacks) and depression. Additionally, 18 participants reported poor academic performance. These findings should be interpreted with caution because our study lacked a control group and was based on self-reported data, which precludes causal inferences.

Study limitations

A key strength of this study is the inclusion of long-term follow-up data from patients diagnosed with early menarche in a paediatric endocrinology outpatient setting. Nonetheless, the study has certain limitations. First, its cross-sectional design prevents the establishment of a causal relationship between AAM and FAH. Second, information regarding menstrual characteristics – such as cycle patterns, duration until regularity, and menstrual pain – was collected through self-reports, which may be subject to recall bias. Third, although chronic diseases and psychiatric treatment were verified from medical records where available, detailed information on disease severity and treatment was incomplete. Finally, the lack of a control group is among the limitations of this study.

Conclusions

Early menarche appears to be associated with an increased risk of developing PCOS and psychiatric disorders compared to peers with later onset. The negative impact of early menarche on FAH was particularly pronounced in patients with underlying chronic illnesses.

Presentation

This study was presented at the European Society for Paediatric Endocrinology 2025 Annual Meeting in Copenhagen, Denmark.