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Health


THE NEW MENSTRUATION: GIRLS ARE GETTING THEIR PERIODS EARLIER AND LESS REGULARLY

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By Annalisa Merelli May 29, 2024

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Adobe
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Menstruation is a critical indicator of health. Whether and when someone with a
uterus gets their period — for the first time, and throughout their life — can
reflect not only their reproductive health, but their risk of cardiovascular
disease, cancer, miscarriage, and premature death.

That also makes menstruation a useful measure of population health. And digital
tools for clinical research are beginning to shed light on just how
significantly periods are changing over time.

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A study published Wednesday in JAMA Network Open, based on data from more than
71,000 women collected through the Apple Research App, shows that girls in the
United States have been getting their first period earlier and earlier over the
last 55 years — and it has taken longer for their periods to become regular,
pointing to worsening overall reproductive and population health.

The research is part of the large Apple Women’s Health Study, launched in 2019
and conducted with the National Institutes of Health and Harvard T.H. Chan
School of Public Health. They found the average age at menarche — when an
individual gets their first period — decreased from 12.5 years in 1950 to 1969
to 11.9 years in 2000 to 2005. In the same period, the percentage of people who
experienced early menarche (before age 11) increased from 8.6% to 15.5%, and the
percentage of those having very early menarche (before age 9) more than doubled
from 0.6% to 1.4%.


RELATED: APPLE WATCH RESEARCH PLOWS AHEAD, REVEALING THE DEVICE’S HEALTH
POTENTIAL

Among the 62,000 participants who shared data on cycle regularity, the
percentage whose cycles became regular within two years of menarche decreased by
74% to 56% between 1950-1969 and 2000-2005.

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Both early menarche and irregular cycles are associated with health issues. An
early first period is associated with increased risk of cardiovascular disease,
cancer, and early death, typically connected to increased exposure to estrogen.
And a longer window to reach cycle stability in the early years is associated
with increased chances of irregular cycles during the rest of reproductive life,
which can be a cause of infertility.

It’s not clear exactly why the experience of menstruation is changing so much.
“The determinants of menarche, and the pubertal transition, are multifactorial,”
wrote study co-author Shruthi Mahalingaiah, an assistant professor of
environmental, reproductive, and women’s health at Harvard, in an email to STAT.
They can be related to body composition, diet, physical activity, and stress,
along with environmental exposure to endocrine-disrupting chemicals and air
pollutants.

But the study offers clues. About 10,000 participants provided data on their
body mass index, and the analysis estimated that about 46% of the drop in age of
menarche could be explained by higher BMI, in part because puberty is dependent
on accumulation of sufficient body fat.

“I think that that is very reflective of the obesity epidemic that we are
seeing,” said Aviva Sopher, a professor of pediatrics at Columbia University,
Irving Medical Center, who was not involved in the study. She suggested the
changes could be related to a possible increase in polycystic ovary syndrome.
“To me, this is concerning as well, this kind of confluence of obesity and
earlier puberty and more irregular cycles,” she said.

Obesity may not tell the whole story. “I think obesity is one factor. I don’t
think it explained the trends fully,” said Lauren Houghton, an epidemiologist at
the Columbia University Mailman School of Public Health and the author of a
commentary accompanying the study, also published in JAMA Network Open. This
study used a one-time measurement of BMI that was close to the age of menarche;
to validate the connection, she said, researchers would need to conduct
prospective longitudinal studies on age of menarche and body mass.


RELATED: GIRLS ARE STARTING PUBERTY EARLIER THAN EVER. FOR SOME, THAT COMES WITH
MAJOR MENTAL HEALTH RISKS

“Another concern is stress and the effect of stress on earlier puberty and
earlier menarche,” said Houghton, who highlighted that during Covid-19, stress
was associated with younger age at puberty. Stress could also be driven by
environmental factors like financial instability or racism: In the study, racial
and ethnic minority groups and people of lower socioeconomic status were most
likely to experience cycle irregularity and a reduction in the age of first
menstruation.

Early menarche could also be a cause of further stress down the line, said
Sopher, who has researched the psychological consequences of early menstruation.
“With more girls, going through puberty earlier, it might make it more
comfortable for those experiencing it,” she said. “But on the other hand, in
general, girls who go through puberty earlier are at increased risk of sexual
abuse because they look very mature, but they’re immature.”

Overall, the research stands as an important reminder of the value of
menstruation data as a health indicator, said Houghton. “For most of history,
people have thought of menstruation as noise or nuisance,” she said. But as
individuals have turned to wearables and mobile apps to track their cycles more
regularly, menstruation empowers people to better understand their own unique
cycle, she said.

Someone who has a consistently short cycle may want to bring a change in length
to the attention of a medical provider, for example, even if it still appears as
a “normal” 28-day cycle. For providers, the data offers important information on
a person’s health, including potential reproductive and endocrine issues.

And for population-level health researchers, large-scale data like that from the
Apple Women’s Health Study offer the opportunity to understand factors affecting
menstrual and fertility trends — including the reproductive health of
gender-diverse populations, said Houghton — and what kind of systemic
interventions are necessary to improve it.

Menstrual variation could be used to enhance diagnostics and provide a better
picture of individual and population health, for example. “We know that
biomarkers for cardiovascular disease differ depending on where you are in your
menstrual cycle, and then it can lead to misdiagnoses and underdiagnoses,” said
Houghton; mammogram quality varies by menstrual stage, too.

Menstrual health and women’s health is understudied and underfunded. “We need
significantly greater investment in early counseling, education around menstrual
health as a vital sign, and individualized healthcare plans,” wrote
Mahalingaiah.

“We are making strides right now … but it doesn’t make up for like decades of
being understudied,” Houghton added. “And so for me, the ability to use the app
data is amazing. It makes me be able to do research that I was never able to do
before — and with no funding.”

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ABOUT THE AUTHOR REPRINTS


ANNALISA MERELLI

General Assignment Reporter

Annalisa (Nalis) Merelli is a general assignment reporter at STAT. Her interests
are ever-expanding, but she is especially drawn to the coverage of reproductive
and maternal health, and their intersection with health equity.


Annalisa.Merelli@statnews.com

@missanabeem


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