A study of association between early menarche and anxiety in undergraduate  students

Introduction

Anxiety is the world’s most common mental health disorder, affecting 301 million people worldwide in 2019. It has also been reported that women are affected more by anxiety disorders than men, and their symptoms surge during childhood or adolescence. It is also stated that approximately one in four people with anxiety disorders receive treatment, which reflects that only a minority of the population affected is receiving adequate healthcare.¹

The United Nations Sustainable Development Goal (UN SDG 3) focuses on good health, which includes mental health, whereas the UN SDG 5 focuses on gender equality. An intersection between these two goals is the mental health of women, which has long been neglected, leading to a gap in the quality of the healthcare provided to men and women. To bridge this gap, it is imperative to study the factors affecting mental health specific to women.²

In recent decades, there has been a trend of decreasing mean age at menarche in India.³ Early menarche is defined as menarche at or below 12 years of age.⁴ Eating habits and a higher body mass index have been implicated as risk factors for early menarche.⁴

Puberty is a formative period during which several hormonal, reproductive, and social changes occur. The psychological effects of early puberty may not be limited to adolescence but may also affect mental health during adulthood.⁵

A study conducted on secondary school female students aged 12 to 17 years reflected the association between menarche and the prevalence of anxiety and depression comorbidities.⁶

Studies have evaluated the difference in the effect of pubertal timing between males and females. While early puberty tends to have a positive impact in males, it is linked to increased symptoms of depression among females.⁷

Social stress after puberty and changes in peer, sexual and family connections have been linked to emotional issues in early adolescence.^7,8

The long-term developmental consequences of pubertal timing reported that girls who mature early continue to have a higher risk of anxiety throughout adolescence and early adulthood.^9,10 Because early menarche leads to an abrupt transition, it leaves little time for emotional preparation. Girls who mature early may experience anxiety and related symptoms.¹¹

Several studies have reported an association between early menarche and psychosocial pathologies in adolescents. Early menarche is associated with increased substance abuse, elevated depression, and suicidal behaviors in adolescent girls.^12,13

The effect of early menarche on mental health in adulthood remains controversial. Some studies have shown that early menarche is associated with depressive symptoms and antisocial behavior in adults,¹⁴ while other studies have shown that there is no association between early menarche and symptoms of depression.¹⁵ An association has been found between anxiety disorders in adult women and early perceived pubertal timing.¹⁶

The fluctuation of estrogen levels during the reproductive lifespan of women has been frequently studied and linked to various psychiatric disorders.¹⁷ However, the role of estrogen in anxiety has not been determined. Increased anxiety levels are observed during menarche, which is the time at which estrogen levels become elevated.⁶ In contrast, animal experiments have shown that acute and chronic estrogen administration have anxiolytic effects.¹⁸ Estrogen acts through three estrogen receptor (ER) subtypes, which have different effects on anxiety. Estrogen Receptor alpha (ER alpha) has anxiogenic effects, estrogen receptor beta (ER beta) has anxiolytic effects, and G protein-coupled estrogen receptor (GPR30) has both anxiolytic and anxiogenic effects.¹⁹

Methods

Study setting: The study was conducted in Kasturba Medical College and Hospital, Mangalore.

Study design: This study was conducted as an analytical observational case control study.

Study participants: Female undergraduate students studying in Kasturba Medical College, Mangalore and Manipal College of Dental Sciences, Mangalore.

Results

The present study comprised a total of 146 participants after excluding participants who did not adhere to our inclusion and exclusion criteria.

The age of the participants in our study ranged from 18 to 25 years. The mean age was 20.54±1.7 years.

The age at menarche of the participants ranged from 10 to 16 years. The mean age at menarche of our participants was 12.48±1.17 years.

The participants were grouped into case and control groups based on age at menarche. The participants with age at menarche less than or equal to 12 years were the cases and the control group consisted of participants with age at menarche greater than 12 years. We had 74 participants in the cases group and 72 participants in the control group.

The mean score for the cases on the GAD-7 questionnaire was 9.93 (Standard deviation=6.05). The mean score for the controls on the GAD-7 questionnaire was 6.89 (Standard deviation=5.24). An independent t-test was performed, and it was found that the GAD-7 scores of the cases were significantly higher than the GAD-7 scores of the controls with a (t(144)=3.26, p<0.05). Thus, the difference in the GAD-7 scores between the cases and controls was found to be significant.

Among the cases, 20.3% had minimal anxiety, 32.4% had mild anxiety, 21.6% had moderate anxiety, and 25.7% had severe anxiety. Among the controls 38.9%, 30.6%, 25.0% and 5.6% had minimal, mild, moderate, and severe anxiety, respectively.

In the cases, 66 of 74 participants entered their age at the onset of anxiety symptoms. Among the controls, 56 out of 72 participants entered their age at the onset of anxiety symptoms. These findings are summarized in Table 1.

Among the cases out of 74 participants, 65 responded to the question regarding the duration of their anxiety symptoms. Among the controls, 55 out of 72 participants responded to questions regarding the duration of their anxiety symptoms. The findings regarding the duration of the anxiety symptoms are summarized in Table 2.

Of the 146 participants in the present study, 122 answered the question regarding whether they had received treatment for their anxiety symptoms. 20.5% had received treatment for their symptoms. Thirty participants reported details of the treatment they received. Of these, 12 participants (40%) received pharmacological treatment, 16 (53.3%) received psychological treatment, 1 (3.3%) received both psychiatric and Ayurvedic treatment, and 1 (3.3%) received crystal stone treatment.

Among 146 study participants, 26 participants reported to have known gynecological condition, among them 23 reported to have polycystic ovarian syndrome. Six participants reported to have known thyroid condition.

Discussion

The present study focused on the association between early menarche and anxiety during adulthood. This was an analytical observational case-control study of female undergraduate students aged more than or equal to 18 years.

The mean age at menarche in our study was 12.48±1.17 years. Their ages ranged from 10 to 16 years. The mean age at menarche was found to be lower than the mean age at menarche in India calculated as of 2005 which was 13.76 years.³ More recently, studies have shown a decline in the mean age at menarche between mothers and daughters.²² A study conducted among North Indian girls in 2023 found the mean age of menarche to be 13.13±1.23 years.²³ The mean age at menarche in our study was found to be even lower than these.

The present study found that anxiety symptoms were significantly higher in participants with an early age at menarche. These findings further support those of numerous studies, which show that early puberty and menarche are associated with greater rates of morbidity of anxiety and other psychiatric illnesses than relatively late menarche.^9–13 Other studies have found that females who mature early are more likely to experience symptoms of psychiatric illnesses, including anxiety, throughout adolescence and during the early stages of adulthood.^9,10

Emotional problems in early adolescence have been connected to social stress following puberty and modifications in peer, sexual, and family relationships.^7,8 It is evident that in females, menarche becomes a sudden transition that provides little time for emotional preparation and can cause anxiety and related symptoms.¹¹ During the perimenarcheal phase, participants described feeling puzzled, worried, and ambivalent, but eventually acclimated to these changes.¹¹

The relationship between mental health and early puberty is complex. In this study, we did not address some factors which may also affect the mental health of women during puberty and as young adults. The psychological effects of early puberty have been attributed to the social and cultural environment.²⁴ Factors like race and ethnicity have also been found to play a role.²⁵ In this study we did not consider the cultural background of the participants which could also play a role. Another study conducted in India, showed that girls who were communicated with regarding taboos associated with menstruation showed greater stress about staining.²⁶ Such studies emphasise the need for accurate and effective communication in order to promote the emotional and mental health of adolescent girls.

Our study also did not consider the traumatic childhood experiences of the participants. Traumatic events during childhood have been linked with early puberty in girls.²⁷ Traumatic events have also been linked to increased risk of both cardiovascular disease as well as anxiety.^27,28

While our study was conducted on adult undergraduate students, it is important to also understand the potential reasons for poor mental health among girls during puberty so that we can prevent the development of mental health disorders. A study found that girls who achieve menarche earlier are less prepared for puberty and tend to have more negative emotions associated with menstruation.²⁹ Parental support has been found to be related to more preparedness among girls during menarche.³⁰ Motivational interviews and peer groups have also been found to be effective tools in promoting the mental health of adolescent girls as well as their knowledge about puberty.³¹ On the other hand, while girls who achieve menarche early have poorer mental health outcomes, they use less non-productive coping strategies when compared with their peers.³² This is encouraging and shows that even though there are emotional challenges associated with early menarche, using the right tools can help ease this transition for girls.

The findings of this study can also be explained by estrogen variations in women. Several studies have attempted to explain the effects of estrogen on mental health.^33–35 Menarche, the period when estrogen levels rise, is associated with higher anxiety levels.¹⁷ However, the anxiolytic effects of both acute and chronic estrogen treatments have been demonstrated in animal models.¹⁸ Estrogen has distinct effects on each subtype of the receptor through a complex interaction.¹⁹ This study followed an objective metric, age at menarche, to investigate the relationship between anxiety during adulthood and early puberty.

Among the cases, 20.3% had minimal anxiety, 32.4% had mild anxiety, 21.6% had moderate anxiety, and 25.7% had severe anxiety. Among the controls 38.9%, 30.6%, 25.0% and 5.6% had minimal, mild, moderate, and severe anxiety, respectively. A larger percentage of the women in the case group experienced severe anxiety. However, a greater percentage of the women in the control group experienced minimal anxiety.

In our study, we found that 59.1% of cases and 67.9% of controls first experienced anxiety symptoms after 18 years of age. In contrast, 27.3% of the cases and 25% of the controls first experienced anxiety symptoms between the ages of 14-17 years of age. A previous study found that the mean age of onset of generalized anxiety disorder was between 21.1 and 34.9 years.³⁶ However, this was only partially reflected in our study, probably because the mean age of our participants was 20.54±1.7 years.

According to our study, the duration of anxiety symptoms was less than 6 months in 30.8% of cases and 32.7% of controls. The duration of anxiety symptoms was between 6 and 12 months in 16.9% of cases and 29.1% of controls. The duration of anxiety symptoms was greater than one year in 52.3% of the cases and 38.2% of the controls. A study found the mean duration of anxiety symptoms to be 15.2 months,³⁷ which was in line with our findings.

Of the 122 participants who answered the question, 20.5% received treatment for their symptoms. A study by the World Health Organization on the treatment gap in anxiety disorders also showed that only 27.6% of the respondents who had anxiety disorder had received treatment of any form, and only 9.8% had possibly received adequate treatment. It is evident that there is a need to diagnose anxiety disorders and improve the treatment quality.³⁸

Of the participants who reported receiving treatment, 12 participants (40%) received pharmacological treatment, 16 (53.3%) received psychological treatment, 1 (3.3%) received both psychiatric and Ayurvedic treatment, and 1 (3.3%) received crystal stone treatment. In general, the first-line treatment for generalized anxiety is cognitive behavioral therapy (CBT) and pharmacotherapy (SSRIs, SNRIs). Others include benzodiazepines for acute cases, metacognitive therapy, mindfulness techniques, physical activities, and Acceptance and Commitment Therapy).³⁹ Most participants in our study relied on allopathic treatments, whereas a minority resorted to alternative treatment methods.

This study sheds light on anxiety symptoms associated with early menarche. Further implications of this study include understanding other psychiatric comorbidities associated with early menarche and puberty.

Conclusion

This study suggests a significant association between early menarche (age ≤ 12 years) and higher levels of anxiety among female undergraduate students. The findings of this study support the hypothesis that early physiological development could contribute to increased vulnerability to anxiety in young adults. This knowledge could help healthcare providers give the required support to girls during puberty as well as young adult women. Recognizing early menarche as a potential marker for heightened anxiety risk could guide preventive measures and mental health interventions tailored to young women during critical developmental stages. It could also help understand the potential factors which may have contributed to the development of anxiety in young adults. Hence, there is a need for healthcare providers to be sensitized to early pubertal timing in adults with anxiety.

In summary, while the study provides evidence of a significant association between early menarche and increased anxiety levels among adult female undergraduate students, further research is needed to elucidate the underlying mechanisms and causal pathways. These findings underscore the importance of early detection and support for mental health issues in young women experiencing early puberty.

Consent

The introductory form of the online survey had information about the background, aim of the study and the consent form. Once the participant clicked on the ‘I agree’ button, this was considered consent for participating in the study and the participant was taken to the rest of the questionnaire. The participants had the right to withdraw from the study at any time.