An exploratory study on perception of adolescent girls towards early menarche in a union territory of India

INTRODUCTION

Puberty is a transitional period between childhood and adulthood during which sexual maturation occurs. Menarche, a milestone event in adolescent girls usually occurs 2-2.5 years after pubertal onset and also an important determinant of physical, nutritional and reproductive health outcomes though often overlooked as a public health indicator.¹ However, the Indian Human Development survey (2004-2005) established a reduction of ‘age of menarche’ by nearly one month per decade, suggesting a secular decline in age at menarche among Indian women.² Menarche is already a challenging experience for both adolescent girls and their mothers as it is often associated with poor knowledge regarding puberty, cultural beliefs and gender restrictions. So, attaining menarche at an earlier age made it even worse and affects their mental well- being. Studies also showed that early menarche (before the age of 12 or 13) has been linked to an increased risk of several adverse reproductive health outcomes and mental health problems.^3-6 There is also a dearth of community based studies on early menarche in India. Hence, we planned this study to explore the perception and attitude of adolescent girls towards early menarche.

METHODS

A qualitative study design was adopted and Focus Group Discussions (FGD) were conducted among adolescent girls who were residing in the rural field practice area of a medical college in Puducherry to gain an insight onto their perception and attitude towards early menarche. The study was conducted during January to March 2022. Purposive sampling technique was adopted for the selection of study participants. Adolescent girls who attained menarche and those who were willing to participate were considered for the study after obtaining written informed consent from their parents.

The key informants were contacted and the participants were intimated about the time and venue (convenient to them) and were mobilised for the FGD which was conducted using interview guide by the principal investigator using a 32 item checklist according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) pertaining to the study domains with respect to the research team and reflexivity, study design and conduction, data analysis and documentation of findings.⁷ Written informed consent was obtained from the participants for their participation and also for the audio-recording of the interviews. Each FGD consists of 5 to 6 participants and the discussion was guided by the moderator, formally trained in qualitative research methodology. A conducive environment was provided for the participants to speak freely and openly about their experiences. All efforts were made to ensure participation and contribution by all members. Participant validation was done by summarizing the findings of discussion from the FGDs. At the end of each discussion, health education on menstruation was given to the study participants. The ethical approval for this study was obtained from the Institutional Ethical Review Committee.

Statistical analysis

After every focus group discussion, the contents were transcribed, the transcript was read and re- read and inductive and deductive codes were derived. The codes were combined according to their similarities to form categories and finally, themes were generated from the concepts that emerged and were interpreted.

RESULTS

In total, four focus group discussions were conducted among the selected adolescent girls to explore their attitude and perception about early menarche. The following themes were emerged: 1) Sources of information on menarche, 2) Perception of adolescent girls towards early menarche, 3) Phenomenology of ‘Lived in Experiences of Menarche’ Among Adolescent Girls.

Source of information on ‘menarche’ – adolescent girls’ perspectives

As told by the adolescent girls, the various sources of information on menarche that they received, were from family members (mother, elder sisters and relatives), from the schools, (Peer groups, being taught at schools or health camp by NGOs), from the health system functionaries (Doctors, ASHAs and Anganwadi teachers), and from the mass media (advertisements, radio & social media) (Figure 1).

However, the information they received was not always timely and was inadequate as said by them. They seemed to be struggling because of their limited knowledge on puberty. As told by one of them “I don’t know what exactly the menstruation is! I was told that bad blood would shed from our whole body every month.” Another participant told that, (regarding her menarche experience), “One fine day, while I was getting ready for school, I was shocked to see blood stains on my inner wear and I apprehended that I had cancer!” Most of the adolescent girls had limited understanding of puberty even after they had attained menarche. Most of the information they received from their families were mainly based on the changing social norms and cultural beliefs but not on the biology of puberty or how to cope up with the behavioural adaptations expected of them. They also felt that, even at schools; the teachers were hesitant to discuss in detail on menstruation with them. All the study participants suggested that there was a need for educating boys too about puberty as it was necessary to make them sensitive and empathetic to these problems of women. The girls felt that the role of health sector was important in giving health education to management of health problems (physical and psycho social) of menstruating girls as they were expected to have the right medical knowledge on the same. However, to them, in some of the health facilities, female doctors were not available for providing treatment and most of them stressed about menstrual hygiene only but not on the aspects of the psychosocial health problems of the menstruating girls. As suggested by one of the study participants, “It would be good if an expert (Speciality doctors) took classes on menstrual health and the appropriate diet to be followed, at least once in 6months, because it could then be explained clearly and could guide us properly if we had any menstrual problems.”

Perception of adolescent girls towards ‘early menarche’

According to the study participants, there had been a trend of early menarche in current times and they had attained menarche earlier compared to their mothers. The various reasons for early puberty stated by them were unhealthy childhood diet, obesity, hormonal problems, and changes in life style and also could be due to factors like mothers with early age of menarche (Figure 2). As told by one of them, “most of the parents these days, fed unhealthy food items (high in calories and fat)) to their kids right from their childhood which caused early puberty.”

The adolescent girls faced inconvenience in their daily routine as a consequence of early menarche. To them, menarche was a shocking experience when they had it for the first time as they were clueless about it. There was no mental preparedness for accepting it and attaining it even earlier, made it still worse. As narrated by one of the study participants, “one of my friends attained menarche at the age of 8 and she didn’t know how to deal with it! She took leave on those days as she was anxious about staining her clothes and it affected her academic performance too”. Additionally, they felt that the girls who attained menarche early lost their childhood identity at a younger age as they looked more matured compared to their peers. The rapid biological changes made them more identified in their social circle which ultimately impacted their self-esteem. They were unable to adjust themselves and it affected their psychosocial state.

Phenomenology of ‘lived in experiences of menarche’ among adolescent girls

The adolescent girls were asked to narrate their lived in experiences of series of changes that they had undergone after puberty. As told by most of the adolescent girls, after menarche, they experienced the many physical changes such as, sudden increase in height, breast changes, development of axillary and pubic hair, acne over the face and changes in sleep pattern etc.

With a drastic physical change, there were many social changes; change in their social relationships, expansion of their social circle, development of habit of exploration of new things and risk taking behaviours etc. They preferred to spend more time with their peer groups to share their thoughts and feelings and emotions as they shared similar thoughts. They were hesitant to share their feelings with their families as there was no free communication before and imposition of restrictions by their families.

With regards to their psychological health, it was affected very much as there was no mechanism to address those. At the time of puberty, most adolescent girls were anxious and were not prepared mentally due to poor communication of information on menstruation and pubertal changes to them. They got irritated when they were forced to follow cultural practices after puberty. According to them, they were marked differently (due to physical changes) in their own class than their peer groups who did not attend menarche by then. Most of them became self- conscious about their body image after puberty which affected their eating behaviour in turn. Increased body weight, perceived pressure from peer groups and parents about their body weight and internalisation of mass media with cultural standards of ideal body image made them more critical of their self-body image. As stated by one participant, “I stand before the mirror for hours and check my appearance before stepping out of my house.” As stated by another participant, “I controlled my eating pattern and it was discussed in our circle”. These changes which were unimportant before, suddenly assumed importance in their lives.

DISCUSSION

Our study findings had offered an insight into the perception of adolescent girls towards pubertal changes and the difficulties faced due to early menarche. It was perceived by most of the adolescent girls, that they were either ignorant or had inadequate knowledge about menstruation and sometimes, the quality of information they received, were not credible. The lack of psycho social support and appropriate counselling in addition to the existing discriminatory societal norms, made them more vulnerable as their health needs were not addressed. Qualitative studies by Mirzaee et al, and Kumar et al also revealed there was inadequate knowledge regarding puberty among adolescent girls.^8,9 As explored by Gold-Watts et al, in their study at rural Tamil Nadu, the adolescent girls’ experiences of menarche and menstruation are largely shaped by cultural codes and gender norms, which further influenced gendered attitudes, beliefs, and practices.¹⁰ These in turn, constructed and maintained their conceptions of womanhood which alienated and isolated them.

In addition to this, the adolescent girls with early menarche experienced more negative outcomes across all the domains of health as they were less equipped (physically and psychologically) to cope up with these pubertal transitions. A qualitative study by Bhattarai et al found that health seeking practice among the adolescence was poor due to inadequate knowledge about the importance of health seeking for the menstrual problems, fear of losing confidentiality, lack of user friendly services and existence of stigma and taboos in their culture.¹¹ As told by one of the study participants, “After puberty, I felt embarrassed as I was looked older than everybody in my class. I looked for friends who could understand and support me.” The inability of the adolescent girls in adapting to these new conditions leads to the emergence of behavioural and psycho social problems among them. As suggested by one of the participants, “It would be better if we were taught about menstruation before puberty, to be able to handle it without any fear or anxiety.” So, comprehensive understanding of menstruation would help the adolescent girls as well as their mothers to address the myths and cultural taboos and ensure the adoption of proper menstrual hygienic practices. This would also address their emotional vulnerability and identity crisis during puberty and improve their self- confidence and self-esteem. This educational initiative should also include adolescent girls in their pre-menarcheal age groups to facilitate positive menarche experience.

CONCLUSION

From the adolescent girl’s perspective, it was revealed that they had received inappropriate and limited knowledge on puberty from various sources of information on menarche. Adolescent girls’ especially early maturers were not able to cope up with pubertal changes due to various factors such as socio- cultural norms, poor communication between mothers and daughters and lack of psychosocial support from the health system. It had affected their self-confidence and made them psychologically vulnerable.

Recommendations

The appropriate age of educating the adolescent girls on puberty and menstrual hygienic practices should be decided by the policymakers considering the decreasing trend of menarche age. At the community level, an awareness program should be conducted among adolescent girls and their parents by the involvement of grass-root level health workers regarding causes and consequences of the early onset of puberty. As ‘age at menarche’ is considered as one of the important health indicators for adolescent girls, the policymakers should consider the inclusion of menarche age as one of the components in future health surveys of the country.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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