Routledge International Handbook of Women's Sexual and Reproductive Health

Jane M. Ussher, Joan C. Chrisler, Janette Perz, Jane M. Ussher, Joan C. Chrisler, Janette Perz

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351035606
• Edition: 1
• Topic: Medicine
• Subtopic: Pediatric Medicine

The Routledge International Handbook of Women's Sexual and Reproductive Health is the authoritative reference work on important, leading-edge developments in the domains of women's sexual and reproductive health.

The handbook adopts a life-cycle approach to examine key milestones and events in women's sexual and reproductive health. Contributors drawn from a range of disciplines, including psychology, medicine, nursing and midwifery, sociology, public health, women's studies, and indigenous studies, explore issues through three main lenses:

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• the biopsychosocial model

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• feminist perspectives

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• international, multidisciplinary perspectives that acknowledge the intersection of identities in women's lives.

The handbook presents an authoritative review of the field, with a focus on state-of-the-art work, encouraging future research and policy development in women's sexual and reproductive health. Finally, the handbook will inform health care providers about the latest research and clinical developments, including women's experiences of both normal and abnormal sexual and reproductive functions.

Drawing upon international expertise from leading academics and clinicians in the field, this is essential reading for scholars and students interested in women's reproductive health.

PART I

Menarche, menstruation and menopause

1

PUBERTAL DEVELOPMENT AND MENARCHE

Physiological and developmental aspects

Margaret L. Stubbs

Development in puberty includes complex biological processes that result in the physical maturation of the reproductive system and related physical growth. Some of these begin during childhood, but reproductive or sexual maturity (i.e., the biological capacity to reproduce) culminates in adolescence. Adolescence is more broadly recognized as a transitional period of development between childhood and adulthood, which includes not only pubertal changes but also changes in cognitive abilities, self-perception, and social relations with family members and peers. For girls, menarche is a major pubertal event, but it is only one such event, and a late occurring one at that. Menarche is sometimes noted as a marker for, a signal of, or synonymous with puberty, but these notions obscure the complexity of pubertal growth that develops over time within childhood and adolescence. This chapter addresses how menarche is situated within puberty as girls become reproductively and psychosocially mature. The information to follow related to the physiological aspects of pubertal development comes from studies conducted in the United States or other developed countries unless specially stated.

Physiological aspects of puberty

This physiology is multifaceted and not completely understood. One pubertal process is clinically known as gonadarche, involving the reactivation of the hypothalamus-pituitary-gonadal (HPG) axis. This axis is active in fetal development but becomes inactive until puberty when the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the anterior pituitary to release luteinizing hormone (LH) and follicle stimulating hormone (FSH) to the gonads, in girls, the ovaries. In turn, LH and FSH stimulate the ovaries to produce estradiol. The increase in estradiol is first externally noticeable with breast bud development, known as thelarche (Dorn & Rotenstein, 2004). Along with an increase in other hormones throughout early puberty, menarche eventually occurs in mid to late puberty; menstruation becomes cyclical and ovulatory later, about one year after menarche, for most girls (Hillard, 2014).

Research into what influences the reactivation of the HPG axis at puberty indicates that nutritional support is needed to begin and maintain pubertal development. Leptin, a hormone produced by fat cells, plays a key role. Leptin levels signal the hypothalamus when there is enough nutritional support for pubertal development to begin and proceed (Dorn & Biro, 2011). Researchers have identified additional neurotransmitters, neuropeptides, notably Kisspeptin and its receptor, growth factors, and metabolic signals that contribute to the onset of puberty (Manfredi-Lozano et al., 2016). How these factors interact to stimulate the reactivation of GnRH by the hypothalamus has yet to be fully revealed (Biro, Greenspan, & Galvez, 2012).

Another pubertal process is the activation of the hypothalamic-pituitary-adrenal (HPA) axis. This process, known as adrenarche, involves the maturation of the adrenal glands and their production of certain androgens (Dorn & Biro, 2011). Adrenarche begins in children aged 6–8, although no outward signs of the process appear until later in puberty when increased androgen levels result in observable pubic hair growth (i.e., pubarche), other ancillary body hair, body odor, and perhaps acne (Abrue & Kaiser, 2016; Dorn & Biro, 2011). Typically, pubarche occurs before thelarche, and menarche occurs last. However, variations in this sequence also occur, such as thelarche before pubarche, or pubarche and thelarche appearing together (Biro, Huang, Daniels, & Lucky, 2008). In studying peripubertal girls, Biro et al. (2014) found that hormonal changes related to adrenarche occurred before those associated with gonadarche, suggesting that two pathways may represent the onset of puberty.

While adrenarche and gonadarche are thought to be distinct processes, research continues to explore their timing as sequential, oppositional, or coactivated (Shirtcliff et al., 2015). Some have noted that, in addition to its function in advancing pubertal changes, the HPA axis also regulates the stress response. To maximize the body’s capacity to perceive and defend against a threat, the stress response has been found to suppress other physiological systems, including reproductive function (Chrousos & Gold, 1992). Although this oppositional relationship between the stress response and reproductive function has been demonstrated in adults, Ruttle, Shirtcliff, Armstrong, Klein, and Essex (2013) suggested that it may not occur in adolescence. They argue that it makes more sense that coactivation, or positive coupling, would advance the development of both axes during adolescence, as opposed to the suppression of one by the other. As Shirtcliff et al. (2015) pointed out, “Stress and puberty can, and frequently do, co-occur” (p. 646), certainly an understatement.

An evolutionary/life history theory of development supports the notion of coactivation (Belsky, Steinberg, & Draper, 1991). This perspective differentiates between various kinds of stress and evolutionary strategies employed to manage them within specific contexts. Within this explanation, early puberty given significant childhood adversity may be adaptive in an evolutionary sense to maximize reproductive success, though not without associated costs (e.g., early sexual activity). Several studies have demonstrated a relationship between early menarche and stressful aspects of family adversity, including early maternal harshness (Belsky, Steinberg, Houts, & Halpern-Felsher, 2010), father absence (Tither & Ellis, 2008), maternal depression, and stepfather presence (Ellis & Garber, 2000). Researchers continue to explore relationships between HPA hormones and specific kinds of early life adversity in girls (and boys), though no consistent results have yet emerged (Negriff, Saxbe, & Trickett, 2015).

Related research regarding increases in children’s and adolescents’ body weight (Jasik & Lustig, 2008) has prompted investigations of “excessive” weight as a contributor to early puberty onset. Heavy weight children typically experience puberty earlier than their average or underweight peers, both in the U.S. (Kaplowitz & Bloch, 2016) and many other countries, e.g., India (Banik, Mendez, & Dickinson, 2015), Korea (Lee, Kim, Oh, Lee, & Park, 2016), and Turkey (Tekgül, Saltik, & Vatansever, 2014).

These data are in line with the theory that reproductive function requires enough nutritional support to occur, but when does “enough” lead to “excessive”? Castilho and Nucci (2015) noted that, with the improvement in economic conditions in Brazil, many fewer people experience food shortage and, instead of eating the healthier food provided in the public schools, children often prefer to consume junk food. Though lack of access to a healthy diet persists in many locations, where it does exist, healthy eating is not necessarily ensured.

Further, food intake is entwined with socioeconomic status. Researchers have documented earlier menarche in girls in the lowest levels of income in U.S., despite the general downward trend in menarcheal age in that country (Kreiger et al., 2015). Similar results come from research conducted elsewhere, e.g., Ghana (Ameade & Garti, 2016) and China (Meng, Li, Duan, Sun, & Jia, 2017). How might lower socioeconomic status, and poverty in particular, impact menarche? More often poverty is associated with lack of access to improved/healthier food and later menarche in many secular trend studies. However, living in poverty is a significant stressor (Kreiger et al., 2015). Thus, along with adverse family interactions, poverty could be considered to contribute to earlier pubertal development. This is especially relevant considering the functional relationships between the HPA and HPG axes during puberty that are currently being explored.

Finally, naturally occurring and manufactured endocrine-disrupting chemicals (EDCs) have been noted throughout the world as impacting pubertal physiology. In the U.S., the Endocrine Society (Gore et al., 2015) has documented the relationship between early breast development and exposure to EDCs, as does the International Federation of Obstetrics and Gynecology (Di Renzo et al., 2015). Some data indicate a relationship between EDCs and early menarche in the U.S. (Boswell, 2014). However, in a review of studies from the U.S., Europe, and Asia, Mouritsen et al. (2010) concluded that the link between exposure to EDCs and early thelarche is stronger than that between EDC exposure and early menarche. At the same time, studies show that specific compounds (e.g., lead) have been found to be related to late or delayed aspects of pubertal development in girls (Schoeters, Hond, Dhoog, van Larebeke, & Leijs, 2008). These researchers stressed that the relationships that may occur between the myriad of EDCs and disruptions of the endocrine process throughout the lifespan have yet to be fully understood, and called for more studies of EDC exposure related to human health. Importantly, Shakeel, George, Jose, Jose, and Mathew (2010) noted the disproportionate exposure to EDCs worldwide and associated negative health consequences among low-income people. They called specifically for more studies in developing countries, emphasizing that results from developed countries cannot be generalized to low-income or resource-poor countries.

A trend in earlier pubertal onset?

Determination by the timing of breast bud development

A key study by Herman-Giddens et al. (1997) raised clinical concern about earlier pubertal onset. Previous data had indicated that the average age of thelarche was 11.5 years (Marshall & Tanner, 1969), but Herman-Giddens et al. (1997) reported that the average age was 9.96 years for European American girls and 8.87 years for African American girls. Their study was criticized for its lack of a representative sample and for the use of inspection rather than palpation to evaluate breast bud development. However, subsequent studies with methodological corrections have shown similar results (Jasik & Lustig, 2008).

One outcome of these studies was renewed concern about precocious puberty. Kaplowitz and Bloch (2016) recommended that girls who experience breast bud development assessed by palpation before the age of 8 be referred for an evaluation of precocious puberty. Observable signs of adrenarche before age 8, especially the appearance of pubic hair, should also be referred to investigate a diagnosis of premature adrenarche (Kaplowitz & Bloch, 2016). Premature adrenarche has been studied in relation to the development of polycystic ovarian syndrome (PCOS) and other related health issues that might ensue (Dorn & Biro, 2011). Despite these concerns, Kaplowitz and Bloch (2016) defined central precocious puberty in girls as the full activation of the HPG axis, and further, that true precocious puberty entails increased development and growth of breasts, though pubic hair may not exist. Diagnosis usually includes bone age determination and hormonal assays. Studies of the incidence of precocious puberty have also occurred in other parts of the world, e.g., in Korea (Kim, Huh, Won, Lee, & Park, 2015), and Pakistan (Atta et al., 2014), albeit with various diagnostic indicators. It is important to note that precocious puberty is distinct from early puberty.

Determination by the timing of menarche

Interest in documenting girls’ pubertal onset is often framed as concern about potential consequences for health and well-being, not the least of which is early sexual activity and pregnancy (see Marvàn & Alcalá-Herrera, Chapter 2, this volume). Accordingly, many studies world-wide have investigated location-specific population norms, or a secular trend, in the decline in age of pubertal onset. Deriving these norms is complicated, as it can take 1–7 years to complete pubertal growth (Mendel, 2014). Many of these studies focus on girls’ pubertal timing, whereas research on boys’ pubertal timing is not as plentiful but has been increasing (Hermann-Giddens et al., 2012; Mendel & Ferrero, 2012). The age of menarche is very often used as a marker of pubertal onset, even though it is a late occurring pubertal event. Although breast bud development is currently the best indicator of the reactivation of the HPG axis, Wacharasindhu (2009) explained that it is rarely used by researchers, partly because participants can more easily recall the age of menarche than the age of thelarche. He also noted that, in some locations, physical examination of the breast is not considered polite or an accepted procedure.

Further, many factors, some mentioned previously, are investigated as contributors to menarcheal timing in these studies. For example, ethnicity, location, and religious differences have been explored. In the U.S., Black and Hispanic girls have been found to experience earlier menarche than non-Hispanic White and Asian girls (Hillard, 2014). In China, the downward trend in the age of menarche was documented for girls from rural but not urban areas (Meng et al., 2017). In India, Christian and Muslim women reported earlier menarche than women who practice Hindu, Sikh, and other religions Pathak, Tripathi, and Subramanian (2014).

Unlike early thelarche, a trend in earlier ...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• Author biographies
• Introduction
• PART I: Menarche, menstruation and menopause
• PART II: Reproductive and gynecological disorders
• PART III: Contraception and infertility
• PART IV: Pregnancy and childbirth
• PART V: Sexuality and sexual health
• PART VI: Marginalized women’s health
• Index