Obstetrics & Gynecology · Medical Literature
Age at menarche in South Asia: an interplay of sociodemographic, nutritional, lifestyle, anthropometric, biological, and environmental factors-a systematic review.
Abstract
Age at menarche is a dynamic indicator of a female's health trajectories. Despite its relevance, the cohesive synthesis of its multifactorial determinants in South Asia is lacking, limiting the targeted public health strategies. This review examines the sociodemographic, nutritional, lifestyle, anthropometric, biological, and environmental determinants of age at menarche among females aged 8-21 years across South Asia. A systematic review of observational studies on determinants of age at menarche was conducted. Adhering to PRISMA guidelines, articles published between January 2014 and May 2025 were identified from ScienceDirect, PubMed, Web of Science, and Google Scholar. Methodological quality of eligible studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Due to significant heterogeneity across the studies, findings were narratively synthesized precluding meta-analysis. Out of 729 articles, 18 studies from South Asian countries were included. The mean age at menarche clustered between 12 and 13 years across the studies. Menarche 14 years of age was associated with rural residence, lower socioeconomic status, stunting and underweight. While heredity, demographics, and early-life programming influence age at menarche, modifiable nutrition and lifestyle factors are critical determinants in South Asia. Targeted interventions focusing on these determinants could reduce the burden of metabolic and growth-related disorders among adolescent females. Paucity of studies in South Asian countries is a critical evidence gap that needs attention to better inform policies for adolescent health. INPLASY, Identifier: INPLASY202610051.
Clinical relevance
Age at menarche is a sentinel biomarker of long-term cardiometabolic, reproductive, and growth-related health trajectories in females. This systematic review addresses a critical evidence gap by synthesizing multifactorial determinants of menarche timing across South Asia—a region encompassing over 600 million adolescent females—where targeted public health strategies have been hampered by the absence of cohesive regional data. Clinicians managing adolescent health, pediatric endocrinology, and reproductive medicine in or serving South Asian populations need this contextual framework to identify at-risk individuals and counsel families appropriately.
Key findings
1. Mean age at menarche clustered between 12 and 13 years across 18 observational studies from South Asian countries published between January 2014 and May 2025, based on a PRISMA-adherent systematic review screened from 729 articles. 2. Early menarche ( 14 years) was associated with rural residence, lower socioeconomic status, stunting, and underweight—underscoring the role of chronic undernutrition and socioeconomic deprivation in menarcheal delay. 5. Maternal age at menarche was identified as a biological determinant of daughters' menarche timing, consistent with known heritability of pubertal onset. 6. Environmental factor exposure was associated with earlier menarche timing; however, significant heterogeneity across included studies precluded meta-analysis, limiting precise effect size quantification—a critical methodological caveat for all findings.
Practice implications
Clinicians evaluating pubertal timing in South Asian adolescent females should systematically assess modifiable risk factors—including BMI trajectory, dietary pattern (particularly high animal-protein and high-fruit intake), screen time, sleep adequacy, and physical activity levels—as these represent actionable intervention targets to mitigate early menarche and its downstream cardiometabolic sequelae. In rural or low-socioeconomic-status settings, nutritional screening for stunting and underweight should be integrated into adolescent well-care visits, as these conditions independently predispose to delayed menarche and associated growth-related morbidity. Public health programs targeting South Asian adolescents should adopt a stratified approach: obesity and lifestyle-focused interventions in urban, higher-SES populations to prevent precocious menarche, and micronutrient and caloric supplementation strategies in rural, lower-SES populations to address menarcheal delay.