Relationship between some indicators of reproductive history, body fatness and the menopausal transition in Hungarian women
© Zsakai et al. 2015
Received: 21 April 2015
Accepted: 13 October 2015
Published: 22 October 2015
This paper analyzed the relationship between some indicators of reproductive history and body fatness in relation to the timing of the menopause transition in Hungarian women using survival analysis after controlling for birth cohort.
Data on menstruation and reproductive history were collected during the personal interviews in a sample of 1932 women (aged 35+ years). Menarcheal age, the length of menstrual cycles and menstrual bleedings, regularity of menstrual cycles, number of gestations, lactation, the ever use of contraceptives, menopausal status and age at menopause were used as indicators of reproductive history. The body fat fraction was estimated by bioelectrical impedance analysis. Body fatness was also estimated by dividing women into obese and non-obese categories (considering body mass index and waist-to-hip ratio). Survival analyses were used to analyze the relationship between the indicators of reproductive history and body fatness during the menopausal transition.
Only the menarcheal age among the investigated reproductive life characteristics showed secular changes in the studied decades in Hungary; the mean age at menarche decreased by approximately 2.5 months per decade from the 1920s until the 1970s. Ever use of hormonal contraceptives, a relatively long cycle length in the perimenopausal transition and higher parity were all related with lower risk of early menopause. Later menarcheal age, normal length of menstrual cycle or bleeding in the climacterium, irregular bleeding pattern and postmenopausal status were associated with a higher amount of body fatness, while never use of contraceptives, regular menstruation, postmenopausal status and relatively early menopause were associated with a higher risk of abdominal obesity.
This report confirms that age of menarche is not significantly predictive of age at menopause but prior use of oral contraceptives, longer mean cycle length and smaller number of gestations all are. In addition, age of menarche, irregular bleeding pattern before the climacterium, length of menstrual cycles and bleedings during the climacterium and postmenopausal status were associated with obesity during the climacterium.
The age at menopause is a distinctive milestone in female reproductive life since it indicates not only the increased risk of morbidity and premature mortality due to the decreased level of sex hormone levels but also a biological marker of overall ageing and general health status. Menopause is universal and shows little variation in the timing of its occurrence (~50 years) across contemporary human populations and has remained mainly constant over the last 100 years in developed societies [1–3].
Previous studies on the onset of natural menopause have revealed that its variance is determined mainly by the interactions of multiple genes through control of the ageing processes of the neuroendocrine system [4, 5], and environmental factors explain only a small part of the variance in the age of menopause. It has been found that lifestyle factors and general health status can influence reproductive ageing by damaging the oocytes and decreasing the level of sexual hormones [6, 7].
The main purposes of this study were to analyze (1) the relationship between the age at menopause and the other characteristics of reproductive life in Hungarian women and (2) the relationships between body fatness at the time of menopause and reproductive life characteristics. The secular changes of the studied reproductive variables were analyzed only in those women who never used hormonal contraceptives, since the use of this kind of contraceptives can significantly modify the natural characteristics of menstrual cycles.
Since it was confirmed by many epidemiological surveys  that the improvement of the socioeconomic environment in the last century significantly influenced the pattern of growth and maturation (the block of the growth velocity was disengaged, the manifestation of genetically established metric features increased, the sexual maturation shifted toward an earlier chronological age), the positive secular trend of menarcheal age was hypothesized.
According to our hypothesis, the age at menopause is influenced not only by extrinsic factors (e.g. by socioeconomic factors) but also by the factors of the reproductive life; therefore, the relationship between the age at menopause and the other main characteristics of reproductive life (as menarcheal age, number of gestations, lactation, length of menstruation cycles) was presupposed.
The possible advancement in timing of puberty was hypothesized to be accompanied by the earlier onset of menopause due to the positive secular socioeconomic changes and the earlier onset of reproductive life and a decrease in the number of gestations per women over recent decades.
Since the transitions between prereproductive, reproductive and postreproductive stages are accompanied not only by the changing levels of female sex hormones but also by significant changes of metabolic status and body structure, a hypothesis of a relation between the risk of obesity/abdominal obesity and the characteristics of reproductive life was proposed as well. The characteristics of reproductive life that can be related to higher level of female sex hormones (e.g. earlier menarcheal age, oral contraceptives) were supposed to increase the risk of obesity in the menopausal transition because these reproductive life parameters were considered as indicators of a lifelong higher level of sex hormones.
Subject recruitment was done by using multilevel multistage sampling so as to obtain subjects that represented the diverse types of settlements (types of settlements were as follows: Budapest with two million inhabitants, large towns with more than 100,000 inhabitants, small towns with 10,000−99,999 inhabitants, villages with 1000−9999 inhabitants, small villages below 1000 inhabitants) as well as the age distribution of Hungarian women . The sample was designed by the Hungarian Central Statistical Office. Women living in the selected settlements were contacted (via personal interviews at home or place of residence and workplaces) and were screened for eligibility (eligibility criteria were as follows: age between 25 and 94 years, able to give verbal consent; elderly people under guardianship was excluded). This process continued until a sufficient number of eligible women was identified in all settlement categories in every age-group. The socioeconomic status of the sample (by considering the level of subjects’ education and the marital status: 8.5 % not completed elementary school, 22.4 % completed elementary school, 16.7 % vocational training school, 35.3 % secondary school, 17.1 % higher education; 12.4 % never married, 41.0 % married, 28.5 % widowed, 18.1 % divorced or separated) fitted the socioeconomic stratification of the selected age-group of women in the Hungarian population . Participation was voluntary and data were anonymised and analyzed for scientific purposes only.
The main purposes of the Hungarian Menopause Study were (1) to analyze the nature of menopausal transition in Hungary; (2) to analyze the manner in which the onset of menopause and the length of menopausal transition are affected by the nutritional status and body composition, lifestyle and socioeconomic background of women; (3) to estimate the influence of genetic and endocrinological factors on reproductive ageing process by comparing autophagic activity and the female sex hormone levels in women being in different menopausal status; and (4) to identify the most important intrinsic and extrinsic risk factors that can lead to early or late menopause.
The distribution of studied women (born between the 1920s and 1980s) by birth cohort and menopausal status
Hyster- or ovariectomized
Anthropometric description of the studied sample (for continuous parameters—mean, SD, 95 % CI; for discrete parameters—relative frequency of the categories)
95 % CI
Body mass (kg)
Upper arm circumference (cm)
Waist circumference (cm)
Hip circumference (cm)
Absolute body fat mass (kg)
Relative body fat mass (%)
Nutritional status categories
Normal nutritional status
Abdominal obesity categories
Not abdominal obese
Women who had any diseases or were taking any medications known to affect body composition or who had been hysterectomized or bilaterally ovariectomized were not included in the present analysis. During the analysis of secular changes in the reproductive life variables, only the data of those women who had never used oral contraceptives were considered.
Reproductive life characteristics
Data on menarcheal age, length of menstrual cycles and menstrual bleeding in puberty, youth, adulthood and climacterium, ever use of hormonal contraceptives (including past and current oral contraceptive use: date, length of use, name of contraceptives), number of pregnancies (maternal age at pregnancies, length of pregnancies), number of live births with or without lactation, age at which any irregularity of menstrual cycle length commenced, age at the last menstrual cycle and age at menopause were collected during the personal interviews. The questionnaires were constructed by considering the WHO and Stages of Reproductive Aging Workshop (STRAW) recommendations on collecting data on reproductive life characteristics in women [12, 13].
Menstrual and reproductive history parameters of studied Hungarian women (n 1932, born between the 1920s and 1980s) included in multivariate survival analyses
Menstrual and reproductive variables
Definition of categories
Length of menstrual cycles
28–30 days till adulthood and 28–70 days in climacterium
≥31 days till adulthood and ≥71 days in climacterium
Length of menstrual bleeding
≤3 days till adulthood and −2 days in climacterium
4–6 days till adulthood and 3–6 days in climacterium
Number of gestations and number of gestations with or without lactation
4 or more
Menstrual period in the past 3 months, no decreased predictability
Menstrual period in the past 3 months but less predictability in the preceding 12 months
Menstrual bleeding in the past 12 months but not in the past 3 months
Amenorrheic for the past 12 months
Age at menopause
Body fatness estimation
The body fat fraction was estimated by bioelectrical impedance analysis (NutriGuard M device, DataInput, Germany). Subjects were divided into nutritional status categories (underweight: BMI < 18.50 kg/m2, normal nutritional status: BMI = 18.50-24.99 kg/m2, preobse/overweight: 25.00-29.99 kg/m2, obese: BMI > 30.00 kg/m2) using the WHO cut-off points of BMI . Waist-to-hip ratio was used to assess abdominal obesity. Subjects were divided into abdominal obesity categories by using WHO cut-off point (abdominal obesity: WHR ≥ 0.85) .
As some women had not reached menopause, survival analyses (Kaplan-Meier and Cox proportional hazards regression models) were used to analyze the data. Initially, analyses were undertaken using only one independent variable (potential estimates of age at menopause were as follows: menarcheal age, the length of menstrual cycles and menstrual bleeding in puberty, youth, adulthood and climacterium, ever use of hormonal contraceptives, the number of pregnancies, lactation, birth cohort; potential estimates of obesity indicators were the same reproductive characteristics as in the case of age at menopause by adding menstrual irregularity, menopausal status and age at menopause) and those that were significant were entered into a multivariate analysis (stepwise analysis). The omnibus test was used for testing the overall fit of Cox regression models.
The statistical analyses were done by using SPSS v. 20. Hypotheses were tested at the 5 % level of random error.
Ethics committees’ informed consent
All subjects were asked to give their written informed consent to participate in the study. All attendants were provided by detailed information on the main purposes of the study and on all examinations before their approval. The participation was voluntary and anonym in the study. The research objectives, the research methodology and the questionnaires were approved by the National Human Research Ethics Committee (108/2011) and the Hungarian Scientific Research Fund (EIK-1001/2011).
Limitations of the study
The main limitations of the study were the cross-sectional study design and the retrospective data collection (the possibility of recall bias cannot be excluded, especially not among older respondents). The personal interviews helped to diminish this methodological limitation of the study. The menopausal status and the reproductive life characteristics, especially the characteristics of the menstrual cycles, can be estimated more accurately by longitudinally. Moreover, the menopausal status can be estimated more accurately by following the complete STRAW staging system for ovarian ageing including menstrual and qualitative hormonal criteria . Although the STRAW system is widely considered as the gold standard for characterizing the menopausal transition, but due to the total cost of qualitative hormonal estimations, this system cannot be always used in epidemiological studies, mostly in clinical surveys. Therefore, only the characteristics of menstrual cycle pattern were considered to divide women into menopausal status subgroups in the present analysis.
Secular changes in the characteristics of reproductive life
Statistical parameters (mean, SD, 95 % CI) of menarcheal age and age at menopause by birth cohort
95 % CI
95 % CI
Reproductive life parameters and the onset of menopause
Significance levels (p (χ 2), significant values are in italics) in the Kaplan-Meier univariate survival analysis of the relation between the studied reproductive parameters and the age at menopause, body fatness and abdominal obesity in the studied Hungarian women (n 1932, born between the 1920s and 1980s)
Age at menopause
Cycle length: puberty
Bleeding length: puberty
Number of gestations
Age of menarche
Age at menopause
Hazard ratio (HR) of the onset of menopause according to the studied reproductive parameters (adjusted for birth cohorts) in the Cox proportional regression modelling (95 % CI, p = 0.019, omnibus test)
Reproductive life variables
95 % CI
Cycle length in climacterium
Number of gestations
Body fatness in the menopause transition in relation to the reproductive history
Hazard ratio (HR) of obesity according to the studied reproductive parameters (adjusted for birth cohorts) in the Cox proportional regression modelling (95 % CI, p = 0.020, omnibus test)
Reproductive life variables
95 % CI
Cycle length in climacterium
Bleeding length in climacterium
Hazard ratio (HR) of higher abdominal body fat distribution (abdominal obesity) according to the studied reproductive parameters (adjusted for birth cohorts) in the Cox proportional regression modelling (95 % CI, p = 0.048, omnibus test
Reproductive life variables
95 % CI
Age at menopause
By considering the secular changes in the studied reproductive parameters, it could be stated that the results of presented retrospective data collection were in very good concordance with the results of status quo data collection on menarcheal age in the last century ; the menarcheal age decreased significantly in the last decades in Hungary. The observed menopausal age (median age 51.6 years) was stable in the studied decades and consistent with other available data from Europe with median age at menopause in this region ranging between 50 and 52 years. This means that the length of the reproductive period extended with about 1.5 year in the studied interval. Neither the length of the menstrual cycle nor the menstrual flow showed secular change in the studied decades.
Reproductive risk factors of early menopause, obesity and abdominal obesity in the menopause transition—a review of literature (reviewed from the late 1990s)
Higher risk of early menopause
Higher risk of obesity in the climacterium
Higher risk of abdominal obesity in the climacterium
Never use of hormonal contraceptivesa
High variability in cycle length prior to age 40 years a
Long period of lactation 
Irregular bleeding pattern before the climacteriuma
Normal length of menstrual cycle in the climacteriuma
Normal length of menstrual flow in the climacteriuma
Early age at menopause 
High variability in cycle length prior to age 40 years 
The Cox proportional hazards regression modelling revealed that (1) the ever use of contraceptives, long menstrual cycles and higher number of gestations related to lower risk of earlier menopause, while (2) later menarcheal age, normal length of menstrual cycle or bleeding in the climacterium, irregular bleeding pattern and the postmenopausal status were associated with higher prevalence of obesity and (3) the never use of contraceptives, the regular menstruation, the postmenopausal status and relatively earlier age at menopause increased the risk of abdominal obesity in the studied sample. Overall, the characteristics of reproductive life were found to have significant influence on the onset of the menopausal transition. Moreover, the presented results suggest that the risk of obesity is also related to the reproductive life parameters.
Contrary to expectations, the results from this study suggest there is no relationship between age of menarche and age at menopause. The results of the present study add to a growing body of literature showing that prior use of oral contraceptives, longer mean cycle length and smaller number of gestations are all associated with later age of menopause.
Our results also confirm those from previous studies showing that the later age of menarche, the irregular bleeding pattern before climacterium, the normal length of menstrual cycles and menstrual bleedings in the climacterium and the postmenopausal status were associated with a higher risk of obesity in climacterium.
By considering the relationship between the reproductive life characteristics and body fatness distribution in the menopausal transition, these findings confirm—beyond the never use of hormonal contraceptives—the formerly evidenced association that the menopausal status was related to abdominal obesity.
Recent studies have shown that variation in age at menopause and the other biological characteristics of the menopausal transition, e.g. body structural changes, are associated with several factors, such as genetic, reproductive, socio-demographic and certain behavioural, lifestyle influences [4, 5, 57]. These analyses confirmed the relationship between the ever use of hormonal contraceptives, the length of menstrual cycle and bleeding in the climacterium with the age of menopause and the same reproductive variables and menopausal status with the body fatness in the menopausal transition.
The study was supported by the Hungarian Scientific Research Fund (OTKA grant K83966). The work of the first author was also supported by the Janos Bolyai Research Scholarship (2014-2017) of the Hungarian Academy of Sciences.
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