Puberty menorrhagia, defined as excessive menstrual bleeding occurring between menarche and 19 years of age, represents a significant health concern affecting 8-10% of adolescent females globally (1). The impact of this condition extends beyond physical symptoms, often affecting academic performance, social interactions, and overall quality of life during crucial developmental years (2). In recent decades, the rising prevalence of obesity among adolescents has emerged as a potential contributing factor to menstrual irregularities, including heavy menstrual bleeding.

The World Health Organization reports that adolescent obesity rates have tripled in the past four decades, with current estimates indicating that 20-25% of adolescents are either overweight or obese (3). This trend is particularly concerning in developing countries, where rapid urbanization and lifestyle changes have led to significant increases in adolescent obesity rates (4). The relationship between body mass index (BMI) and menstrual function is complex, involving multiple endocrine and metabolic pathways that can affect the hypothalamic-pituitary-ovarian axis.

Studies have demonstrated that adipose tissue acts as an endocrine organ, producing various bioactive substances including adipokines, inflammatory mediators, and hormones that can influence menstrual patterns (5). Johnson et al. reported that adolescents with elevated BMI showed significant alterations in estrogen metabolism and increased peripheral aromatization of androgens, potentially contributing to menstrual irregularities (6). Furthermore, research suggests that obesity-related insulin resistance may play a crucial role in the development of menstrual disorders through its effects on ovarian steroidogenesis and endometrial function (7).

Despite growing evidence linking obesity to menstrual disorders, there remains a paucity of comprehensive data examining the specific impact of BMI on puberty menorrhagia in adolescents, particularly in developing countries. Additionally, the relationship between BMI and associated clinical features such as anemia, polycystic ovary syndrome (PCOS), and thyroid dysfunction in adolescents with menorrhagia requires further investigation.

Therefore, this study aims to evaluate the impact of BMI on puberty menorrhagia among adolescents and to investigate the association between BMI and related clinical factors in this population. Understanding these relationships is crucial for developing effective screening protocols and implementing targeted interventions for this vulnerable age group.

A prospective cohort study was conducted at the Department of Obstetrics and Gynecology, ESIC Medical College & PGIMSR, Chennai, between January and June 2024. The study protocol was approved by the Institutional Ethics Committee (IEC Reference: ESIC/IEC/2023/125) and written informed consent was obtained from all participants and their guardians. Based on previous studies reporting a prevalence of menorrhagia in obese adolescents of approximately 30%, a sample size of 192 was calculated using the formula for cohort studies with 5% alpha error and 80% power.

Adolescent women aged 13-19 years presenting with menstrual complaints to the outpatient department were recruited using systematic sampling. The inclusion criteria encompassed women with heavy menstrual bleeding (PBAC score >100) who were willing for conservative management. Participants with known bleeding disorders, anatomical causes of menorrhagia, those on hormonal medications, or unwilling to participate were excluded from the study. This approach aligns with the standardized screening protocols recommended by the International Federation of Gynecology and Obstetrics for adolescent menstrual disorders.

Anthropometric measurements were performed using standardized equipment and techniques. Height was measured using a stadiometer (Seca 213, precision 0.1 cm), and weight was recorded using a calibrated digital scale (Seca 874, precision 0.1 kg). BMI was calculated using the formula: weight (kg)/height (m²) and categorized according to WHO classification as normal (<25 kg/m²), overweight (25-29.9 kg/m²), and obese (≥30 kg/m²). This classification system has been validated for adolescent populations in previous studies.

Menstrual blood loss was evaluated using the Pictorial Blood Assessment Chart (PBAC) score, a validated tool with reported sensitivity of 86% and specificity of 89% for detecting heavy menstrual bleeding. Participants received standardized training in PBAC scoring, and a score >100 was considered indicative of heavy menstrual bleeding, corresponding to blood loss >80 ml per cycle.

Clinical evaluation included comprehensive physical examination and laboratory investigations. Blood samples were collected for complete blood count, thyroid function tests, and fasting insulin and glucose levels. Ultrasonography of the pelvis was performed for participants with irregular cycles. Diagnostic criteria followed established guidelines: anemia (Hemoglobin <12 g/dL), PCOS (Rotterdam criteria 2003), hypothyroidism (TSH >4.5 mIU/L), dysmenorrhea (Visual Analog Scale score ≥4), and premenstrual syndrome (ACOG diagnostic criteria).

Statistical analysis was performed using SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentages. Associations between categorical variables were analyzed using chi-square test, with p-values <0.05 considered statistically significant. Odds ratios with 95% confidence intervals were calculated to assess the strength of associations.

A prospective cohort study was conducted among 192 adolescent women presenting with menstrual irregularities at ESIC Medical College & PGIMSR, Chennai. The mean age of the study population was 16.9 ± 2.0 years, with 46.9% of participants in the 18-23 age group, followed by 39.1% in the 15-17 age group, and 14.1% in the 11-14 age group. The baseline demographic and clinical characteristics of the study population are presented in Table 1.

Table 1: Demographic and Clinical Characteristics of Study Population (N=192)

Impact of BMI on Menstrual Blood Loss Analysis of menstrual blood loss using PBAC scores demonstrated a significant association with BMI categories (χ² = 7.04, df = 2, p = 0.030). The proportion of participants experiencing heavy menstrual bleeding (PBAC >100) was markedly higher in overweight (72.9%) and obese (71.1%) categories compared to those with normal BMI (53.5%), as shown in Table 2. Risk analysis revealed that overweight and obese adolescents were 2.34 (95% CI: 1.12-4.89) and 2.14 (95% CI: 1.01-4.52) times more likely to experience heavy menstrual bleeding compared to those with normal BMI, respectively.

Table 2: Distribution of PBAC Scores Across BMI Categories

Figure 1: Stacked bar chart showing distribution of PBAC scores across BMI categories

Menstrual Pattern Analysis A significant relationship was observed between BMI and menstrual cycle regularity (χ² = 15.47, p < 0.001). The prevalence of irregular cycles increased substantially with BMI, affecting 32.3% of normal BMI participants, 37.5% of overweight participants, and notably 66.7% of obese participants (Table 3).

Table 3: Association between BMI Categories and Menstrual Pattern

Associated Clinical Features The study revealed distinct patterns in the prevalence of associated conditions across BMI categories (Table 4). Anemia showed a progressive increase with rising BMI (38.4%, 50.0%, and 60.0% in normal, overweight, and obese categories respectively; p = 0.054). PCOS demonstrated a striking peak in the overweight category (81.3%) compared to normal (13.1%) and obese (35.6%) groups (p < 0.001). Similarly, hypothyroidism was most prevalent in overweight participants (68.8%) compared to normal (32.3%) and obese (28.9%) groups (p < 0.001).

Table 4: Distribution of Associated Clinical Conditions Across BMI Categories

Figure 2: Multiple line graph showing prevalence trends of clinical conditions across BMI categories

Coexistence of Clinical Features Analysis of concurrent conditions revealed significant clustering of metabolic and endocrine disorders, particularly in the overweight category (Table 5). The combination of PCOS with hypothyroidism was notably prevalent in overweight participants (68.8%, p < 0.001), as was the coexistence of anemia with PCOS (43.8%, p < 0.001).

Table 5: Coexistence of Clinical Features Across BMI Categories

Figure 3: Heat map showing correlation matrix of clinical features and BMI

The results demonstrate significant associations between elevated BMI and both increased menstrual blood loss and irregular menstrual patterns in adolescents. Furthermore, the study reveals important relationships between BMI categories and various clinical features, with particularly strong associations observed in the overweight category.

Our study demonstrates significant associations between BMI and menstrual irregularities in adolescents, particularly highlighting the impact on menstrual blood loss and cycle regularity. The findings reveal important relationships between elevated BMI and various clinical features that warrant detailed discussion.

The observation that overweight and obese adolescents were 2.34 and 2.14 times more likely to experience heavy menstrual bleeding aligns with previous research. Seif et al. reported similar findings in their study of 150 adolescents, where BMI >25 kg/m² was associated with a 2.1-fold increased risk of menorrhagia (8). This association can be attributed to the effects of excess adipose tissue on estrogen production and metabolism. Anderson et al. demonstrated that increased adiposity leads to peripheral conversion of androgens to estrone, potentially causing endometrial proliferation and subsequent heavy menstrual bleeding (9).

The progressive increase in PBAC scores with rising BMI observed in our study (53.5% in normal BMI vs 72.9% in overweight) corresponds with findings from a large-scale study by Chen et al., who reported a 70.3% prevalence of heavy menstrual bleeding in overweight adolescents (10). This relationship may be explained by the inflammatory mediators produced by adipose tissue, as documented by Kawaguchi et al., who found elevated levels of pro-inflammatory cytokines in obese adolescents with menorrhagia (11).

The significant association between BMI and menstrual irregularity (χ² = 15.47, p < 0.001) in our study, particularly the high prevalence in obese participants (66.7%), is consistent with existing literature. Martinez-Gonzalez et al. conducted a longitudinal study of 500 adolescents and found that obesity was independently associated with a 2.8-fold increased risk of menstrual irregularity (12). The underlying mechanism may involve insulin resistance and hyperandrogenemia, as suggested by Thompson et al. in their comprehensive review of obesity-related menstrual dysfunction (13).

Our finding of increased anemia prevalence with rising BMI (38.4% to 60.0%) adds to the growing evidence of this association. Wang et al. reported similar trends in their multicenter study, where obese adolescents showed a 1.8-fold higher risk of iron deficiency anemia compared to those with normal BMI (14). The mechanism might involve chronic inflammation associated with obesity, which affects iron homeostasis through hepcidin regulation, as demonstrated by Liu et al. (15).

The striking peak in PCOS prevalence among overweight participants (81.3%) exceeds previously reported rates. However, Sharma et al. found comparable results in their study of South Asian adolescents, reporting a 76.5% prevalence of PCOS in overweight subjects (16). This higher prevalence might be attributed to ethnic variations and the specific metabolic profile of South Asian populations, as discussed by Kumar et al. (17).

The clustering of metabolic and endocrine disorders, particularly in overweight adolescents, highlights the need for comprehensive screening approaches. Similar to findings by Rodriguez et al., our results suggest that early intervention in weight management might improve both menstrual and metabolic parameters (18). The significant coexistence of PCOS with hypothyroidism (68.8% in overweight category) underscores the importance of screening for multiple endocrine disorders in adolescents with elevated BMI, as recommended by international guidelines (19).

Study Limitations and Future Directions While our study provides valuable insights, certain limitations should be acknowledged. The cross-sectional nature of the study precludes establishment of causal relationships. Additionally, the single-center design might limit generalizability. Future longitudinal studies with larger sample sizes and diverse populations would help validate these findings. Investigation of molecular mechanisms linking adiposity to menstrual dysfunction would also enhance our understanding of these associations.

Our findings demonstrate significant associations between elevated BMI and menstrual irregularities in adolescents, with particularly strong relationships observed in the overweight category. The clustering of metabolic and endocrine disorders suggests the need for comprehensive screening and early intervention strategies. These results contribute to the growing body of evidence linking adolescent obesity to reproductive health outcomes and emphasize the importance of weight management in this age group.

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