JOURNAL READING

LAPORAN KASUS TENTANG OLIGOMENORRHEA, HUBUNGAN

STATUS GIZI, AKTIVITAS FISIK, STRESS, MENARCHE DAN
OBESITAS DENGAN GANGGUAN MENSTRUASI
(OLIGOMERORRHEA) PADA ULASAN TIGA JURNAL
INTERNASIONAL

Disusun Untuk Memenuhi Tugas Praktik Asuhan Kebidanan Holistik

Pada Remaja dan Pranikah

Oleh:

Dwie Yunita Baska

NIM P01740523010

Pembimbing Akademik:

Ratna Dewi, SKM, MPH

NIP. 197810142001122001

PROGRAM STUDI PENDIDIKAN PROFESI BIDAN

PROGRAM PROFESI JURUSAN KEBIDANAN
POLTEKKES KEMENKES BENGKULU
TAHUN AKDEMIK 2022/2023
 HALAMAN PENGESAHAN

Journal Reading

LAPORAN KASUS TENTANG OLIGOMENORRHEA, HUBUNGAN

STATUS GIZI, AKTIVITAS FISIK, STRESS, MENARCHE DAN
OBESITAS DENGAN GANGGUAN MENSTRUASI
(OLIGOMERORRHEA) PADA ULASAN TIGA JURNAL
INTERNASIONAL

Disusun Oleh :

Dwie Yunita Baska

NIM P01740523010

Menyetuji,
Pembimbing Akademik

Ratna Dewi, SST, M.Keb

NIP. 197810142001122001

Mengetahui,

Ketua Program Studi Pendidikan Profesi Bidan

Diah Eka Nugraheni, SST., M.Keb

NIP: 198012102002122002

ii
 KATA PENGANTAR

Puji syukur penulis panjatkan kepada Tuhan Yang Maha Esa, karena atas
berkat dan rahmat-Nya, sehingga dapat menyelesaikan Journal Reading ini.
Penulisan Journal Reading ini dilakukan dalam rangka memenuhi tugas Praktik
Asuhan Kebidanan Holistik Pada Remaja dan Pranikah. Journal Reading ini
terwujud atas bimbingan, pengarahan dan bantuan dari berbagai pihak yang tidak
bisa penulis sebutkan satu persatu dan pada kesempatan ini penulis
menyampaikan ucapan terima kasih kepada :
1. Ibu Eliana, SKM., MPH selaku Direktur Poltekkes Kemenkes Bengkulu
2. Ibu Yuniarti, SST, M.Kes selaku Ketua Jurusan Kebidanan Poltekkes
Kemenkes Bengkulu
3. Ibu Diah Eka Nugraheni, SST., M.Keb selaku Ketua Prodi Profesi Bidan
Jurusan Kebidanan Poltekkes Kemenkes Bengkulu
4. Ibu Ratna Dewi, SKM,MPH selaku pembimbing Akademik
5. Ibu Yulismita, SST selaku Pembimbing Lahan.
Mengingat keterbatasan pengetahuan dan pengalaman, penulis menyadari
bahwa penulisan Journal Reading ini masih belum sempurna. Oleh karena itu,
penulis mengharapkan kritik dan saran yang bersifat membangun dari semua
pihak. Akhir kata, penulis berharap semoga Journal Reading ini bermanfaat bagi
semua pihak.

Bengkulu, September 2023

Penyusun

iii
 DAFTAR ISI

Halaman
HALAMAN JUDUL ...................................................................................... i
HALAMAN PENGESAHAN ........................................................................ ii
KATA PENGANTAR .................................................................................... iii
DAFTAR ISI ................................................................................................... iv

BAB I PENDAHULUAN
A. Judul Jurnal ................................................................................... 1
B. Abstrak .......................................................................................... 1

BAB II ULASAN JURNAL

A. Latar Belakang dan Tujuan ........................................................... 3
B. Metodelogi .................................................................................... 4
C. Hasil Penelitian ............................................................................. 5

BAB III TELAAH KRITIS

A. PICOT ........................................................................................... 8
B. RAMMbo ...................................................................................... 9

BAB IV PENUTUP ........................................................................................ 10

DAFTAR PUSTAKA ..................................................................................... 11
LAMPIRAN

iv
 BAB I
PENDAHULUAN

A. Judul, Penulis, Tahun Terbit Jurnal

1. Jurnal 1
a. Judul : Hyperandrogenism, oligomenorrhea, and
erythrocytosis caused by an ovarian Leydig cell
tumor: A case report

b. Penulis : Fernando Mendonca, Selma Suuto, Daniela M, ect.

c. Tahun Terbit : March, 26, 2021

d. Published : Wiley online library-clinical case report

2. Jurnal 2
a. Judul : The Relationship of Nutritional Status,
Physical Activity, Stress, and Menarche to
Menstrual Disorder (Oligomenorrhea)
b. Penulis : Vriska Roro Sekar Arum, Ari Y, and Oktia
c. Tahun Terbit : April, 20, 2019

d. Published Pulic Health Perspectives Jurnal

3. Jurnal 2
a. Judul : Association between obesity and oligomenorrhea
or irregular menstruation in Chinese women of
childbearing age: a cross-sectional study
b. Penulis : Dewi Sumdika Sari, Herawati dan Rizki Amalia
c. Tahun Terbit : August, 12, 2020

d. Published : Gynecological Endocrinology Journal

1
B. Abstrak Artikel pada Jurnal
1. Artikel 1
Tumor sel Leydig adalah neoplasma ovarium yang jarang terjadi.
Individu yang terkena dampak biasanya hadir dengan amenore/
oligomenore dan gambaran virilisasi yang progresif cepat. Eritrositosis
juga dapat terjadi akibat kadar testosteron yang tinggi.
2. Artikel 2
Oligomenore adalah masalah siklus menstruasi yang disebabkan oleh
beberapa hal faktor antara lain status gizi, usia, aktivitas fisik, penyakit
reproduksi dan stres. Oligomenore dapat menyebabkan terganggunya
kesuburan dan stres emosional pada pasien. Oligomenore lebih sering
terjadi pada remaja. Penelitian ini menggunakan metode purposive
sampling dengan desain cross sectional. Populasi dalam hal ini Penelitian
ini adalah siswa SMK di Brebes yang terdiri dari 6 sekolah sebanyak 66
siswi yang mempunyai riwayat oligomenore dan bersedia menjadi
responden. Instrumen yang digunakan adalah angket. Analisis data
menggunakan uji Chi Square dengan taraf signifikansi 5% (α = 0,05) dan
Regresi logistik Berganda. Hasil penelitian menunjukkan tidak ada
hubungan antara gizi status (p value = 0,002), aktivitas fisik (p value
=0,035), stres (p value =0,037) dengan oligomenore pada remaja SMK
desa di Brebes. Tidak ada hubungan menarche (p value = 0,147) dengan
oligomenore pada sekolah kejuruan desa remaja di Brebes. Ada hubungan
antara status gizi dengan oligomenore pada remaja di sekolah kota (p value
= 0,000). Tidak ada hubungan aktivitas fisik (p value = 0,627), stres (p
value = 0,164), menarche (p value = 0,147) dengan oligomenore pada
remaja di sekolah kota. Remaja diharapkan lebih memperhatikan faktor-
faktor tersebut yang dapat dikontrol seperti indeks massa tubuh, aktivitas
fisik, dan stres agar memiliki siklus haid yang teratur sehingga dapat
mempengaruhi kesehatan organ reproduksi wanita.

2
3. Artikel 3
Pada studi ini, diinvestigasikan hubungan antara indeks masa tubuh
(BMI), Lingkar pinggang (WC) atau rsio pinggang-pinggul (WHR) dan
oligomenore atau menstruasi tidak teratur pada wanita subur di Tingkok.
oligomenore, dan 22,6% mengalami menstruasi tidak teratur. Sebanyak
1.423 wanita Han berusia 19-39 tahun yang diperiksa secara rutin di RS
Pusat Latihan Fisik Universitas Peking yang didaftarkan secara
convenience sampling. Semua peserta diminta mengisi kuesioner
menstruasi. Model regresi logistik biner digunakan untuk menilai rasio
odds (OR) dari kelompok BMI, WC dan WHR yang berbeda untuk
prevalensi oligomenore dan menstruasi tidak teratur. Hasil: dari 1423
partisipan didapatkan 93 wanita (6,5%) memiliki BMI > 30kg/m2, 6,5%
partisipan mengalami oligomenore yakni siklus menstruasi yang lebih
panjang dari siklus normal mestruasi biasanya. Prevalensi mentruasi
irreguler lebih tinggi dialami bagi BMI >30 kg/m2 (p < 0.001), WC >90
cm, dan grup WHR > 0.86. Selain itu, digunakan kurva ROC untuk
membandingkan efek prediksi BMI, WC dan WHR pada oligomenore dan
menstruasi tidak teratur. Obesitas, oligomenore, dan menstruasi tidak
teratur sering terjadi pada wanita usia subur di Tiongkok, dan obesitas
dikaitkan dengan oligomenore dan menstruasi tidak teratur. Obesitas perut
mungkin memiliki efek prediksi yang lebih kuat terhadap menstruasi yang
tidak teratur.

3
 BAB II
ULASAN ARTIKEL JURNAL

A. Latar Belakang dan Tujuan

1. Artikel 1
Artikel ini memaparkan tentang studi kasus pada seorang pasien
berusia 39 tahun dengan produksi hormon testosteron berlebihan yang
berasal dari Leydig Tumor Cell (LCT) pada ovarium kiri, mengakibatkan
oligomenorea, tinggi jumlah eritrosit, dan tanda-tanda vilirisasi progresif
cepat. Sekitar 75% penderita tumor ini menunjukkan gejala-gejala hiper-
androgenisme akibat produksi testosteron yang berlebihan, seperti
hirsutism (jumlah rambut yang tumbuh berlebihan pada organ tubuh
wanita), klitoromegali (pembesaran abnormal klitoris), alopecia
androgenic (kerontokan rambut), jerawat, peningkatan massa otor, atrofi
payudara, suara berat, dan atau peningkatan libido.
2. Artikel 2
Kesehatan reproduksi remaja adalah kesehatan fisik, mental, dan
kesejahteraan sosial secara menyeluruh pada segala hal yang berkaitan
dengan sistem dan fungsinya, serta proses reproduksi remaja, bukan
sekedar keadaan bebas dari penyakit atau kecacatan. Siklus menstruasi
pada wanita normalnya berkisar antara 21-32 hari dan hanya 10-15% yang
memiliki siklus 28 hari dengan lama menstruasi 3-5 hari atau 7-8 hari.
Data Badan Riset Kesehatan (Rikesdas, 2018) persentase wanita usia 10-
59 tahun yang mengalami menstruasi tidak teratur 14,5%. Lebih detailnya,
sebanyak 11,7% remaja usia 15-19 tahun di Indonesia mengalami
menstruasi tidak teratur dan sebanyak 14,9% wanita yang tinggal di
perkotaan di Indonesia mengalami menstruasi tidak teratur. Oligomenore
merupakan masalah siklus menstruasi yang disebabkan oleh beberapa
faktor antara lain status gizi, usia, aktivitas fisik, penyakit reproduksi dan
stres (John, 2010). Penelitian Yassin (2012) di Alexandria, persentase
remaja putri yang mengalami polimenorea 6,8%, oligomenorea 8,4%. Di

4
 Indonesia, penelitian Serly (2014) mencatat, remaja yang mengalami
siklus menstruasi normal sebanyak siswa SMA (61,8%), sedangkan yang
mengalami menstruasi normal sebanyak (38,2%).Menurut Adnyani (2011)
dengan hasil siklus menstruasi pada remaja putri diperoleh 38,9%
mengalami menstruasi tidak teratur. Sedangkan menurut Rachmawati
(2017) sebanyak 51,6% wanita yang berprofesi sebagai penari dengan
aktivitas fisik berat dapat mengalami gangguan siklus menstruasi.
Penelitian lain yang dilakukan oleh Rosendi (2011), stres dapat
mempengaruhi siklus menstruasi, karena hormon kortisol sebagai produk
korteks adrenal disintesis glukokortioid yang pada dua karakteristik lokasi
yang berbeda, baik dari segi letak geografis memungkinkan terjadinya
perbedaan usia menarche. Tujuan penelitian ini untuk menganalisis status
gizi, aktivitas fisik, stres, usia menarche hingga oligomenore.
3. Artikel 3
Pada jurnal ini

B. Metodologi
1. Artikel 1
Studi ini menyajikan paparan studi kasus pada seorang wanita dengan
produksi testosteron berlebihan dari tumor sel Leydig (LCT) pada ovarium
kiri yang mengakibatkan oligomenore dan tanda-tanda virialisasi yang
progresif cepat.
2. Artikel 2
Penelitian ini merupakan penelitian kuantitatif. Desain studi cross-
sectional. Populasi dalam penelitian ini adalah SMK di Brebes yang terdiri
dari 6 sekolah diatas pertimbangan Dinas Pendidikan dan Kebudayaan
Brebes dengan jumlah populasi adalah 1211 orang. Terdiri dari 3 SMK
yang berlokasi di kota dan 3 SMK yang berlokasi di pedesaan. Teknik
pengambilan sampel adalah purposive sampling. Jumlah sampel sebanyak
66 siswi yang mempunyai riwayat oligomenore dan bersedia menjadi

5
 responden. Penelitian ini menggunakan teknik analisis univariat, bivariat
dan multivariat.
3. Artikel 3
Adanya peningkatan prevalensi kegemukan dan gangguang
menstruasi pada populasi rakyat China. Kazemijaliseh dan rekannya telah
melaporkan lebih dari 10,6% wanita subur mengalami gangguan
keteraturan menstruasi, dan 23,8% mengalami frekuensi menstruasi yang
tidak normal. Prevalensi kelebihan berat badan atau oesitas pada wanita di
China sebesar 35,2% di daerah pedesaan dan 33,4% di Perkotaan. Obesitas
dikaitkan dengan siklus menstruasi yang tidak normal. Studi dari Wei et al
telah menemukan bahwa hubungan antara prevalensi kelainan siklus
menstruasi dan indeks massa tubuh (BMI) menunjukkan kurva berbentuk
U. Angka kejadian oligomenore dan menstruasi tidak teratur meningkat
seiring dengan peningkatan BMI >25 kg/m2. Proporsi wanita gemuk
dengan siklus menstruasi abnormal lebih tinggi dibandingkan populasi
umum, dan penurunan berat badan mengurangi siklus menstruasi
abnormal pada wanita obesitas. Selain itu, distribusi lemak tubuh rupanya
juga berdampak pada siklus menstruasi. Wanita dengan obesitas
abdominal dan BMI tinggi cenderung memiliki siklus menstruasi yang
lebih panjang dibandingkan wanita dengan BMI tinggi saja. Belum banyak
cukup bukti mengenai hubungan keseluruhan antara obesitas dan
oligomenore atau menstruasi tidak teratur pada wanita usia subur di
Tiongkok, dan masih belum jelas apakah hubungan tersebut dipengaruhi
oleh distribusi lemak. Dalam penelitian ini bertujuan untuk mengetahui
hubungan antara BMI, lingkar pinggang (WC/Waist Circumference) atau
rasio pinggang-pinggul (WHR/Waist-to-hip Ratio) dan oligomenore atau
menstruasi tidak teratur.

6
C. Hasil Penelitian
1. Artikel 1
Dalam studi kasus ini, melibatkan seorang wanita dengan produksi
testosteron berlebihan dari tumor sel Leydig pada ovarium kiri yang
mengakibatkan oligomenore dan tanda-tanda virialisasi yang progresif
cepat. Pada pasien dengan gambaran klinis seperti ini, anamnesis yang
cermat dan pemeriksaan fisik yang menyeluruh tetap merupakan prediktor
yang baik untuk hiperandrogenisme terkait neoplasma. Waktu timbulnya
tanda dan gejala mungkin merupakan petunjuk penting untuk diagnosis.
Hal ini berkaitan dengan fakta bahwa penyebab hirsutisme dan kelainan
siklus menstruasi non-tumor yang biasa terjadi, seperti PCOS (Polycystic
Ovarian Syndrome) dan hiperplasia adrenal kongenital nonklasik, biasanya
memerlukan waktu bertahun-tahun atau puluhan tahun untuk
menimbulkan gejala-gejala tersebut, sedangkan penderita dengan
neoplasma virilisasi hanya membutuhkan waktu beberapa bulan (seperti
dalam laporan kasus yang disajikan).
Pasien melaporkan ketidakteraturan menstruasi disertai oligomenore
setelah menghentikan kontrasepsi oral 9 bulan sebelumnya. Dia mengaku
merasa lebih tertekan dengan perubahan progresif pada tubuhnya, terutama
karena masalah estetika. Tidak ada perubahan libido, perubahan otot, atau
patah tulang yang dilaporkan. Dia menyangkal konsumsi alkohol atau
tembakau sebelumnya atau baru-baru ini. Dia didiagnosis menderita
hipotiroidisme primer pada tahun 2011 (penyebab tidak diketahui, antibodi
antitiroid negatif), mengalami obesitas kelas 1 dan hipertensi arteri sejak
tahun 2008 (TD maksimum 150/94 mm Hg dalam 12 bulan sebelum
konsultasi endokrinologi, namun biasanya dalam keadaan normal sampai
pengobatan antihipertensi). Pasien ini diberi pengobatan levothyroxine 100
µg sekali sehari, nebivolol 5 mg, dan kombinasi amlodipine 5 mg/
valsartan 20 mg. Mengenai riwayat keluarganya, pasien melaporkan
bahwa ibunya menderita kanker tiroid dan payudara, hipertensi, dan
diabetes tipe 2, yang terakhir juga menderita kanker tiroid dan payudara.

7
 Pemeriksaan fisik menunjukkan fasies androgenik dan alopesia,
adipositas dorsoserviks, akantosis nigrikans aksila, dan klitoromegali
(Gambar 1). Tidak ada massa yang terdeteksi pada palpasi perut. Tidak
ada atrofi payudara, miopati proksimal, atau striae keunguan yang
ditemukan. Berat badannya saat presentasi adalah 87,6 Kg, dengan indeks
massa tubuh 31,8 Kg/m2.
Kasus klinis ini sangat menarik karena dua alasan: Pertama adalah
gambaran LCT yang atipikal pada wanita pramenopause dan kedua adalah
adanya eritrositosis yang berhubungan dengan kelebihan testosteron, yang
menjadi normal setelah pengangkatan tumor. Setidaknya tiga kasus
eritrositosis sekunder akibat LCT ovarium dijelaskan dalam literatur, salah
satunya menggambarkan seorang wanita dengan hiperandrogenisme dan
emboli paru berulang. Hiperandrogenisme dapat disebabkan oleh berbagai
tumor, beberapa diantaranya berasal dari ginekologi, seperti
koriokarsinoma, mola hidatidosa, atau tumor penghasil androgen adneksa.
Neoplasma ini seringkali berukuran sangat kecil (<3 cm) sehingga dalam
banyak kasus bahkan tidak dapat ditemukan, sehingga menimbulkan
tantangan diagnostik bahkan setelah pemeriksaan ginekologi dan radiologi
yang cermat. Untungnya, hal tersebut tidak terjadi pada pasien ini yang
LCT-nya terdeteksi melalui USG transvaginal (TVU). Pemeriksaan ini
seringkali merupakan pemeriksaan imajinasi awal karena sensitivitasnya
yang baik, ketersediaan yang tinggi, dan biaya yang rendah.

2. Artikel 2
Oligomenorrea adalah permasalahan pada siklus menstruasi yang
dapat disebabkan oleh beberapa faktor, diantaranya status nutrisi, usia,
aktivitas fisik, penyakit masalah reproduksi dan stress. Pada penelitian ini
menunjukkan ada hubungan antara gizi status (p value = 0,002), aktivitas
fisik (p value =0,035), stres (p value =0,037) dengan oligomenore pada
remaja SMK Desa di Brebes. Tidak ada hubungan menarche (p value =
0,147) dengan oligomenore pada sekolah vokasi di Brebes. Ada hubungan

8
 antara status gizi dengan oligomenore pada remaja di sekolah kota (p
value = 0,000). Tidak ada hubungan aktivitas fisik (p value = 0,627), stres
(p value = 0,164), menarche (p value = 0,147) dengan oligomenore pada
remaja di sekolah kota. Remaja diharapkan lebih memperhatikan faktor-
faktor tersebut yang dapat dikontrol seperti indeks massa tubuh, aktivitas
fisik, dan stres agar memiliki siklus haid yang teratur sehingga dapat
mempengaruhi kesehatan organ reproduksi wanita.
Menurut Almatsier (2015) mengemukakan bahwa status gizi
merupakan ukuran kondisi tubuh seseorang yang dilihat dari makanan
yang dikonsumsi dan penggunaan zat gizi dalam tubuh. Hal ini didukung
oleh teori Paath (2005) bahwa pada remaja putri perlu menjaga status gizi
yang baik, dengan mengkonsumsi makanan yang seimbang karena
diperlukan pada saat menstruasi, terbukti menstruasi pada saat terutama
pada fase leutal akan meningkatkan kebutuhan nutrisi. Menurut Rabe
(2002), kelelahan akibat aktivitas berlebihan dapat menyebabkan disfungsi
hipotalamus yang menyebabkan gangguan sekresi GnRH. Hal ini
menyebabkan terganggunya siklus menstruasi. Faktor utama penyebab
penekanan GnRH pada wanita adalah penggunaan energi berlebihan yang
melebihi asupan energi.
Pada kondisi stress, dijelaskan bahwa pengaktifan keadaan stres
terjadi pada amigdala pada sistem limbik. Sistem ini merangsang
pelepasan hormon dari hipotalamus yaitu corticotropic-releasing hormone
(CRH). Peningkatan CRH merangsang pelepasan hormon endorfin dan
adrenokortikotropik (ACTH) ke dalam darah. Peningkatan kadar ACTH
akan menyebabkan peningkatan kadar kortisol darah. Hormon-hormon
tersebut secara langsung dan tidak langsung menyebabkan penurunan
kadar GnRH, yang melalui jalur ini kemudian stres menyebabkan
terganggunya siklus menstruasi.
3. Artikel 3
Pada artikel ini secara kolektif, data wanita usia subur di Tiongkok
menunjukkan bahwa obesitas berhubungan dengan siklus menstruasi yang

9
tidak teratur dan oligomenore. WC lebih efektif dalam memprediksi
menstruasi tidak teratur dibandingkan BMI, hal ini menunjukkan bahwa
obesitas abdominal memiliki efek prediksi yang lebih kuat terhadap
menstruasi tidak teratur. Namun, mekanisme yang mendasari efek tersebut
terhadap siklus menstruasi perlu dipelajari lebih lanjut.
Penelitian ini merupakan studi komprehensif pertama tentang
hubungan antara komposisi tubuh dan oligomenore atau menstruasi tidak
teratur pada wanita usia subur di China. Pada penelitian sebelumnya,
definisi oligomenore dan menstruasi tidak teratur berbeda. Dalam
penelitian yang berbeda, prevalensi oligomenore berkisar antara 2,32%
hingga 7,8%, dan menstruasi tidak teratur berkisar antara 6,25% hingga
16,9%. Prevalensi oligomenore dan menstruasi tidak teratur masing-
masing adalah 6,5% dan 22,6% dalam penelitian ini, yang mengadopsi
definisi terbaru AUB yang diterbitkan oleh FIGO pada tahun 2018 untuk
mengidentifikasi oligomenore dan menstruasi tidak teratur, menjadikan
temuan pada penelitian ini lebih berguna dalam memandu pekerjaan klinis.
Peneliti pertama kali menyelidiki efek prediktif BMI, WC, dan WHR
pada periode menstruasi yang jarang dan tidak teratur, meskipun hanya
analisis awal yang dilakukan dalam penelitian ini. Namun, hasil kami
menunjukkan bahwa BMI tinggi dan obesitas sentral memiliki efek
prediktif pada siklus menstruasi yang tidak normal, sehingga harus
meningkatkan kewaspadaan terhadap kelebihan berat badan dan obesitas
pada wanita usia subur. Penelitian ini menganalisis hubungan antara
oligomenore atau menstruasi tidak teratur dan komposisi tubuh pada
sekelompok besar wanita usia subur di Tiongkok. Peneliti menemukan
bahwa obesitas,termasuk BMI 30 kg/m2 atau WC 90 cm, dikaitkan dengan
oligomenorhea, dan wanita dengan BMI 30 kg/m2, WC 90 cm atau WHR
0,86 secara signifikan berhubungan dengan menstruasi tidak teratur.

10
 BAB III
TELAAH KRITIS
A. PICOT
1. Artikel 1

Populasi : Tidak ada populasi pada penelitian studi kasus ini,

hanya melibatkan satu orang wanita berusia 39 tahun
berkebangsaan Portugal.
Intervensi : USG transvaginal, Surgery, and oral medication.
Comparatif : Tidak ada
Outcome : Penurunan kuantitas sel eritrosit dan hormon
testosteron setelah di operasi.

Time : Tahun 2021

2. Artikel 2

Populasi : Siswa sekolah vokasi di Departemen Pendidikan dan

Budaya, Brebes, Indonesia
Intervensi : Tidak ada
Comparatif : Tidak ada
Outcome : Adanya hubungan antara status nutrisi, aktivitas fisik,
dan stress terhadap kejadian oligomenorea. Namun
tidak berhubungan terhadap menarche.
Time : Tahun 2019

3. Artikel 3

Populasi : 1529 wanita Tiongkok berusia 19-39 tahun.

Intervensi : Tidak ada
Comparatif : Tidak ada
Outcome : Secara kolektif menunjukkan bahwa obesitas
berhubungan dengan siklus menstruasi yang tidak

8
 teratur dan oligomenorea.
Time : Tahun 2020

B. RAMMbo
1. Artikel 1

Representatif : Ya
Alokasi fair : Ya
Maintenance fair : Ya
Measurement : Serum androgen measurement as the important
Blinded Objektif diagnostics keystone.

2. Artikel 2

Representatif : Ya
Alokasi fair : Ya
Maintenance fair : Ya
Measurement : Tidak dijelaskan
Blinded Objektif

3. Artikel 3

Representatif : Ya
Alokasi fair : Ya
Maintenance fair : Ya
Measurement : Petugas medis terlatih yang melakukan
Blinded Objektif pengukuran height, weight, WC, WHR, MI, WC
and Hip Circumference (HC) partisipan

9
 BAB IV
PENUTUP

A. Kesimpulan
Berdasarkan hasil telaah jurnal 1, 2 dan 3, memiliki kesamaan yakni
kejadian oligomenorea berkaitan erat dengan kondisi body mass indeks
atau BMI yang melebihi batas normal. Pada artikel ke tiga, diketahui
bahwa pengukuran WC lebih efektif dalam memprediksi menstruasi tidak
teratur dibandingkan BMI, hal ini menunjukkan bahwa obesitas abdominal
memiliki efek prediksi yang lebih kuat terhadap menstruasi tidak teratur.
Namun masih perlu penelitian lebih lanjut terkait mekanisme yang
mendasari efek tersebut.
B. Saran
1. Artikel 1
Sangat baik sekali, karena paparan kasus tergambar dengan sangat
jelas dan relevan. Kasus ini pun sangat jarang ditemukan serta menarik
untuk dibahas. Terutama pada penjelasan mengenai gambaran LCT yang
atipikal pada wanita pramenopause dan kedua adalah adanya eritrositosis
yang berhubungan dengan kelebihan testosteron, yang menjadi normal
setelah pengangkatan tumor.
2. Artikel 2
Diharapkan bagian editorial lebih teliti saat mengecek abstrak dan
hasil/discussion jurnal, karena saat di abstrak disebutkan tidak ada
hubungan pada semua variabel (status nutrisi, aktivitas fisik, dan stress)
terhadap kejadian oligomenorea, sedangkan saat di conclusion semua
variabel memiliki hubungan yang signifikan, kecuali menarche, hal ini
cukup membingungkan pembaca.
3. Artikel 3
Artikel ini sangat baik, karena menjadi temuan baru bahwa
pengukuran WC lebih efektif dalam memprediksi menstruasi tidak teratur
dibandingkan BMI, hal ini menunjukkan bahwa obesitas abdominal
memiliki efek prediksi yang lebih kuat terhadap menstruasi tidak teratur.

10
Diharapkan adanya penelitian lebih lanjut terkait mekanisme yang
mendasari efek tersebut.

11
 DAFTAR PUSTAKA

Nurjannah, S. N., dan Putri, E. A. (2021). Hubungan Status Gizi dengan Kejadian
Anemia Pada Remaja Putri di SMP Negeri 2 Garawangi Kabupaten
Kuningan. Journal Of Midwifery Care, 1(02), 125–131.
https://Doi.Org/10.34305/Jmc.V1i02.266. Diakses januari 2023.

Sari, Dewi Sumdika, et al. (2020). Hubungan Lama Menstruasi Dan Status Gizi
Dengan Kejadian Anemia Pada Remaja Putri. Jurnal Kesehatan dan
Pembangunan 10(19). Sumber: http://e-jurnal.stikesmitraadiguna.ac.id
Diakses januari 2023.

11
Received: 2 November 2020
| Revised: 9 December 2020
| Accepted: 2 January 2021

DOI: 10.1002/ccr3.4001

CASE REPORT

Hyperandrogenism, oligomenorrhea, and erythrocytosis caused

by an ovarian Leydig cell tumor: A case report

Fernando Mendonça1,2,3 | Selma Souto1,2,3 | Daniela Magalhães4 | Raquel Portugal5 |

Ana Rita Coelho5 | Ana Sofia Fernandes6 | Vera Falcão6 | Sara Tavares6 |
Inês Portugal7 | Jorge Beires6 | Davide Carvalho1,2,3
1
Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar e Universitário de S. João, Porto, Portugal
2
Faculdade de Medicina da Universidade do Porto, Porto, Portugal
3
i3S -­Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
4
Hospital da Luz, Clínica do Porto, Porto, Portugal
5
Serviço de Anatomia Patológica, Centro Hospitalar e Universitário de S. João, Porto, Portugal
6
Serviço de Ginecologia, Centro Hospitalar e Universitário de S. João, Porto, Portugal
7
Serviço de Radiologia, Centro Hospitalar e Universitário de S. João, Porto, Portugal

Correspondence
Fernando Mendonça, Serviço de
Endocrinologia, Diabetes e Metabolismo,
Centro Hospitalar e Universitário de S.
João, Alameda Prof. Hernâni Monteiro,
4200-­319 Porto, Portugal.
Email: fernandomiguel_92@hotmail.com
Abstract
Leydig cell tumors are rare ovarian neoplasms. Affected individuals typically present
with amenorrhea/oligomenorrhea and rapidly progressive features of virilization.
Erythrocytosis can also occur as a result of high testosterone levels.
KEYWORDS
erythrocytosis, hyperandrogenism, Leydig cell tumor, oligomenorrhea

1 | IN T RO D U C T ION include hirsutism, clitoromegaly, androgenic alopecia, acne,

increased muscle mass, mammary atrophy, deep voice, or
In this case report, we present the case of a 39-­year-­old increased libido. Some of the differential diagnosis of these
woman with excessive testosterone production from a Leydig virilizing tumors include non-­neoplastic causes of androgen
cell tumor of the left ovary resulting in oligomenorrhea, high excess such as polycystic ovary syndrome (PCOS), nonclas-
erythrocyte count, and rapidly progressive virilization signs. sical congenital adrenal hyperplasia (or other adrenal enzy-
Leydig cell tumors (LCTs), a subtype of steroid cell matic defects), or ovarian hyperthecosis. Another important
tumors of the ovary, account for <0.1% of ovarian neo- diagnosis to consider is Cushing syndrome, that can some-
plasms.1,2 LCTs are more common after menopause (average times be the result of an adrenocortical carcinoma cosecret-
age of 58), being usually benign, unilateral, and small-­sized ing androgens and cortisol.1
solid tumors.3,4 Approximately 75% of individuals with Given the rarity of these tumors (that constitute only
these tumors exhibit symptoms of hyperandrogenism due <0.2% of the cases of hyperandrogenism) and the multiplic-
to excessive testosterone production.5,6 Affected individuals ity of possible alternative diagnosis,7 it is essential to have a
typically present with amenorrhea/oligomenorrhea and rap- high index of suspicion. This is especially important before
idly progressive signs and symptoms of virilization (usually menopause and when no masses are detected on physical
within months) with or without mass effect.7 Those features examination.1 The authors report a case of a premenopausal
This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

Clin Case Rep. 2021;9:e04001.  wileyonlinelibrary.com/journal/ccr3 | 1 of 5

https://doi.org/10.1002/ccr3.4001
 |
2 of 5   
woman presenting with hirsutism, androgenic alopecia, and
oligomenorrhea who was found to have a left ovarian LCT.
An informed consent was obtained to use patient's medi-
cal data regarding the diagnosis and management of this
Leydig cell tumor in our medical center (Centro Hospitalar e
Universitário de S. João).
2 | CA S E RE P O RT
A 39-­year-­old nulligravid Caucasian woman was referred to
the Endocrinology Department with complains for the last
8 months regarding androgenic alopecia, facial acne, and
hirsutism, more pronounced on the face, dorsum, and arms
(score 12, Ferriman-­Gallwey scale). Dorsocervical fat pad
and axillary acanthosis nigricans were also found on physical
examination. During the last 3 months, the patient noticed
a weight gain of 6 Kg, mainly in the abdominal area, and
20500904, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ccr3.4001 by Nat Prov Indonesia, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MENDONÇA et al.
sporadic ecchymosis with no recollection of trauma. She also
reported menstrual irregularities with oligomenorrhea after
stopping oral contraceptive 9 months before. She sustained
she felt more depressed about the progressive changes on her
body, mainly for esthetic concerns. No alterations in libido,
muscular changes, or bone fractures were reported. She de-
nied previous or recent consumption of alcohol or tobacco.
She was diagnosed with primary hypothyroidism in 2011
(unknown cause, negative antithyroid antibodies), having
class 1 obesity and arterial hypertension since 2008 (maxi-
mum tensional values of 150/94 mm Hg within the 12 months
before endocrinology consultation, but usually with normo-
tensive values under antihypertensive medication). Our pa-
tient was medicated with levothyroxine 100 µg once daily
(q.d.), nebivolol 5 mg q.d., and an association of amlodipine
5 mg/valsartan 20 mg q.d. Regarding her family history, the
patient reported that her mother had thyroid and breast can-
cer, hypertension, and type 2 diabetes, with the latter also
F I G U R E 1 Clinical, imagiological, and
pathological data regarding the presented
clinical case. Physical examination findings
of the patient before surgery (A1-­3).
Suprapubic ultrasound (B1) depicting a
well-­defined iso-­mildly hyperechoic solid
nodule in the central left ovarian stroma;
pelvic MRI (B2) showing a moderately
hyperintense nodule on axial fluid sensitive
sequence; salpingoophorectomy specimen
containing an ovary Leydig cell tumor (C1).
The tumor (bottom) is well circumscribed.
The tumor cells have uniform round nuclei
and abundant eosinophilic to pale cytoplasm
(C2). The eosinophilic fibrinoid changes
in the walls of the blood vessels are a
characteristic finding. Nuclear expression of
androgen receptors (C3). Some cells contain
Reinke crystals (arrow) (C4). Tumor cells
are positive for inhibin (C5) and calretinin
(C6)
 |

20500904, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ccr3.4001 by Nat Prov Indonesia, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MENDONÇA et al.    3 of 5

present in other members of the family. Physical examination clitoromegaly. After evaluating all the presented data, the
revealed an androgenic facies and alopecia, dorsocervical gynecological team decided to perform a laparoscopic left
adiposity, axillary acanthosis nigricans, and clitoromegaly salpingoophorectomy (that proceeded without complica-
(Figure 1). No masses were detected on abdominal palpation. tions). A microscopic analysis of the surgical specimen
No breast atrophy, proximal myopathy, or violaceous striae revealed a Leydig cell ovarian tumor. This mass presented
were noted. Her body weight was 87.6 Kg on presentation, expansive limits and contained cells with uniform round
with a body mass index of 31.8 Kg/m2 and blood pressure of nucleus and abundant cytoplasm that stained positive for
140/92 mm Hg. inhibin α, calretinin, and androgen receptors. Crystals of
The analytical diagnostic workout demonstrated a marked Reinke were also detected on microscopy as well as rare
increase of total testosterone levels and normal levels of mitotic figures.
DHEA and estradiol, with suppression of FSH and LH. In the postsurgery follow-­up medical consultations at 1
Normal prolactin and thyroid function as well as normal and 4 months, there was a marked improvement of the clini-
24-­hours urinary free cortisol level and 1mg dexametha- cal hyperandrogenism (hirsutism, androgenic alopecia), with
sone suppression test were documented. The hemogram of regularization of the menstrual cycles and normalization of
the patient evidenced erythrocytosis and increased level of the serum total testosterone and erythrocyte count. The pa-
plasmatic hemoglobin (Table 1). Gynecological imaging as- tient underwent fertility treatments with ovulation inductors
sessment through suprapubic and transvaginal ultrasound re- (human chorionic gonadotropin and clomiphene citrate),
vealed a well-­defined solid lesion in the left ovary, measuring being actually pregnant with twins.
15 × 15 × 16 mm, slightly heterogeneous, but with no clear
suspicious findings. No abnormal endometrial thickening was
detected. Pelvic magnetic resonance imaging (MRI) findings 3 | DISCUSSION
were consistent with ultrasound, revealing a solid left adnexal
lesion, with smooth margins and moderate hyperintensity on In this case, we present a woman with excessive testoster-
T2 sequences, with no evidence of aggressive features. There one production from a Leydig cell tumor of the left ovary
were also no ascites or abnormal lymph nodes, and the adre- resulting in oligomenorrhea and rapidly progressive viri-
nal glands were unremarkable at computed tomography im- lization signs. In patients with this clinical presentation, a
aging (CT). careful history and thorough physical examination remain
Considering these findings, our patient was referred good predictors of neoplasm related hyperandrogenism.5,7
to the Gynecology Department. She presented no rel- The time of signs and symptoms onset may be an impor-
evant findings on gynecological examination beyond tant clue to diagnosis. This relates to the fact that the usual
nontumoral causes of hirsutism and menstrual cycle abnor-
T A B L E 1 Analytical parameters determined before (initial malities, such as PCOS and nonclassical congenital adrenal
consultation) and 6 mo after surgery hyperplasia, commonly need years or decades to develop
those symptoms, whereas those with virilizing neoplasms
Reference
only take a few months (as in the presented case report).7
Before After values
In the particular case of adrenal tumors, these signs of hy-
Hemoglobin (g/dL) 18.2 14.7 12.0-­16.0 perandrogenism can be associated with cushingoid fea-
Erythrocyte count (×1012/L) 5.84 4.81 4.0-­5.0 tures due to the concomitant production of androgens and
Total testosterone (ng/dL) 1052 38 6-­82 cortisol by some tumors. Regarding physical examination,
Androstenedione (ng/mL) 5.13 1.47 0.3-­3.3 attention should be paid to presence of clitoromegaly or ad-
DHEAS (µg/dL) 246.6 186.3 60.9-­337 nexal masses during gynecological examination. Another
FSH (mUI/mL) 0.87 5.98 2.1-­12.6 important diagnostic keystone is serum androgen measure-
LH (mUI/mL) 0.61 13.11 2.4-­12.6
ment, such as total testosterone and dehydroepiandroster-
one sulfate (DHEAS). Most physicians start to look for a
Free T4 (ng/dL) 1.28 1.08 0.70-­1.48
tumor when the serum total testosterone concentration is
TSH (µUI/mL) 1.98 2.54 0.35-­4.94
higher than 150-­200 ng/dL (5.2-­6.9 nmol/L) or, in the case
Estradiol (pg/mL) 41.8 1.3-­266 of an adrenal source of androgens, when the DHEAS is
Prolactin (ng/mL) 32.7 4.8-­23.3 higher than 700 µg/dL (18.9 micromole/L).8 Our patient
24-­h urinary free cortisol 15.6 36.0-­137.0 presented high total testosterone levels (pointing to a neo-
(µg/day) plastic source of virilization) and a normal serum DHEAS
1 mg overnight 0.8 0-­1.8 concentration with absence of adrenal CT abnormalities,
dexamethasone which all together raised the concern for an ovarian tumor.
suppression test (µg/dL)
It is important to stress that although concomitant Cushing
 |
4 of 5   
syndrome strongly indicates an adrenal cancer, rare steroid
cell tumors of the ovary may also coproduce androgens and
cortisol.9 In our case, despite the presence of some features
such as central obesity, dorsocervical fat pad, ecchymosis,
or axillary acanthosis, the possibility of associated Cushing
syndrome was ruled out by two normal screening tests (24-­
hours urinary free cortisol and overnight 1 mg dexametha-
sone test). This clinical case is particularly interesting for
two reasons: One is the atypical presentation of a LCT in
a premenopausal woman and the other is the presence of
erythrocytosis related to testosterone excess, that has nor-
malized after tumor removal. At least three cases of eryth-
rocytosis secondary to ovarian LCT are described in the
literature, one of them describing a woman with hyperan-
drogenism and recurrent pulmonary embolism.3
Hyperandrogenism can be the result of a variety of
tumors, some of them of gynecological origin, such as
choriocarcinoma, hydatidiform mole, or adnexal androgen-­
producing tumors. Among the latter, there are several
groups such as the sex cord-­stromal tumors (that include
the Sertoli-­Leydig neoplasms), tumors of the ovary with
functioning stroma, or the steroid cell tumors (which in-
corporate the presented LCT of our patient).10 LCTs are
masses of steroid cells usually with abundant eosinophilic
cytoplasm, very few mitosis, and round nuclei.11 The pres-
ence of crystals of Reinke (rod-­shaped structures within the
cytoplasm) is a very characteristic feature that supports the
diagnosis of LCT.12 Among the multiplicity of immunohis-
tochemical markers, the ones frequently studied are inhibin
and calretinin because they are expressed by many steroid
cell tumors like LCT.1
These neoplasms are frequently so small (<3 cm) that
in many cases they are not even able to be found, posing a
diagnostic challenge even after careful gynecological and
radiological investigation.12 Fortunately, that was not the
case of our patient, who had her LCT detected on trans-
vaginal ultrasound (TVU). This examination is often the
initial imagiological examination due to its good sensi-
tivity, high availability, and low cost.7 However, its accu-
racy relies on the operator performing the examination.
MRI is the second-­line imaging modality for evaluating
adnexal masses due to the high soft tissue resolution. It
can sometimes find masses not otherwise diagnosed at the
TVU (78% positive and 100% negative predictive value, as
revealed by the results of a large study).13,14 When TVU
and MRI are inconclusive or fail to detect any neoplasm
but there is still a strong clinical suspicion, bilateral ovar-
ian vein catheterization may be an option to confirm the
source of androgen excess. This method has some setbacks:
It may pose risks for the patient (such as ovarian vein
thrombosis or intracorporeal hemorrhage), and it is per-
formed only in a few centers worldwide and does not pro-
vide satisfactory sensitivity. For these reasons, the option
20500904, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ccr3.4001 by Nat Prov Indonesia, Wiley Online Library on [17/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MENDONÇA et al.
that is usually preferred in these difficult diagnostic cases
is 18F-­fluorodeoxyglucose PET imaging (18F_FDG-­PET),
that uses pathologic glucose uptake by neoplastic cells as a
mean to visualize the tumor.11
Surgery is the preferred therapeutic approach for
androgen-­secreting tumors, usually leading to permanent
cure (most of these tumors are benign).7 The option to per-
form a unilateral or bilateral salpingoophorectomy depends
on the ability to find the tumor and on the woman meno-
pausal status. In postmenopausal women (the main group
affected by LCT), bilateral salpingoophorectomy with or
without total hysterectomy is the favored approach (con-
sidering the concomitant risk of endometrial carcinoma
in some cases).14 Regarding our case of a premenopausal
woman, after evaluation of the results of TVU and MRI,
a laparoscopic left salpingoophorectomy was performed.
This option was taken to preserve fertility. This issue was a
major concern to our patient because she had no offspring
to date and wanted to conceive.
After surgery, the aim is to normalize the levels of andro-
gens, that should be assessed during follow-­up to diagnose a
possible recurrence. Our patient had a significant improve-
ment of both clinical and analytical hyperandrogenism, as a
successful surgical result.
ACKNOWLEDGMENTS
Published with written consent of the patient.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
AUTHOR CONTRIBUTIONS
FM: primary author of the final manuscript. SS: co-­authored
manuscript. DM: contributed with endocrinological exper-
tise and images of the patient. RP and ARC: contributed with
pathological expertise and images and revised the manu-
script. IP: contributed with her radiological knowledge and
images and revised the manuscript. ASF, VF, ST, and JB:
followed the patient and advised FM in gynecological issues
related with this case report. DC: advised and oversaw manu-
script drafting and publishing.
ETHICAL APPROVAL
An informed consent was obtained. All procedures per-
formed in this study involving human participants were in
accordance with the ethical standards of the institutional and/
or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical
standards.
ORCID
Fernando Mendonça https://orcid.
org/0000-0002-7020-4311

MENDONÇA et al.
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2. Aimakhu VE, Adeleye JA, Hendrickse M, de Von Hendrickse
JP, Iloabachie G. Masculinizing tumors of the ovary. J Natl Med
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3. Kozan P, Chalasani S, Handelsman DJ, Pike AH, Crawford BA.
A Leydig cell tumor of the ovary resulting in extreme hyperan-
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jc.2013-­3108
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6. Sanz OA, Martinez PR, Guarch RT, Goñi MJ, Alcazar JL. Bilateral
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org/10.1016/j.matur​itas.2006.11.013
7. Faria AM, Perez RV, Marcondes JAM, et al. A premenopausal
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nrendo.2011.15
8. Welt CK, Barbieri RL. Evaluation and management of secondary
amenorrhea. UpToDate. Last updated Jun 28, 2020
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Pathol. 1987;6:40-­48. https://doi.org/10.1097/00004​347-­19870​
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11. Klotz RK, Müller-­Holzner E, Fessler S, et al. Leydig-­cell-­tumor of
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How to cite this article: Mendonça F, Souto S,
Magalhães D, et al. Hyperandrogenism,
oligomenorrhea, and erythrocytosis caused by an
ovarian Leydig cell tumor: A case report. Clin Case
Rep. 2021;9:e04001. https://doi.org/10.1002/
ccr3.4001
 Public Health Perspectives Journal 4 (1) 2019 37 - 47

Public Health Perspectives Journal

http://journal.unnes.ac.id/sju/index.php/phpj

The Relationship of Nutritional Status, Physical Activity, Stress, and

Menarche to Menstrual Disorder (Oligomenorrhea)

Vriska Roro Sekar Arum1 , Ari Yuniastuti2, Oktia Woro Kasmini2

1.
SMK SEMESTA, Bumiayu, Indonesia
2.
Universitas Negeri Semarang, Indonesia

Article Info Abstract

______________
History of Article : Oligomenorrhea is problematic menstrual cycle, which is caused by several
Accepted 28 January factors, including nutritional status, age, physical activity, reproductive diseases
2019 and stress. Oligomenorrhea can cause disruption of fertility and emotional stress
Approved 28 March on the patient.Oligomenorrhea more common in adolescents.Research were
2019 purposive sampling method with cross sectional design. The population in this
Published 20 April
research were students of VocationalHigh Schoolin Brebes consisting of 6school
2019
as many as 66 students who have a history of oligomenorrhea and willing to
become respondents. The instrument used was a questionnaire. Data analysis
Keywords: using Chi Square test with significance level of 5% (α = 0.05) and Multiple
Nutritional Status, Logistic Regression. The results showed no association between nutritional
Physical Activity, status (p value = 0.002), physical activity (p value = 0.035), stress (p value =
Stress, menarche, 0.037) with oligomenorrhea in adolescents villagevocational schoolin Brebes.
There is no relationship menarche (p value = 0.147) with oligomenorrhea in
oligomenorrhea
adolescents villagevocational hgh schoolin Brebes. There is a relationship
____________ between nutritional status and oligomenorrhea in adolescent at cityschool(p
value = 0.000). There is no relationship of physical activity (p value = 0.627),
stress (p value = 0.164), menarche (p value = 0.147) with oligomenorrhea in
adolescents at cityschool. Teens are expected to be more attention to the factors
that can be controlled such as body mass index, physical activity, and stress in
order to have regular menstrual cycles that can affect both the health of the
female reproductive organs.

© 2019 Universitas Negeri Semarang

address:
p-ISSN 2528-5998
Jl.Pangeran Diponegoro, Km.1, Bumiayu, Taloksari,Dukuhturi, e-ISSN 2540-7945
Brebes, Jawa Tengah 52273, Indonesia
E-mail: ihdasuryaji@gmail.com
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47
INTRODUCTION
Adolescent reproductive health is physical
health, mental and social well-being as a whole on
all things related systems and functions, as well as
adolescent reproductive process, not just the state
that is free from disease or disability.
Reproductive health problems can occur due to
lack of access to information on reproductive
health (Manuaba, 2012).
Information about reproductive health for
adolescents is seen as very important, since
adolescence is this happening milestones of sexual
maturity. In girls menarche is marked by the first
menstuation (Susanti, 2012). Mensturation cycle
in women normally ranges between 21-32 days
and only 10-15% have a 28-day cycle with a long
menstruation 3-5 days, or 7-8 days (Proverawati
& Misaroh, 2009). Data from the Health Research
Association (Rikesdas, 2018) the percentage of
women aged 10-59 years old who have irregular
menstruation 14.5%. More details, as many as
11.7% of adolescents aged 15-19 years in
Indonesia experienced irregular menstruation and
as much as 14.9% of women who live in urban
areas in Indonesia have irregular menstruation.
Oligomenorrhea is problematic menstrual
cycle, which is caused by several factors,
including nutritional status, age, physical activity,
reproductive diseases and stress (John, 2010).
Research Yassin (2012) in Alexandria, the
percentage of young women who have
polimenorea 6.8%, 8.4% oligomenorrhea. In
Indonesia,Serly (2014) research note that,
adolescents who experienced normal menstrual
cycles as many high school students (61.8%),
while experiencing normal menstruation as many
(38.2%).
According Adnyani (2011) with the results
of the menstrual cycle in young women earned
38.9% experiencing irregular periods. Meanwhile,
according Rachmawati (2017) as much as 51.6%
of women who work as a dancer with heavy
physical activity may experience menstrual cycle
disorders. Another study conducted by Rosendi
(2011), stress can affect the menstrual cycle, as the
hormone cortisol as a product of the adrenal
cortex were synthesized glukokortioid the
38
fasciculata zone can disrupt the menstrual cycle
because it affects the amount of the hormone
progesterone in the body. Another study
conducted by Toduho et al. (2014) concluded that
the moderate psychological stress that can affect
menstrual cycles more (72.1%) of the weight
(5.95%) and light (22,
Abdulla and Ibraheem (2010) research
shows that the age of menarche had a significant
association with body mass index (BMI), stress,
and physical activity. Late menarche age also
may be associated with menstrual cycle disorders.
Based on research conducted by Zageye (2013)
concerning suggested that delayed menarche may
affect mentstruasi cycle, where 48.2% of
adolescents in Ethopia experience abnormal
menstrual cycles.
On two different areas characteristics, both
in terms of geographical location allows the
difference in age of menarche in young women, as
shown in research Burhanuddin (2007) where
there is a significant difference in age of menarche
in young women in Bugis City and Village, South
Sulawesi. The average age of menarche in young
women is lower Bugis City (12.93 years) than in
Bugis Village (13.18 years).
The purpose of this study to analyze
nutrition status, physical activity, stress, age of
menarche to oligomenorrhea.
METHOD
This study is a quantitative research. Cross-
sectional study design. The population in this
study is Vocational High School in Brebes
consisting of 6 school above considerations the
Department of Education and Culture Brebes by
the number of population is 1211 people. Consists
of 3 vocational high school located in the city and
3 vocational high school located in villages.The
sampling technique was purposive sampling. The
total sample of 66 students who have a history of
oligomenorrhea and willing to become
respondents. This study used a technique
univariate, bivariate and multivariate analyzes.
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47

RESULTS AND DISCUSSION

Factors Affecting Oligomenorrhea

Table 1. Frequency Distribution of Factors Affecting oligomenorrhea On Vocational High Students in Brebes,
December 2018 (N = 66)
Village City Total
Factor
F % F % F %
Nutritional status
Abnormal 6 9.1 6 9.1 12 18.2
Normal 26 39.4 28 42.4 54 81.8
Physical activity
Light 10 15.2 13 19.7 23 34.8
moderate 22 33.3 21 31.8 43 65.2
Stress level
Mild stress 16 24.2 18 27.3 34 51.5
stress Medium 16 24.2 16 24.2 32 48.5
age of menarche
Normal 29 43.9 33 50.0 62 93.9
menarche Tarda 3 4.5 1 1.5 4 6.1
Total 32 48.5 34 51.5 66 100.0

Nutritional status Proverawati, (2009) explains that menstrual

Table 1 shows that the majority of
vocational high school students in Brebes
Kabupaen had normal nutritional status as much
as 54 respondents (81.8%) and 42.4% of them in
city vocational high school. Students who have
moderate physical activity as much as 43
respondents (65.2%) and 33.3% of them in village
vocational school. Schoolgirl has a mild stress
levels as much as 34 respondents (51.5%) and
27.3% of them in city vocational high school
whereas normal menarche age were 62
respondents (93.9%) and 50.0% were female
students in city vocational high school.
According Almatsier (2015) suggested that
nutritional status is a measure of a person's body
condition that can be seen from the food
consumed and the use of nutrients in the body.
This is supported by the theory Paath (2005) that
in young women need to maintain a good
nutritional status, by eating a balanced diet
because they were needed at the time of
menstruation, menstrual evident at the time was
primarily on leutal phase will increase nutrient
needs.
disorders basically closely related to sexual
hormones in women that progesterone, estrogen,
LH (luteinizing hormone) and FSH (Follicle
Stimulating Hormone). The disruption of
hormonal systems work is related to nutritional
status. People with better nutritional status as well
as implement a pattern of overeating anyway.
Vice versa. Normally, organ function will be
influenced by the behavior of the applied human.
If the teen has a good nutritional intake with
lifestyle and a good diet can make the
hypothalamus to be good so that it can produce
hormones that the body needs.
The results showed that most respondents
had a normal nutritional status of as many as 54
respondents (81.8%) and there (77.3%) of
respondents did not experience oligomenorrhea
incident. Respondents who had a normal
nutritional status not as many as 12 respondents
(18.2%) and there (15.2%) of respondents
experienced anything oligomenorrhea
The results are consistent with research
Noviandari (2016) that there is a relationship
between nutritional status and the menstrual cycle
in young girls. Dieny (2014) says that the

40
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47
nutritional status plays an important role in
influencing the function of the reproductive
organs. Not only in adolescents who have less
nutritional status, however, menstrual cycle
disorders are also found in adolescents with better
nutritional status. This is associated with the
amount of body fat tissue. This statement is
supported by the results of research Pratama
(2011) that the respondents who have experienced
a cycle irregular menstrual cycles are a group of
girls with thin nutritional status.
Physical activity
The results showed that students who have
moderate physical activity as much as 43
respondents (65.2%) and 33.3% of them in village
vocational school in Brebes. The results also show
that responden light physical activity that has
largely escaped oligomenorrhea as many as 22
respondents (33.3%). Respondents who have
moderate physical activity most also do not
experience oligomenorrhea as many as 31
respondents (47.0%).
In accordance with the theory that heavy
physical activity inhibition of gonadotropin
Releasig stimulating hormone (GnRH) and
gonadotropin activity resulting in lower levels of
serum estrogens. So in this case strenuous
activities cause menstrual disorders.
According to Rabe (2002), fatigue due to
excessive activity can cause hypothalamic
dysfunction that causes disturbances in the
secretion of GnRH. This causes disruption of the
menstrual cycle. The main factors causing
suppression of GnRH women is the use of
excessive energy that exceeds the energy intake.
In accordance with the results of research
Rachmawati (2017) which states that as many as
51.6% of women who work as a dancer with
heavy physical activity experienced a disruption
of the menstrual cycle.
Stress level
The results showed that students who has a
mild stress levels as much as 34 respondents
(51.5%) and 27.3% of them in city vocational high
school. Respondents were mild stress level
41
category largely escaped the incident
oligomenorrhea as many as 32 respondents
(48.5%) and respondents who stress level
categories are being largely escaped the incident
oligomenorrhea as many as 21 respondents
(31.8%).
In accordance with the theory that the
activation state of stress occur in the amygdala in
the limbic system. This system stimulates the
release of hormones from the hypothalamus is
corticotropic releasing hormone (CRH). Increased
CRH stimulates the release of endorphins, and
adrenocorticotropic hormone (ACTH) into the
blood. Increased ACTH levels will cause an
increase in blood cortisol levels. These hormones
are directly and indirectly lead to decreased levels
of GnRH, which through this path then the stress
causes disruption of the menstrual cycle (Sriati,
2008).
According to Rafique and AL-Sheikh
(2018) showed that the menstrual problems not
only of economic factors, but also the absence of
class and poor academic achievement among
adolescents.
In accordance with research Rosendi
(2011), stress can affect the menstrual cycle,
because in times of stress, the hormone cortisol
stress hormone as a product of the adrenal cortex
were synthesized glukokortioid the fasciculata
zone can disrupt the menstrual cycle because it
affects the amount of the hormone progesterone
in the body. Another study conducted by Toduho
et al. (2014) concluded that the moderate
psychological stress that can affect menstrual
cycles more (72.1%) of the weight (5.95%) and
mild (22.1%) this was due to the workloads that
much so stressful becomes larger.
Age of Menarche
The results showed that normal menarche
age were 62 respondents (93.9%) and 50.0% were
female students in city vocational high school.
Respondents who had a normal age of menarche
largely escaped oligomenorrhea as many as 52
respondents (78.8%) and respondents age of
menarche tarda majority have oligomenorrhea as
many as three respondents (4.5%).
Late age of menarche may be associated
with menstrual cycle disorders. According to
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47
research Dambhare (2012) on adolescent girls in
India, showed that young women who experience
menarche late with an average age of menarche
13.51 + 13.67 + 1.04 years and 0.8 years and
affects the menstrual cycle length be abnormal.
Another study conducted by Esen et al.
(2016) in young women in Turkey, showed that
about half of the girls surveyed get menarche <2
years of reported irregular menstruation,
Genesis oligomenorrhea
Table 2. Frequency distribution Genesis oligomenorrhea On Vocational high Students, December 2018 (N =
66)
Village
Genesis oligomenorrhea
F %
not oligomenorrhea 24 36.4
oligomenorrhea 8 12.1
Total 32 48.5
Table 2 shows that the majority of students
vocational high school oligomenorrhea not
experienced anything as much as 53 respondents
(80.3%) and 43.9% of those in vocational Town,
while experiencing the incidence of
oligomenorrhea as many as 13 respondents
(19.7%) and among which 12.1% were in village
vocational high school.
The results showed that the majority of
vocational high school students oligomenorrhea
not experienced anything as much as 53
respondents (80.3%) and 43.9% of those in
42
compared to young women who are
menstruating> 2 years.
Late menarche age also may be associated
with menstrual cycle disorders. Based on research
conducted by Zageye in 2013 on "The age of
menarche and menstrual pattern Teen Secondary
school in western Ethiopia" suggests that delayed
menarche may affect mentstruasi cycle, where
48.2% of adolescents in Ethopia experience
abnormal menstrual cycles.
City Total
F % F %
29 43.9 53 80.3
5 7.6 13 19.7
34 51.5 66 100.0
vocational Town, while experiencing the
incidence of oligomenorrhea as many as 13
respondents (19.7% ) and 12.1% among which are
village vocational school in Brebes.
Oligomenorrhea is problematic menstrual
cycle, which caused by several factors, including
nutritional status, age, physical activity,
reproductive diseases and stress (John, 2010). In
addition hormone imbalance disorders in the
hypothalamic-pituitary-ovarian. The disorder
causes the normal menstrual cycle length becomes
elongated.
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47

Factors Affecting Oligomenorrhea

Table 3. Frequency Distribution of Factors Affecting Oligomenorrhea on Vocational High School, December
2018 (N = 66)
Oligomenorrhea * P
Total OR
Factor not oligomenorrhea oligomenorrhea value
F % F % F %
Nutritional status 0,000 0,012
Abnormal 2 3.0 10 15.2 12 18.2
Normal 51 77.3 3 4.5 54 81.8
Physical activity 0,022 8.516
Light 22 33.3 1 1.5 23 34.8
moderate 31 47.0 12 18.2 43 65.2
Stress level 0,004 8.381
Mild stress 32 48.5 2 3.0 34 51.5
stress Medium 21 31.8 11 16.7 32 48.5
age of menarche 0,004 15,600
Normal 52 78.8 10 15.2 62 93.9
Menarche Tarda 1 1.5 3 4.5 4 6.1
Total 53 80.3 13 19.7 66 100.0
* Chi-square test

Table 3 shows that most of the respondents
had a normal nutritional status of as many as 54
respondents (81.8%) and there (77.3%) of
respondents did not experience oligomenorrhea
incident. Respondents who had a normal
nutritional status not as many as 12 respondents
(18.2%) and there (15.2%) of respondents
experienced anything oligomenorrhea.
Respondents who have mild physical activity
largely escaped oligomenorrhea as many as 22
respondents (33.3%). Respondents who have
moderate physical activity most also do not
experience oligomenorrhea as many as 31
respondents (47.0%). Respondents were mild
stress level category largely escaped the incident
oligomenorrhea as many as 32 respondents (48,
5%) and respondents who stress level categories
are being largely escaped the incident
oligomenorrhea as many as 21 respondents
(31.8%). Respondents who had a normal age of
menarche largely escaped oligomenorrhea as
many as 52 respondents (78.8%) and respondents
age of menarche tarda majority have
oligomenorrhea as many as three respondents
(4.5%).
There is a relationship of between
nutritional status (p value = 0.002), physical
activity (p value = 0.022), stress (p value = 0.004),
menarche (p value = 0.004) with oligomenorrhea
in adolescents vocational Brebes.

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Nutritional Status, Physical Activity, Stress, Menarche to Oligomenorrhea in Adolescents

Table 4. Frequency distribution of nutrition status, physical activity, stress, menarche toward oligomenorrhea
in adolescent village, December 2018 (N = 32)
Genesis oligomenorrhea
* P
not oligomenorrhea Total OR
Factor value
oligomenorrhea
F % F % F %
Nutritional status 0,002 0,026
Abnormal 1 3.1 5 15.6 6 18.7
Normal 23 71.9 3 9.4 26 81.3
Physical activity 0,035 1,571
Light 10 31.3 0 0.0 10 31.3
moderate 14 43.8 8 25.0 22 68.8
Stress level 0,037 11.667
Mild stress 15 46.9 1 3.1 16 50.0
stress Medium 9 28.1 7 21.9 16 50.0
Age of menarche 0.147 7.667
Normal 23 71.9 6 18.8 29 90.6
menarche Tarda 1 3.1 2 6.3 3 9.4
Total 24 75.0 8 25.0 32 100.0
* Chi-square test

Table 4 shows that adolescents in villlage distinguished in intensity and frequency of

most respondents had a normal nutritional status
as much as 26 respondents (81.3%) and 71.9% of
them did not experience oligomenorrhea incident.
Adolescents in village most have moderate
physical activity as much as 22 respondents
(68.8%) and the total (43.8%) did not experience
oligomenorrhea among them. Adolescents in
villagemost have mild stress level categories and
some categories of being. Respondents who have
mild stress level category (46.9%) of them did not
experience oligomenorrhea incident. Age of
menarche mostly normal teenagers as much as 29
respondents (90.6%) and (71.9%) of them did not
experience oligomenorrhea incident.
The results showed that the responden light
physical activity that has largely escaped
oligomenorrhea as many as 22 respondents
(33.3%). Respondents who have moderate
physical activity most also do not experience
oligomenorrhea as many as 31 respondents
(47.0%).High-intensity physical activity increases
the risk of menstrual disorders (Sianipar,
Bunawan, Almazini, Calista, Wulandari,
Rovenska, 2009). In this study can not be
physical activity undertaken by respondents.
The results also showed ada relationship
between nutritional status (p value = 0.002),
physical activity (p value = 0.0358), stress (p value
= 0.037) with oligomenorrhea in adolescents
village. This suggests that the nutritional status,
physical activity and stress experienced by
students in village associated with
oligomenorrhea.
The results showed that most had normal
nutritional status of as many as 54 respondents
(81.8%) and there (77.3%) of respondents did not
experience oligomenorrhea incident. Respondents
who had a normal nutritional status not as many
as 12 respondents (18.2%) and there (15.2%) of
respondents experienced anything
oligomenorrhea.In accordance with the statement
Banudi (2012) that the lack of nutrition can affect
the growth and function of organs, it will also
cause disruption of reproductive function.
Proverawati, (2009) explains that menstrual
disorders basically closely related to sexual
hormones in women. The disruption of hormonal
systems work is related to nutritional status. In

44
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47

line with the opinions Proverawati and Asfuah
(2009) that the nutritional status of the excess as
fat and obesity will have an impact on the
functioning of the body's hormonal system,
considering that fats are capable of producing
estrogen clicking akibatkan menstrual cycle
disorders.
The results also showed ada relationship
between stress (p value = 0.037) with
oligomenorrhea in adolescents
village.Respondents were mild stress level
category largely escaped the incident
oligomenorrhea as many as 15 respondents
(46.9%) and respondents who stress level
categories are being largely escaped the incident
oligomenorrhea as many as 9 respondents
(28.1%).
In the state of stress occur in the amygdala
activation in the limbic system. This system
stimulates the release of hormones from the
hypothalamus is corticotropic releasing hormone
(CRH). Where this path then the stress causes
disruption of the menstrual cycle.
There is no relationship menarche (p value
= 0.147) with oligomenorrhea in adolescents
village vocational school in Brebes Respondents
who had a normal age of menarche largely
escaped oligomenorrhea as many as 23
respondents (71.9%) and respondents age of
menarche tarda majority have oligomenorrhea as
many as 2 respondents (6.3%).
The results are consistent with research
conducted by Fatimah (2015) and Daughter
(2015) concluded that there was no association
with age of menarche menstrual cycle. This is
supported in the research Sonia et al. (2014),
where there is no statistically significant
relationship between the age of menarche and
menstrual cycle. These results indicate the
possibility that the relationship of age of
menarche and menstrual cycles or
oligomenorrhea in teens are caused by many
factors. Many other factors affect the menstrual
cycle of the students, one of which is a hormonal
factors as well as social and environmental
interaction (Kusmiran, 2012). Very solid student
activities could lead to the emergence of stress on
students so that affects the body's hormonal
system.

Status Nutrition, Physical Activity, Stress, Menarche Toward Oligomenorrhea in Adolescents

Table 5. Frequency distribution of status nutrition, physical activity, stress, menarche toward oligomenorrhea
in adolescent city, December 2018 (N = 34)
Oligomenorrhea * P
Total OR
Factor not oligomenorrhea oligomenorrhea value
F % F % F %
Nutritional status 0,000 0.167
Abnormal 1 2.9 5 14.7 6 17.6
Normal 28 82.4 0 0.0 28 82.4
Physical activity 0.627 2,824
Light 12 35.3 1 2.9 13 38.2
moderate 17 50.0 4 11.8 21 61.8
Stress level 0.164 5.667
Mild stress 17 50.0 1 2.9 18 52.9
stress Medium 12 35.3 4 11.8 16 47.1
age of menarche 0.147 0.121
Normal 29 85.3 4 11.8 33 97.1
menarche Tarda 0 0.0 1 2.9 1 2.9
Total 29 85.3 5 14.7 34 100.0
* Chi-square test

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 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47

Table 5 shows that teenagers in city
majority of respondents had a normal
nutritional status as much as 28 respondents
(82.4%) and not at all experienced something
oligomenorrhea. Adolescents in city mostly
have moderate physical activity as much as 21
respondents (61.8%) and the total (50.0%) did
not experience oligomenorrhea among them.
Adolescents in city mostly mild levels of stress
category as many as 18 respondents (52.9%)
and (50.0%) of them did not experience
oligomenorrhea incident. Age of menarche
mostly normal teenagers as much as 33
respondents (97.1%) and (85.3%) of them did
not experience oligomenorrhea incident.
Results of research on adolescent city
showed ada relationship between nutritional
status and oligomenorrhea in adolescent city
vocational school in Brebes (p value = 0.000).
There is no relationship of physical activity (p
value = 0.627), stress (p value = 0.164),
menarche (p value = 0.147) with
oligomenorrhea in adolescents city. This
suggests that any physical activity done
teenagers in the city, regardless of the level of
stress and menarche was not associated with
oligomenorrhea. This shows that
oligomenorrhea happened not because of the
physical activity, stress and menarche.
In accordance with the statement
Mohamadirizi and Kordi, (2013) which states
that Another factor oligomenorrhea such as
bleeding disorders, drugs are consumed, and
endocrine factors that may affect the menstrual
cycle.

Multivariate analysis

Table 6. Logistic Regression Table Risk Factors Influencing Teens Against oligomenorrhea Incident
At vocational high school in Brebes, December 2018 (N = 66),
Variables in the Equation
95% CIFOR EXP (B)
B SE Wald df Sig. Exp (B) Lower Upper
Step 1a Nutritional status -4.429 1,235 12.856 1 , 000 , 012 .001 , 134
Phyisical activity 2,122 1,634 1,687 1 , 194 8.352 , 339 205.513
Level of Stres , 628 1.168 , 289 1 , 591 1,873 , 190 18.490
AgeofMenarche , 501 1,994 , 063 1 , 801 1,651 , 033 82.243
Constant -, 376 4.986 , 006 1 , 940 , 687
Step 2a Nutritional status -4.503 1,215 13.734 1 , 000 .011 .001 , 120
Phyisical activity 2,180 1,632 1,783 1 , 182 8.845 , 361 216.878
Level of Stres , 674 1,152 , 343 1 , 558 1.963 , 205 18.763
Constant , 565 3,373 , 028 1 , 867 1,760
Step 3a Nutritional status -4.719 1.185 15.869 1 , 000 .009 .001 , 091
Phyisical activity 2.646 1,518 3,041 1 , 081 14.104 , 720 276.136
Constant 1,790 2,699 , 440 1 , 507 5.990
a. Variable (s) entered on step 1: Status_Gizi, Aktivitas_Fisik, Tingkat_Stres, Usia_Menarche.

Table 6 shows that the highest OR values The results showed that ada relations
obtained variables of physical activity that is nutritional status (p value 0.000), stress (p value
equal to 14.104 so that the variables of physical 0.004), physical activity (p value 0.025),
activity is a risk factor that influenced the menarche (p value 0.022) toward
incidence of oligomenorrhea Teen vocational oligomenorrhea in adolescents. Multivariate
high school. analysis showed thatPhysical activity is a risk

45
 Vriska Roro Sekar Arum et al. / Public Health Perspectives Journal 4 (1) 2019 37 - 47
factor most influenced the incidence of
oligomenorrhea Teen vocational high school.
The results of the study correspond
according to Banudi (2013) which states that
emotional stress, poor nutrition, excessive
physical exercise, their eating disorders such as
anorexia nervosa patients and their tumors that
affect estrogen secretion that cause
oligomenorrhea.
Strenuous physical activity inhibition of
gonadotropin Releasig stimulating hormone
(GnRH) and gonadotropin activity resulting in
lower levels of serum estrogens. So in this case
strenuous activities cause menstrual disorders.
CONCLUSION
There is a relationship
betweennutritional status and oligomenorrhea
(p value of 0.000).There is a relationship
betweenphysical activity and oligomenorrhea
(p value 0.025). There is a relationship
betweenstress with oligomenorrhea (p value
0.004). There is a relationship between
menarche with oligomenorrhea (p value
0.022).
There is a relationship between
nutritional status (p value = 0.002), physical
activity (p value = 0.035), stress (p value =
0.037) with oligomenorrhea in adolescents
village. There is no relationship menarche (p
value = 0.147) with oligomenorrhea in
adolescents village.
There is a relationship between
nutritional status and oligomenorrhea in
adolescent city (p value = 0.000). There is no
relationship of physical activity (p value =
0.627), stress (p value = 0.164), menarche (p
value = 0.147) with oligomenorrhea in
adolescents city.
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 Gynecological Endocrinology

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/igye20

Association between obesity and oligomenorrhea

or irregular menstruation in Chinese women of
childbearing age: a cross-sectional study

Xinyu Zhou & Xin Yang

To cite this article: Xinyu Zhou & Xin Yang (2020): Association between obesity and
oligomenorrhea or irregular menstruation in Chinese women of childbearing age: a cross-sectional
study, Gynecological Endocrinology, DOI: 10.1080/09513590.2020.1803823

To link to this article: https://doi.org/10.1080/09513590.2020.1803823

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Published online: 12 Aug 2020.

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GYNECOLOGICAL ENDOCRINOLOGY
https://doi.org/10.1080/09513590.2020.1803823

ORIGINAL ARTICLE

Association between obesity and oligomenorrhea or irregular menstruation in

Chinese women of childbearing age: a cross-sectional study
Xinyu Zhou and Xin Yang
Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, China

ABSTRACT ARTICLE HISTORY

Objective: In this study, we aimed to investigate the relationship between body mass index (BMI), waist Received 3 December 2019
circumference (WC) or waist-to-hip ratio (WHR) and oligomenorrhea or irregular menstruation in Chinese Revised 4 July 2020
women of childbearing age. Accepted 28 July 2020
Methods: A total of 1,423 Han women aged 19–39 years who were routinely examined at the Physical Published online 12 August
2020
Examination Center of Peking University People’s Hospital were enrolled by convenience sampling
method. All participants were asked to fill up menstrual questionnaires. Binary logistic regression models KEYWORDS
were used to assess the odds ratio (OR) of different BMI, WC and WHR groups for the prevalence of oligo- Menstrual disturbance;
menorrhea and irregular menstruation. Moreover, we used the ROC curves to compare the predictive obesity; Chinese women
effects of BMI, WC and WHR on oligomenorrhea and irregular menstruation. of childbearing-age;
Results: Among the 1,423 participants, 93 women (6.5%) had BMI
30 kg/m2, 6.5% of the participants oligomenorrhea; irregular
had oligomenorrhea, and 22.6% had irregular menstrual menstruation. Overall, those with BMI
30 kg/m2 menstruation
(OR ¼ 2.543; 95%CI 1.332–4.856; p ¼ .005) or WC
90 cm (OR ¼ 2.023; 95%CI 1.198–3.416; p ¼ .008) were
more likely to have long menstrual cycle. The prevalence of irregular menstruation was higher in the BMI

30 kg/m2 (OR ¼ 2.509; 95%CI 1.591–3.958; p < .001), WC
90 cm (OR ¼ 2.299; 95%CI 1.619–3.265;
p < .001) and WHR
0.86 (OR ¼ 1.739; 95%CI 1.293–2.339; p < .001) groups. The ROC curve showed that
all three anthropometric indices had predictive effect, while there was no significant difference in predict-
ing oligomenorrhea. WC was a better predictor for irregular menstruation compared with BMI.
Conclusions: Obesity, oligomenorrhea and irregular menstruation were common in Chinese women of
childbearing age, and obesity was associated with oligomenorrhea and irregular menstruation. Abdominal
obesity might have a stronger predictive effect on irregular menstruation.

Introduction
There is an increasing prevalence of both obesity and menstrual
disturbance in Chinese population [1,2]. Kazemijaliseh and col-
leagues have reported that about 10.6% women of childbearing
age have disturbances of regularity, and 23.8% experience abnor-
mal menstrual frequency [3]. The prevalence of overweight/obes-
ity in Chinese women is 35.2% in rural area and 33.4% in urban
area [4].
Obesity is associated with abnormal menstrual cycles. Wei
et al. have found that the relationship between the prevalence of
menstrual cycle abnormalities and body mass index (BMI) exhib-
its a U-shaped curve. The incidence of oligomenorrhea and
irregular menstruation increased with the increase of BMI when
BMI was >25 kg/m2 [5]. The proportion of obese women with
abnormal menstrual cycle is higher than that in the general
population, and weight loss alleviates abnormal menstrual cycle
in obese women [6–8]. In addition, the distribution of body fat
also seems to have an impact on the menstrual cycle. Women
with abdominal obesity and high BMI are more likely to have a
longer menstrual cycle than those with high BMI only [9].
However, most of the existing data are established based on
women in Europe and America. Asians tend to have higher body
fat rates when they have the same BMI as Caucasian women.
Therefore, the BMI threshold that has adverse effects on men-
struation can be lower in Chinese women [8]. Zhang et al. have
investigated 236 Chinese women and found that the prevalence
of abnormal menstrual cycle is higher in the obese group (BMI

24 kg/m2) compared with the control group (BMI < 24 kg/
m2). Abdominally obese women are more likely to have a long
menstrual cycle [10].
There is no enough evidence in relation to the overall associa-
tions between obesity and oligomenorrhea or irregular menstru-
ation in Chinese women of childbearing age, and it remains
unclear whether the associations are affected by fat distribution.
In this study, we aimed to investigate the relationship between
BMI, waist circumference (WC) or waist-to-hip ratio (WHR)
and oligomenorrhea or irregular menstruation.
Methods
Participants and study design
A total of 1,529 Han women aged 19–39 years who were rou-
tinely examined at the Physical Examination Center of Peking
University People’s Hospital, China met the entry criteria by
convenience sampling method from May 2017 to November
2018, 17 of whom refused to participate in the study and 89

CONTACT Xin Yang xinyang_2003@sina.com Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing 100044, China
Supplemental data for this article can be accessed here.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 X. ZHOU AND X. YANG
Figure 1. Flow chart of study population.
were excluded based on the exclusion criteria. The remaining
1,423 women were enrolled in this study finally. The flow chart
of participant enrollment is shown in Figure 1. Exclusion criteria
were set as follows: smoking, breastfeeding within 3 months,
pregnancy, hormonal contraceptives used within 3 months
(including oral contraceptives, subcutaneous implant contracep-
tives, progesterone intrauterine release devices and so on), after
hysterectomy, with gynecological history (history of symptomatic
uterine fibroids, large ovarian tumors, cervical tumors, adeno-
myosis, and endometriosis) and patients with hyperprolactine-
mia, depression, breast cancer, thyroid disease and pituitary
disease. Patients with a history of polycystic ovary syndrome
(PCOS) or a combination of oligomenorrhea and typical features
of hyperandrogenism (including hirsutism, acanthosis, severe
acne and female-pattern alopecia, and so on) were excluded.
Since our participants were 19–39 years old, perimenopausal
women were excluded. Women who had menopause or oligome-
norrhea for more than 4 months and perimenopausal symptoms
(including vasomotor symptoms, mood changes, sleep disturb-
ance, symptoms of vaginal dryness and urogenital atrophy and
so on) might be diagnosed with premature ovarian insufficiency
(POI) and excluded. Moreover, those with amenorrhea

4–6 months and perimenopausal symptoms might be diagnosed
with premature ovarian failure (POF) and excluded [11]. All par-
ticipants were required to fill out a questionnaire about menstru-
ation. The questionnaire included the following questions: ‘How
old were you when you had your first menstruation?’; ‘How
often did you have a menstrual period in the last year?’; ‘In the
past year, what was the longest interval between your two men-
strual periods?’; ‘In the past year, what was the shortest interval
between your two menstrual periods?’; ‘Do you have dysmenor-
rhea?’; ‘How long is your average bleeding duration?’.
The height, weight, WC and hip circumference (HC) for the
participants were measured by trained medical staff. Subjects
were all fasted and asked to wear light clothes and stand on bare
feet with bladder emptied for the measurement, and to defecate
if they had a bowel movement. The WC was determined at the
level of umbilicus, and the HC was measured at the most prom-
inent part of the hip in the standing position. All measurements
and questionnaire data were reviewed on the spot to determine
whether there was missing information.
Definitions of variables
BMI was computed as weight in kilograms divided by the square
of height in meters (kg/m2). The participants were divided into
four groups according to WHO diagnostic criteria: BMI
<18.5 kg/m2, 18.5  BMI <25 kg/m2, 25  BMI <30 kg/m2, and
BMI
30 kg/m2. According to WHO definition, the 25  BMI
<30 kg/m2 group is class 1 obesity group, and BMI
30 kg/m2 is
considered as class 2 obesity. Abdominal obesity in WHO crite-
ria is defined as WC
80 cm in Asians [12]. In our study, a
more detailed equal-interval classification was adopted to divide
WC into four groups: WC <70 cm, 70  WC <80 cm, 80  WC
<90 cm, and WC
90cm. The WHR was calculated by dividing
WC by HC and classified into three groups based on quartiles:
WHR <0.79, 0.79  WHR <0.86, and WHR
0.86. Among
them, 18.5  BMI <25 kg/m2, 70  WC <80 cm and 0.79  WHR
<0.86 groups were defined as normal control groups.
In our study, according to the FIGO AUB system [13], oligo-
menorrhea was confirmed when the length of the menstrual
cycle in most cases in the past year was >38 days. Irregular men-
struation was confirmed when the difference between the longest
menstrual period and the shortest period in the past year was
>7–9 days (for women aged 18–25 years or 42–45 years it was
9 days, and for those aged 26–41 years it was 7 days).
Statistical analysis
Chi-square analysis was used to analyze whether there was any
difference in the prevalence of oligomenorrhea or irregular men-
struation between different BMI, WC and WHR groups. Because
significant difference was found among different BMI, WC and
WHR groups, all further analyses were separately performed for
each body character. Binary logistic analysis models were used in
order to assess the association between BMI, WC or WHR and
the prevalence of oligomenorrhea and irregular menstruation.
The age was introduced as a continuous variable to adjust all the
 GYNECOLOGICAL ENDOCRINOLOGY 3

Table 1. Baseline characteristics of patients. Table 2. Proportion and adjusted ORs for irregular menstruation across body
Variables Total n Proportion (%) Mean SD composition categories.
Age (year) 29.88 4.44 Regular Irregular
19–29 750 52.7 BMI (kg/m2) N (%) N (%) OR 95%CI p
30–39 673 47.3 <18.5 93(80.9%) 22(19.1%) 0.732 0.445–1.203 .218
BMI (kg/m )2
23.12 4.10 18.5  24.9 723(78.8%) 194(21.2%) ref ref
<18.5 115 8.1 25  29.9 229(76.8%) 69(23.2%) 1.157 0.843–1.589 .365
18.5–24.9 917 64.4
30 57(61.3%) 36(38.7%) 2.509 1.591–3.958 <.001
25–29.9 298 20.9 WC (cm)

30 93 6.5 60  69 152(80.0%) 38 (20.0%) 0.837 0.556–1.259 .392
WC (cm) 79.13 9.79 70  79 501(79.0%) 133(21.0%) ref ref
<70 190 13.4 80  89 322(80.9%) 76(19.1%) 0.937 0.682–1.289 .691
70–79.9 634 44.6
90 127(63.2%) 74(36.8%) 2.299 1.619–3.265 <.001
80–89.9 398 28.0 WHR

90 201 14.1 <0.79 288(79.8%) 73(20.2%) 0.909 0.659–1.253 .560
WHR 0.82 0.05 0.79  0.859 561(79.9%) 141(20.1%) ref ref
<0.79 361 25.4
0.86 253(70.3%) 107(29.7%) 1.739 1.293–2.339 <.001
0.79–0.859 702 49.3

0.86 360 25.3
menarche 14.00 1.24
Length of menstrual cycles (day) 30.72 5.48 Table 3. Proportion and adjusted ORs for oligomenorrhea across body compos-
38 1331 93.5 ition categories.
>38 92 6.5 Normal cycle Oligomenorrhea
Duration of bleeding (day) 5.31 1.26 BMI (kg/m2) N (%) N (%) OR 95%CI p
Regularity (day) 6.96 13.02 <18.5 110(95.7%) 5(4.3%) 0.644 0.251–1.652 .360
Regular (7–9d) 1102 77.4 18.5  24.9 861(93.9%) 56(6.1%) ref ref
Irregular (
8–10d) 321 22.6 25  29.9 280(94.0%) 18(6.0%) 1.000 0.578–1.731 1.000
Dysmenerrha
30 80(86.0%) 13(14.0%) 2.543 1.332–4.856 .005
no 1122 78.8 WC (cm)
yes 301 21.2 60  69 181(95.3%) 9(4.7%) 0.668 0.318–1.403 .287
SD: standard deviation; WC: waist circumstance; WHR: waist-to-hip ratio. 70  79 592(93.4%) 42(6.6%) ref Ref
80  89 382(96.0%) 16(4.0%) 0.603 0.334–1.089 .093

90 176(87.6%) 25(12.4%) 2.023 1.198–3.416 .008
WHR
regression models. The receiver operating characteristic (ROC) <0.79 339(93.9%) 22(6.1%) 1.004 0.587–1.719 .988
curves and the area under the curve (AUC) was generated to 0.79  0.859 661(94.2%) 41(5.8%) ref ref

0.86 331(91.9%) 29(8.1%) 1.423 0.868–2.333 .161
compare the predictive effects of BMI, WC and WHR on oligo-
menorrhea and irregular menstruation.
All statistical tests were two-tailed. A p value < .05 was con-
sidered statistically significant. Results from logistic regression 1.619–3.265; p < .001) and WHR
0.86 (OR ¼ 1.739; 95%CI
analyses were presented as odds ratio (OR) and 95% CI. The 1.293–2.339; p < .001) groups compared with the normal-
IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., weight group.
Armonk, NY, USA) was used for all the statistical analyses.

Results The association between obesity and the oligomenorrhea

The study population
Table 1 shows the basic information of the study population. A
total of 1,423 Chinese women of childbearing age participated in
the present study. The mean (standard deviation) age was 29.88
(4.44) years, and the average BMI was 23.13 (4.10) kg/m2, of
which the proportion with 25  BMI < 30 kg/m2 was 20.9%
(298), and that with BMI
30 kg/m2 was 6.5% (93). Based on
the WC, the proportion with 80  WC < 90 cm was 28.0%
(398), and WC
90 cm group accounted for 14.1% (201). The
proportion of central obesity defined by WHR
0.86 was 25.3%
(360). The prevalence of oligomenorrhea and irregular menstru-
ation was 6.5% (92) and 22.6% (321), respectively.
The association between obesity and irregular menstruation
Table 2 shows the association between the different body charac-
ter groups and irregular menstruation. The prevalence of irregu-
lar menstrual cycle was the highest in the BMI
30 kg/m2
group (38.7%). The prevalence of irregular menstruation was sig-
nificantly higher in the BMI
30 kg/m2 (OR ¼ 2.509; 95% CI
1.591–3.958; p < .001), WC
90 cm (OR ¼ 2.299; 95% CI
Table 3 shows the association between the different body charac-
ter groups and the oligomenorrhea. The risk of long menstrual
cycle was significantly higher in the BMI
30 kg/m2 (14.0%),
WC
90 cm (12.4%) groups (women with BMI
30 kg/m2
relative to normal-weight women: OR ¼ 2.543; 95%CI
1.332–4.856; p ¼ .005; women with WC
90 cm relative to nor-
mal-WC women: OR ¼ 2.023; 95%CI 1.198–3.416; p ¼ .008).
Centrally obese women with WHR
0.86 showed a trend of
increased risk of oligomenorrhea compared with the normal
WHR women, although there was no significant difference.
Predictive ability of anthropometric indices for
oligomenorrhea and irregular menstruation
Supplement Table 1 shows the data about the AUC values for
discriminating oligomenorrhea and irregular menstruation by
BMI, WC and WHR for participants. The ROC curves for WHR,
BMI and WC values to detect irregular menstruation (a) and oli-
gomenorrhea (b) were shown in Figure 2. AUCs of WC for
irregular menstruation were larger than BMI (0.556 vs. 0.523),
and the rest were not significantly different.
4 X. ZHOU AND X. YANG
Figure 2. Receiver operating characteristic curves for BMI, WC and WHR values to detect irregular menstruation (a) and oligomenorrhea (b).
Discussion
Our study analyzed the association between oligomenorrhea or
irregular menstruation and body composition in a large group of
Chinese women of childbearing age. We found that obesity,
including BMI
30 kg/m2 or WC
90 cm, was associated with
oligomenorhea, and females with BMI
30 kg/m2, WC
90 cm
or WHR
0.86 were significantly associated with irregular men-
struation. WC had a stronger effect on predicting irregular men-
struation than BMI, suggesting that abdominal fat had a stronger
influence on menstrualcycle.
This was the first comprehensive study on the relationship
between body composition and oligomenorrhea or irregular
menstruation in Chinese women of childbearing age. In previous
studies, the definitions of oligomenorrhea and irregular menstru-
ation are different. In different studies, the prevalence of oligo-
menorrhea ranges from 2.32% to 7.8%, and that of irregular
menstruation ranges from 6.25% to 16.9% [5,7]. The prevalence
of oligomenorrhea and irregular menstruation was 6.5% and
22.6% in this study, respectively, which adopted the latest defin-
ition of AUB published by FIGO in 2018 to identify oligomenor-
rhea and irregular menstruation, making our findings more
useful in guiding the clinical work.
The prevalence of obesity in our study was consistent with
that of other women of childbearing age in China, although the
prevalence of women varies with different regions and different
ages. In a large cross-sectional study, 18.2% of women aged
35–39 are overweight, 3.1% are obese, and the proportion is
higher in the north [4]. Recent studies lack data on the preva-
lence of central obesity among women of childbearing age in
China. According to WHO definition (WC
80 cm), the preva-
lence of central obesity among the participants was as high
as 42.1%.
There are also several studies on the relationship between
obesity and oligomenorrhea and irregular menstruation. A recent
study consisting of 3,779 19  49-year-old Korean has shown
that women with a BMI of 25–29.9 kg/m2 (17.1%) and BMI

30 kg/m2 (21.2%) have a significantly higher prevalence of oli-
gomenorrhea than normal-weight women (11.6%). However, in
this study, oligomenorrheais defined as menstruation every
3 months or more [14]. In previous studies, women with
abdominal obesity (WC
80 cm) are more prone to long men-
strual cycles than those with gluteal obesity and only high BMI.
There are also studies showing that women with irregular men-
struation of childbearing age have a higher BMI, WHR ratio and
WC than those with regular menstruation [15,16].
We first investigated the predictive effects of BMI, WC and
WHR on rare and irregular menstrual periods, although only
preliminary analysis was performed in this study. However, our
results showed that both high BMI and central obesity had pre-
dictive effects on abnormal menstrual cycles, which should
arouse vigilance of overweight and obesity in women of child-
bearing age.
The underlying mechanisms of obesity’s predictive effect on
long menstrual cycle and irregular menstrual cycle remain
unclear, and there are several possible causes. Insulin resistance
and hyperinsulinemia in obese women can lead to hyperandro-
genism, which in turn affects the menstrual cycle. In addition,
changes in the GnRH-LH axis of obese women also result in
menstrual disturbance. In obese women, the rapid frequency of
LH pulses leads to an increased serum LH/FSH ratio, which
ultimately results in anovulation [17–19].
Potential reproductive health damage is a more serious conse-
quence of obesity-related menstrual disturbance. Menstrual dis-
turbance is actually a manifestation of anovulation and
insufficient fertility. A cohort study consisting of 53,910 couples
shows a positive dose-dependent relationship between female
BMI and low fertility (pregnancy time > 12 months) with a rela-
tive risk of 1.32 [8].
Our study has several limitations. Its cross-sectional nature
did not allow the results to infer causality. We did not get the
results of sex hormone levels or transvaginal ultrasonography
and only screened the enrolled population based on symptoms
and medical history because the participants were recruited from
the Physical Examination Center in this study. Therefore, the
diagnostic criteria were not strict enough. Another limitation is
the relatively small sample size. There may be selection bias
because our participants are from the Physical Examination
Center rather than the general population. Our research did not
consider other factors, such as social status, educational back-
ground, marital status, income and so on. Our research also has
several advantages. BMI, WC and HC were measured in our

study, rather than self-reported as in previous studies, which
improved the accuracy of the data and substantially offset the
risk of reporting bias.
Conclusions
Collectively, data from Chinese women of childbearing age
showed that obesity was associated with irregular menstrual cycle
and oligomenorrhea. WC was more effective in predicting
irregular menstruation than BMI, suggesting that abdominal
obesity had a stronger predictive effect on irregular menstru-
ation. However, the underlying mechanism of such effect on the
menstrual cycle needs to be further studied.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The study was approved by the Ethics Committee of Peking
University People’s Hospital [2015PHB087-01].
ORCID
Xinyu Zhou http://orcid.org/0000-0002-5204-2857
Data availability statement
The data that support the findings of this study are available from
the corresponding author, upon reasonable request.
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