Sir,
We wish to share with you a social reality about menstruation that endocrinologists should be aware of. We recently encountered the case of a 23-year-old girl who presented with secondary amenorrhea. She claimed to have attained menarche at the age of 14 years and apparently had her last menses 10 months back. On examination, she was mildly hirsute and had a very small vaginal opening. She had near-normal breast development (B4). Ultrasound showed that she did not have uterus or Mullerian structures! Further evaluation revealed the diagnosis of ovotesticular disorder of sex development.
This is not the first time we have had a patient claim that she had secondary amenorrhea, when indeed the issue is primary amenorrhea. To the best of our knowledge, there is no published medical literature on the prevalence of such false claims of attaining menarche in patients with amenorrhea. As doctors from Tamilnadu, we propose that the local culture and the popular media have contributed much to this and other patients' plight, forcing them to “fake” a history of menstruation.
The custom of celebrating the coming of age is an age-old tradition in Tamilnadu, especially among Hindus. It goes under various monikers such as Sadangu, Manjal Neeratu Vizha, and Poopunitha Neeratu Vizha. The first menses marks a girl's transition to womanhood and is celebrated with grandeur. Depending on the wealth of the parent, this can entail anything from a small family function to brazen display of opulence replete with “flex” posters. It is curious that such a wide publicity of a physiological process is not seen in our neighboring states. Indeed, this function is so deeply entrenched in public psyche that many blockbuster movies feature scenes (many of which are crass in our opinion) of this function.
People outside Tamilnadu might wonder why such celebration of puberty came to fore in the first place. In the olden days, the attainment of puberty was at a considerably older age. So, the celebration was a way of letting the public know the marital eligibility of the girl. This was thus a subtle invitation for suitors at a time when matrimony sites were nonexistent. To that end, the function also served to demonstrate the wealth of the parents and thus the “desirability” of the girl to the potential suitors. A more charitable view claims this as a celebration of womanhood. Indeed, there is no other ceremony in a woman's life that places her exclusively at the center of attention (the baby shower is a close second). Further, it normalizes menstruation in the society–after all if a physiological process is celebrated with all and sundry, how much should one be shy about it?
As years passed, the customs have changed according to the times and have largely become diluted. For example, it is not uncommon to see the “sadangu” informed only to close family members and conducted on the weekends so as to avoid embarrassing the girl child. However, this public celebration is still intact in rural Tamilnadu. A girl who has not attained menarche invites unnecessary comments from near and dear–which can be effectively silenced by a “fake” puberty function. Thus, the function serves to give a modicum of respect (and paradoxically privacy) to the rural girl and shields her from prying questions.
This social construct creates an unintended consequence to the endocrinologists–since many cases of the so-called secondary amenorrhea often turn out to be primary amenorrhea! While a good history and physical examination are the pillars on which our diagnosis rests, we might be led astray when one of the pillars is shaky. Therefore, when there is a discrepancy between history and examination, we tend to trust the examination findings more. As our state is one of the more developed states of our country, we wonder about such social determinants of endocrinology practice in parts of the country which are poorer or underdeveloped. As endocrinologists, it behooves us to know and take into account the local customs so that our management stands on terra firma.
Moral of the story – In some parts of India, the endocrinologist should take the history of “secondary amenorrhea” with a bucket of salt.
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Conflicts of interest
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