In a survey conducted in April 2021, women reported disturbances in menstrual cycles and worsening of premenstrual symptoms

Period pain

Women’s reproductive health has suffered as a consequence of the stresses brought about by the COVID-19 pandemic, with disturbances in menstrual cycles and worsening of premenstrual symptoms, suggest Irish survey data.

‘Our findings highlight a real need to provide appropriate medical care and mental health support to women affected by menstrual disturbance, given the unprecedented psychological burden associated with the pandemic’, said study co-author Dr Michelle Maher, Department of Endocrinology, St James’ Hospital, Dublin, in a news release.

The survey, conducted in April 2021, included more than 1300 women, 56% of whom reported changes to their menstrual cycle. In addition, 64% described worsening of premenstrual symptoms, and 54% reported experiencing a reduced sex drive.

Many respondents were also experiencing depression, anxiety, and poor sleep, which were significant predictors of changes to reproductive health, suggests the research presented at the Society for Endocrinology’s annual conference, SfE BES 2021, in Edinburgh on 9 November 2021.

Study details

The team distributed a digital survey via social media over a 2-week period in April 2021 to women of reproductive age.

The survey contained 55 questions on demographics, reproductive health, lifestyle, and mental health symptoms before and during the pandemic, as well as four validated questionnaires:

  • Patient Health Questionnaire-9 (PHQ-9)

  • General Anxiety Disorder-7 (GAD-7)

  • Pittsburgh Sleep Quality Index (PSQI)

  • 12-item Short Form-12 Health Survey (SF-12) version 1.0.

The survey was completed by 1335 women, who had a median age of 34 years and a median body mass index of 24.6 kg/m2. The overwhelming majority (93%) were White Irish, and 69% were not using contraception.

The results show that 56% of women reported an overall change in their menstrual cycle during the pandemic, while 66% reported worse premenstrual symptoms, and 54% cited reduced libido.

The median cycle length was 28 days, with 5 days of menses. Missed periods were reported by 20% of the sample, while 50% had heavy periods, and 59% had painful periods.

Depression, defined as a score greater than or equal to 20 on the PHQ-9, was reported by 2.5%, compared with 0.9% in historical representative community samples before the pandemic.

Anxiety, defined as a GAD-7 score greater than or equal to 15, was reported by 8% of women versus 2% in historical samples, and poor sleep quality, defined as a PSQI global score greater than or equal to 5, was reported by 96% of women versus 42% in historical samples.

Logistic regression analysis indicated that PSQI scores were an independent predictor of overall change in menstrual cycles, with each unit decrease in sleep quality associated with an 11% increase in the odds of menstrual change. They were also predictive of missed periods, with each unit decrease in sleep quality associated with an 11% increase in the likelihood of missed periods.

Change in GAD-7 scores was also an independent predictor of switching from nonpainful to painful periods during the pandemic, with each unit increase in anxiety associated with a 6% increase in the odds of worsening period pain. Each unit increase in anxiety was also associated with a 6% increase in the odds of worsening premenstrual symptoms.

In contrast, each unit increase in scores on the mental health component scale of the SF-12 was associated with a 3% reduction in the odds of worsening premenstrual symptoms.

‘Women continue to suffer reproductive and mental health disturbances, over a year following the outbreak of the COVID-19 pandemic’, the team said.

‘Further longitudinal studies are needed to elucidate the longer-term reproductive and psychological consequence of the pandemic, which are likely to depend on its duration and vaccine efficacy.’

The GP’s role

Lead researcher Dr Lisa Owens, also of St James’s Hospital, told Medscape News UK that there ‘is a need to educate and inform women, as many women do not know the impact their lifestyle and mental health can have on their reproductive health’.

She also believes that general practitioners have a role to play in providing advice to women with mental difficulties, and highlighted that cognitive behavioural therapy and dietary and exercise changes can help women with hypothalamic amenorrhoea.

The team now plans to conduct the surveys at 6-month intervals to identify any longer-term effects on female reductive and mental health, as well as gathering data on blood pressure, weight, sex hormone, and ovulation.

Dr Owens said that, in the current analysis, they asked participants to record their menstrual cycle data using a smartphone app, and asked if they would consent to be contacted again.

‘We have just sent out a follow-up survey to these women, so it will be very interesting to see the results’, she said.

The researchers are also ‘planning to provide support for women affected by menstrual cycle abnormalities by developing psychological support workshops at our centre’, Dr Maher noted in the release.

‘Plausible’

Cynthia Graham, Professor in Sexual and Reproductive Health, University of Southampton, told Medscape News UK that it is ‘plausible’ that stress during the pandemic could cause disruption to women’s reproductive health, including to menstrual cycles.

‘There’s good evidence from decades ago that stress can influence menstrual cycle … so the premise to this [study] makes sense’, although it is not clear how ‘strongly this can be related to the pandemic’.

She also said she has ‘concerns’ over the study, including how the survey was distributed via social media and how the women were recruited.

She highlighted that the current study is cross-sectional and retrospective, and ‘a better design would be a prospective study’, although that is ‘harder to do’ and would result in fewer women taking part.

Professor Graham also noted that the self-reports covered the duration of the pandemic, which is ‘more than a year’, and it is not clear whether aspects such as sex drive were covered in the survey by a one-time question, despite the availability of ‘standardised measures’.

She also raised questions over the use of historical data samples to derive comparisons for rates of anxiety, depression, and sleep quality, as it is not clear that they refer to similar cohorts.

Nevertheless, Professor Graham said that, overall, studies that have looked at the impact of the COVID-19 pandemic on sexuality have also reported ‘lower sexual interest’ that has been ‘attributed to lockdown’.

‘But there also were some positive things’, with one study showing individuals reported more ‘sexual experimentation or diversity in their relationships’, although it depends on the population sample studied, with single people experiencing more of a ‘negative impact’.

Pandemic impact

Numerous studies, including in the UK, have attested to the impact of the COVID-19 pandemic and its associated public health restrictions on mental health, with women, young people, and those living with preschool-aged children particularly affected.

The authors highlight that psychosocial distress can induce menstrual dysfunction via activation of the hypothalamic–pituitary–adrenal axis, and they hypothesised that menstrual function would therefore have been affected during the pandemic.

Six months into the pandemic, in September 2020, they conducted an online survey of 1031 women of reproductive age, finding significant disruptions to reproductive health.

This included changes in menstrual cycle since the beginning of the pandemic, worsening premenstrual symptoms, new menorrhagia, and new dysmenorrhea, which were associated with mental health symptoms.

Society for Endocrinology British Endocrine Societies Conference 2021: Abstract P234. Presented 9 November 2021.

This article originally appeared on Medscape, part of the Medscape Professional Network.

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