ORIGINAL ARTICLE | https://doi.org/10.5005/jp-journals-10006-1973 |
Impact of COVID-19 Severity on Menstrual and Mental Health in Women of Reproductive Age: A Cross-sectional Survey at a Tertiary Healthcare Center
1,2,4–6Department of Obstetrics and Gynaecology, School of Medical Science and Research, Sharda University, Greater Noida, Uttar Pradesh, India
3Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, Delhi, India
Corresponding Author: Shelly Agarwal, Department of Obstetrics and Gynaecology, School of Medical Science and Research, Sharda University, Greater Noida, Uttar Pradesh, India, e-mail: drshellyagarwal75@gmail.com
How to cite this article: Agarwal S, Gupta S, Goel N, et al. Impact of COVID-19 Severity on Menstrual and Mental Health in Women of Reproductive Age: A Cross-sectional Survey at a Tertiary Healthcare Center. J South Asian Feder Obst Gynae 2021;13(6):387–391.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Background: Coronavirus disease-2019 (COVID-19) has claimed innumerous lives globally resulting in increased stress affecting woman’s menstrual, sexual, and mental health, an area of significant concern. The study was aimed to understand the effect of COVID-19 severity on menstrual and mental health.
Method: A cross-sectional survey using a closed-ended questionnaire was conducted on COVID-19 positive women of reproductive age (18–45 years), admitted at School of Medical Sciences and Research, Greater Noida, during the period of April 1, 2021, to May 31, 2021. One-hundred and thirteen patients were enrolled to evaluate any change in a menstrual pattern along with alteration in sleep and sexual drive. Depression Anxiety Stress Scale-21 was used to assess mental health. Results were analyzed using the Chi-square test.
Results: Nearly, 52.2% of patients reported changes in their menstrual patterns. Change in cycle length was observed in 37.8% of patients, 18% of cases reported heavy or decreased flow while 16.2% of patients had prolonged or short cycles. Patients with moderate-to-severe disease had statistically increased incidence of infrequent cycles, scanty flow, and short cycles and significantly correlated with increased levels of depression, anxiety, and stress.
Conclusion: This study highlights the implication of COVID-19 severity on emotional and menstrual disturbances, an aspect which is least addressed and discussed. It also emphasized the need for more frequent post-COVID counseling sessions to improve women’s health.
Keywords: Anxiety, COVID-19, Depression, Menstruation, Mental health, Stress
INTRODUCTION
The first case of the novel coronavirus infection was reported in the city of Wuhan, China on December 29, 2019. Since then, coronavirus disease-2019 (COVID-19) has rapidly spread across the entire world to become a major human disaster and claim innumerous lives. Our country India reported over 2.93 crore COVID infections by December 31, 2020, with an overall mortality of less than 50,000 cases. However, the country experienced the catastrophic second wave in March 2021 taking its death toll to 3.63 lakhs as of June 11, 2021. With such a dreadful scenario, there was a fear of losing near and dear ones resulting in increased stress among people.
It is a known fact that stress and patient psychology have an adverse effect on a woman’s menstrual cycle.1 Stress can result in decreased gonadotropin-releasing hormone (GnRH),2 leading to decreased or normal levels of follicle-stimulating hormone and decreased levels of luteinizing hormone (LH) as well. This absence of midcycle surge results in chronic anovulation and subsequent functional hypothalamic amenorrhea3 along with an array of other menstrual disturbances, such as dysmenorrhea and premenstrual symptoms (PMS). Menstrual cycle irregularities could also include changes in a menstrual pattern in terms of frequency, regularity, duration, or pain intensity, and even intermenstrual bleeding.4
Apart from stress, various eating disorders and excessive exercises can also result in functional hypothalamic dysmenorrhea.5 However, it can be reversed by behavioral modifications, such as cognitive-behavioral therapy.6
Therefore, the objective of the current study was to survey women of reproductive age who were affected by the COVID second wave and to assess any change in their menstrual pattern in relation to the severity of the disease. The study also aimed to evaluate sleep pattern changes, decreased sexual drive, and affection of psychological health attributed to COVID-19 disease. The novelty of this study was to assess the reproductive health of women on the menstrual parameters and its correlation with stress and severity of the COVID disease, one of the first in the Indian population.
MATERIALS AND METHODS
A cross-sectional survey, using a structured closed-ended questionnaire, was performed on confirmed COVID-positive women of reproductive age, admitted in School of Medical Sciences and Research, Greater Noida . The target population enrolled for the study included women between 18 and 45 years of age, admitted during the period of April 1, 2021, to May 31, 2021.
Inclusion Criteria
Women between 18 and 45 years of age.
Known reverse transcription–polymerase chain reaction COVID-19 positives.
Hospitalized at School of Medical Sciences and Research, Greater Noida, during the defined period.
Exclusion Criteria
Pregnant women
Lactating women who had not resumed their menstruation
Patients with previous menstrual irregularities, especially within 6 months prior to the onset of COVID disease
Patients with menopause (premature/natural/surgical)
Patients who did not give consent for the study
A total of 216 patients were admitted during this period. Out of these only 113 patients met the various inclusion and exclusion criteria and consented to the study.
The study population of 113 participants was categorized into the mild, moderate, and severe categories of COVID disease in accordance with the guidelines issued by AIIMS/ICMR-COVID-19 National Task Force/Joint Monitoring Group, Ministry of Health and Family Welfare, Government of India.7
The menstrual history and information pertaining to change in sleep pattern and sexual drive was obtained telephonically through a questionnaire in the local language.
Important definitions used to assess menstrual abnormality were:
Normal menstrual cycles—menstruation occurring at an interval of 24 days to 38 days, with the duration of 4–8 days and normal flow
Amenorrhea—absence of menstruation for >90 days
Prolonged cycle duration—lasting >8 days
Short cycle duration—lasting <4 days
Infrequent cycles—menstruation occurring > and <90 days
Frequent cycles—menstruation occurring <24 days
Heavy bleeding—in comparison with her previous cycles
Scanty bleeding—in comparison with her previous cycles.
Mental health was assessed using the standard Depression Anxiety Stress Scale-21 (DASS-21) question format.8 DASS score helps to assess the severity of depression, anxiety, and stress which are the key markers of mental and emotional health. All participants were surveyed with 21 questions (seven each to identify depression, anxiety, and stress). The response of each question was rated and interpreted accordingly. The details of the DASS score is given in reference8 (DASS website).
These were independently compared to observe any significant association with the severity of the disease.
The data were analyzed using the Chi-square test.
RESULTS
Two-hundred and sixteen women between 18 and 45 years were admitted to the hospital with varying symptomatology of COVID-19 disease. Of these, 113 participants gave telephonic consent, met the inclusion and exclusion criterion, and were included in the study. They were grouped according to disease severity into mild disease (61/113) and moderate-to-severe disease (52/113). In the moderate-to-severe disease category, 51 patients had moderate COVID disease, and one patient suffered from severe disease (Table 1).
| Severity of COVID-19 disease | Number of patients, n |
|---|---|
| Mild disease | 61 |
| Moderate disease | 51 |
| Severe disease | 1 |
Participants were further distributed according to their age and severity of disease (Table 2).
| Age-group | Mild disease | Moderate-to-severe disease |
|---|---|---|
| 15–20 years | 3 | 1 |
| 20–25 years | 21 | 9 |
| 25–30 years | 13 | 6 |
| 30–35 years | 10 | 11 |
| 35–40 years | 8 | 12 |
| 40–45 years | 6 | 13 |
| Total | N1 = 61 | N2 = 52 |
Menstrual cycle remained unaltered in 54/113 (47.8%) women post COVID irrespective of COVID severity. Fifty-nine of 113 (52.2%) women reported change in their menstrual pattern, either with respect to cycle length, duration of flow, number of pads used, pain during menses, or PMS (Fig. 1).
Fig. 1: Change in menstrual pattern
Two patients, one with mild disease (23 years) and the other having a moderate disease (26 years) reported amenorrhea post-COVID. Hence, they were excluded from the assessment of other menstrual parameters. Further assessment of menstrual parameters has been done with 111 patients (60 patients with mild disease and 51 patients with moderate-to-severe disease).
Change in cycle length was the most significant menstrual change observed. Forty-two of 111 (37.8%) patients had a change in cycle length, either infrequent or frequent, whereas 69/111 patients had unchanged cycle length.
Among cases with mild COVID disease, 49/60 patients (81.7%) did not experience any change in cycle length. Nine of 60 patients (15%) reported infrequent cycles and only 2/60 cases (3.3%) reported frequent cycles.
In patients of moderate-to-severe COVID disease, 20/51 cases (39.2%) reported unchanged cycle length, whereas 28/51 cases (54.9%) had infrequent menstruation and 3/51 cases (5.9%) had frequent cycles. Statistical analysis revealed a significant difference in cycle length in moderate-to-severe disease as compared to mild disease (p <0.00001) (Fig. 2A).
Figs 2A to E: Change in menstrual pattern with COVID disease severity
The majority of the patients, 91/111 (82%) did not report any change in the amount of blood flow, whereas only 20/111 (18%) patients had increased or decreased flow.
Among patients with mild COVID disease, 56/60 cases (93.3%) reported no change in the amount of flow. However, 3/60 (5%) and 1/60 (1.7%) participants had heavy and scanty menstruation, respectively.
In moderate-to-severe disease, the flow remained unchanged in 35/51 cases (68.6%). Sixteen patients (31.4%) had scanty flow, but none experienced heavy flow. Statistical analysis showed a significant difference in scanty blood flow changes between mild and moderate-to-severe category of COVID-19 (0.00008)* (Fig. 2B).
Most of the patients did not report any change in the duration of menstruation. Ninety-three of 111 patients (83.8%) had a normal duration of blood flow averaging between 4 and 8 days. Only 18/111 patients (16.2%) had any alteration in the duration of flow.
In mild COVID patients the duration of blood flow was unchanged in 57/60 cases (95%). One of 60 patient (1.7%) experienced decreased duration while 2/60 cases (3.3%) had increased duration of flow.
In moderate-to-severe disease, 36/51 cases (70.6%) had normal flow, 11/51 cases (21.6%) had a short duration of flow, and 4/51 cases (7.8%) experienced prolonged menstruation. Statistical analysis calculated a significant difference in the duration of flow in regards to COVID-19 severity. The shorter duration was observed in patients with moderate-to-severe as compared to those with mild disease (p-value: 0.0016)* (Fig. 2C).
Dysmenorrhea was newly experienced in three patients (5%) of mild disease and three patients (5.9%) of moderate-to-severe disease. The majority of the patients (105/111) experienced no change in pain during menstruation (Fig. 2D).
Similarly, most of the patients (104/111) did not perceive any change in PMS. Patients with moderate-to-severe disease experienced more change in PMS (8%) as compared to those with mild disease (5%), but both these menstrual parameters were not statistically significant in relation to disease severity* (Fig. 2E).
Sexual health was assessed by the women’s desire for sexual activity and 7/113 participants (6.2%) reported hypoactive sexual desire. Disturbed sleep was experienced by 48/113 participants (42.5%).
Mental health was assessed using the DASS-21 score as previously discussed.
DASS score results in mild COVID disease—forty-two cases, 42/61 (68.8%), reported no depression, while 19 (31.2%) experienced different grades of depression. Of these 19 patients, a mild form of depression was noted in 15 (24.6%) and moderate depression in four cases (6.6%). None of the patients had severe or extremely severe depressive symptoms.
Similarly, 54/61 cases (88.5%) reported no anxiety symptoms, whereas 7/61 patients (11.5%) had different scales of anxiety. Five cases (8.2%) experienced mild anxiety and two patients (3.3%) had moderate anxiety. None reported severe or extremely severe forms of anxiety.
Thirty-five patients (57.4%) reported no stress. Mild stress was noted by 20 patients (32.8%), moderate form by 5 (8.2%), and severe variety by one patient (1.6%). None experienced extremely severe stress levels.
DASS score results in moderate-to-severe COVID disease—fifteen patients (28.8%) reported no depression, while 37/52 patients (71.2%) experienced some form of depression. Mild depression was noted in 26 cases (50%) and moderate depression in 11 cases (21.2%). No patient had severe or extremely severe depressive symptoms.
Similarly, 29/52 patients (55.8%) had no anxiety symptoms. But 18 cases (34.6%) experienced mild anxiety and 5 (9.6%) had moderate anxiety features. None reported severe or extremely severe forms of anxiety.
The majority of the patients reported varying degrees of stress levels. Mild stress was reported by 28/52 patients (53.9%), moderate form by 19 (36.5%), and severe stress was reported by 1/52 patient (1.9%). Only four patients (7.7%) stated no stress in moderate-to-severe COVID disease and none experienced extremely severe stress levels.
The statistical analysis of the above data indicated that patients with moderate-to-severe disease experienced statistically significant levels of depression (p-value: 0.00002), anxiety (p-value: 0.00008), and stress (p-value: <0.00001)* (Fig. 3).
*Chi-square test with Yates’ correction.
Fig. 3: Depression, anxiety, and stress in relation to disease severity
DISCUSSION
Menstruation is regulated by the hypothalamic-pituitary-ovarian axis and is easily disturbed by external factors such as infections, drug treatments, and other organ dysfunctions.9 Apart from these, increased levels of stress are also associated with a high probability of menstrual irregularity.10 Stress inhibits the GnRH release and glucocorticoid inhibits the LH and further release of estrogen and progesterone from the ovary.11 These hormonal changes are responsible for subtle menstrual changes. A large proportion of the female population have experienced reproductive health disturbance during the COVID-19 pandemic3 and menstrual cycle disturbances have been attributed to the stress associated with the unpredictable course of the disease.
A retrospective, the cross-sectional study analyzed the menstrual changes in COVID-19 patients.12 The study observed that 25% of patients had varying menstrual changes, mainly manifesting as prolonged cycles (19%) and decreased volume of blood flow (20%). Importantly these changes were found to be transient. Follow-up of the patients revealed that 84% cases returned to a normal menstrual volume and 99% of patients returned to their normal cycle within 1–2 months of discharge.12
The most common menstrual abnormality observed in this study was also infrequent menstrual cycle (36.3% cases) observed more frequently in patients with moderate-to-severe disease.
Premenstrual symptoms have been associated with high levels of stress.13 A study reported that over half of respondents had worsening symptoms of PMS.3 However in the current study, PMS was reported in only seven (6.2%) cases. PMS has been correlated with sleep disturbance as well.14 Sleep disturbance was observed in 7.96% of women, and it was more commonly seen in patients with a change in menstrual pattern.
Coronavirus disease-2019 has not only affected the physical health and social life of people but also their mental wellbeing. People have gone through difficult times. They faced unemployment, separation from families due to isolation policies, and loss of near and dear ones with subsequent effects on mental health.15 A review article published in The Lancet stated that these difficulties faced by people along with the unpredictive nature of the disease can cause a deterioration in an individual’s mental health status.16
Approximately 33.9% of adults in the United States have reported symptoms of anxiety or depression during COVID (May 14–19, 2020). If we compare the same with pre-COVID times, then from January 2019 to June 2019, only 10.8% of adults reported such symptoms. The difference clearly indicates the impact of the deadly virus.17
This study also revealed statistically increased grades of depression, anxiety, and stress in moderate-to-severe disease as compared to mild COVID disease.17
The strength of this study was that teleconsultation helped to address the emotional disturbances of many women and those in need were referred to counselors and professionals timely.18
The major weakness of this study was that it was not able to evaluate whether these menstrual and emotional changes were transient or persisted long.
CONCLUSION
Coronavirus disease-2019 pandemic has had a significant impact on the physical, mental, and social health of individuals globally. Another aspect that has been affected is the menstrual and reproductive health of women. This study highlights the implication of COVID-19 and its severity on emotional and menstrual disturbances, an area that is least addressed and discussed. Therefore, it is important to have frequent post-COVID counseling sessions to deal with patient queries and concerns. Future research however needs to be continued to assess the long-term impacts, if any.
ORCID
Samta Gupta https://orcid.org/0000-0002-6263-9112
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