October 21, 2021
A survey of more than 12,000 women of reproductive age found that 1 in 3 had experienced changes to their menstrual cycles and symptoms during the COVID-19 pandemic. Noticeably higher stress levels than prepandemic benchmarks could be affecting menstruation.
This has implications for women trying to conceive or struggling with infertility, said Shannon M. Malloy, a research and data associate with Ovia Health, a women's and family health technology company in Boston. Malloy presented this study at the American Society of Reproductive Medicine's 2021 meeting.
COVID-19 has introduced new psychosocial, interpersonal, and environmental stressors. The pandemic is "one of the most stressful, collectively experienced disasters modern society has ever seen," said Malloy. Once imagined as an explicit event in time, COVID-19 has ingrained itself into daily life for the foreseeable future.
Research has shown that chronic, long-term stress produces high cortisol levels, which can alter endocrinology and regulation of menstrual cycles. This can make family building even more challenging, said Malloy. Physicians and other providers have always taken stress into account when managing patients, but never at this level of chronic, episodic stress, she said.
Survey Examines Impact on ART
Ovia Health decided to investigate the relationship between perceived stress and menstrual cycle and symptom changes during the COVID-19 pandemic, to see how it might affect assisted reproductive technology (ART).
From March 2020 to April 2021, users of Ovia Health's Fertility mobile application in the United States took part in a survey. Items captured changes in menstruation pattern and symptomatology and included the Perceived Stress Scale 4-item version (PSS-4). A paired t-test evaluated differences between groups (menstrual changes versus no menstrual changes). The survey asked participants what changes they noticed in their menstrual cycle and why they thought cycle patterns or symptoms changed.
One-Third Report Changes in Cycle, Symptoms
Among 12,302 respondents, 1 in 3 (36%) reported changes in cycle or symptoms. Eighty-seven percent said that their cycle started early or late. Twenty-nine percent reported stronger symptoms during menstruation such as low back pain, cramping, or discharge changes, and 27% said bleeding was heavier during periods.
These results are similar to other studies investigating the affect of episodic stress on menstruation, said Malloy.
Those who reported menstrual cycle or symptom changes scored higher on average on the PSS-4 compared with those who didn't report any changes (8.5 vs 8.3, respectively; P < .05). PSS-4 scores across the board were notably higher in all respondents, regardless of cycle/symptom irregularity, compared with prepandemic benchmarking in similar populations.
Slightly more than half (55%) thought stress contributed to their menstrual cycle pattern and/or symptom changes, whereas 33% pointed to changes in mental health, such as depression or anxiety. "Interestingly, many users believed the COVID-19 vaccine impacted their menstrual cycle symptom changes," said Malloy.
No Definitive Link Between Vaccine, Menstruation
While known side effects of the vaccine include sore arm, fever, fatigue, and myalgia, some women have reported changes in their menstrual cycle, Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida and director of the IVF Center in Orlando, said in an interview.
"Vaccination reaction from the immune response rather than the vaccine may be the implicating factor," said Trolice, who was not involved in the study.
Currently, there's no direct link between the vaccine and subsequent effects on menstruation, he continued. "Most women experience resumption of normal intervals 1 month following vaccination. Further, there is no credible evidence that links the vaccine to infertility.
"Nevertheless, research in this area is vital and underway," he added.
Physicians Can Help With Stress
Menstrual cycle disruption is especially frustrating for women trying to build a family, said Malloy. Providers may be observing more menstrual irregularity in their patient populations, and seeing more patients struggle to conceive on their own, turning to ART.
Providers can't make COVID-19 go away, but they could help patients by doing a better job of integrating mental health screening, connecting patients to treatments that optimize conception and fertility treatment outcomes, said Malloy.
The survey was limited in that its questions didn't consider proper diagnostic criteria for irregularity, versus self-reported changes. But it does highlight the need for more research on the pandemic's affect on menstruation and the vaccine on menstruation, said Malloy. "The National Institutes of Health in August committed $1.6 million to explore this connection. We're looking forward to seeing what their results are."
Trolice and Malloy had no disclosures.