DISCUSSION
Our cross-sectional study aimed to examine the changes in menstrual
symptoms of women had recovered from COVID-19 and determine the factors
associated with these changes. Our results showed that menstrual
symptoms, fatigue, and menstrual pain severity worsened in women after
being diagnosed with COVID-19. In addition, age at menarche and fatigue
and menstrual pain scores differences after COVID-19 were determiners of
the changes in menstrual symptoms. Menstrual symptoms were more severe
in women with prolonged fatigue, dyspnea, muscle–joint pain, and
gastrointestinal symptoms.
Menstruation, which is controlled by the uterus, ovary, and brain, can
be affected by various infections, medications, or other organ
dysfunctions.20 SARS-CoV-2 has been reported to cause
menstrual cycle disorders by affecting female reproductive
functions.5 Among the women who had been diagnosed
with COVID-19, 20% and 19% reported a reduced menstrual volume and
prolonged menstrual cycle, respectively. The changes in sex hormones as
a result of ovarian suppression have been suggested as a possible
cause.7 In a previous study, 38.8%, 37%, and 29.8%
young adolescents reported menstrual pain, menstrual volume changes, and
menstrual cycle duration changes, respectively.11Previous studies have primarily focused on the effects of COVID-19 on
menstrual volume and menstrual cycle duration. To our knowledge, our
study is the first to identify increased menstrual symptoms and related
factors in women who recovered from COVID-19. We believe that the
negative effects of COVID-19 on the female genital organs responsible
for menstrual cycle control as well as persisting post-infection
symptoms may have led to this finding.
The rapid decrease in estrogen levels during menstruation causes
menstrual pain, muscle–joint pain, and gastrointestinal
symptoms.21 The prevalence of dysmenorrhea varies
between 67.2% and 90.0%.22 During menstruation, as
the basal contraction level of the uterus rises from 10 mmHg to 150–180
mmHg, uterine ischemia develops and the released anaerobic metabolites
stimulate Type-C pain fibers, causing dysmenorrhea. In addition, the
incidence of symptoms, such as nausea, vomiting, and diarrhea, increases
with the stimulation of the gastrointestinal system by
prostaglandins.23 In our study, individuals with
prolonged gastrointestinal symptoms after COVID-19 had higher pain
symptoms and coping methods subgroup scores. In addition subjects with
prolonged muscle–joint pain had higher changes in MSQ total score,
negative/somatic effects and coping methods subgroup scores.
Similarities between persistent post-infection symptoms and the
physiological symptoms that occur during the menstrual period may lead
to the disturbed menstrual symptoms.
Regardless of disease severity, the most frequently reported persist
symptoms were fatigue and dyspnea.2 In our study,
21.7% individuals had prolonged dyspnea and had increased negative
effects/somatic complaints subgroup scores. In studies investigating
airway sensitivity during menstrual periods, a significant increase in
bronchial hyperactivity was found during the luteal
phase.24,25 In a study by Gibbs et
al.,26 40% patients with asthma experienced worsening
symptoms and reduced peak expiratory flow during the premenstrual
period. In our study, individuals with prolonged dyspnea symptoms after
COVID-19 had higher difference in MSQ total score and negative/somatic
effects subgroup scores. This result shows that there is a link between
the subjective respiratory symptoms and menstrual symptom disorders
especially associated with somatic complaints after recovery from
COVID-19.
Fatigue is a premenstrual symptom and has been associated with excessive
bleeding during menstruation.27,28 Juhi et
al.29 reported that muscle fatigue occurs with
decreased estrogen levels in the early follicular and luteal phases.
Among women who were evaluated 60 days after being diagnosed with
COVID-19, 53.1% reported persistent fatigue.2 El
Sayed et al.30 emphasized that the symptoms of fatigue
and anhedonia persist in individuals who had recovered from COVID-19.
Therefore we specifically focused on fatigue as a frequent ongoing
symptom in those subjects. Consistent with this finding, fatigue was the
most common persistent COVID-19 symptom in our study, and individuals
with prolonged fatigue had higher changes in MSQ total score and
negative/somatic effects subgroup scores subgroup scores.
Individuals with increased menstrual pain severity showed higher anxiety
levels.10 The risk of developing depression, anxiety,
and post-traumatic stress disorder is high in people who had recovered
from COVID-19, and this tendency is more common in
women.31 In our study, although the negative
effects/somatic complaints subgroup scores increased in women after
COVID-19, no correlation was identified between the coronavirus anxiety
and changes in menstrual symptom scores. A possible reason is that the
CAS is not a sensitive scale for evaluating anxiety disorders caused by
post-traumatic stress or other reasons. In future studies, using a more
comprehensive measurement tool to evaluate the relationship between
menstrual symptoms and anxiety is recommended.
Zurawuecka et al.32 have reported that an early age at
menarche is associated with menstrual pain, and Anikwe et
al.33 have reported that the mean age at menarche is
13 ± 1.0 years and that menstrual pain is more common in this age group.
However, Çakir et al.34 did not identify ant
relationship between menstrual pain and age at
menarche.34 We found no relationship with between age
at menarche and the pain symptoms but observed a negative relationship
with the coping methods subgroup scores. Moreover, the regression
analysis showed that, each 1-year decrease in the age at menarche
increased the change in MSQ by 0.82.
This finding may indicate an increased incidence of menstrual symptoms
in women recovering from COVID-19 who were younger at menarche, and that
women’s ability to cope with menstrual symptoms may not have developed
at an early age.
Li et al.7 reported no difference in menstrual volume,
sex hormones, and Anti-Müllerian hormone between women who had recovered
from mild and severe COVID-19. Furthermore, the menstrual cycle duration
was longer in women who had severe COVID-19 than in those who had
recovered from mild COVID-19. In our study, only three individuals had
moderate COVID-19, while the other individuals were asymptomatic or had
only a mild disease. Therefore, menstrual symptoms were not compared
according to the disease severity in our study. However, when the
individuals were examined according to the time after COVID-19
diagnosis, the changes in the MSQ total scores and subgroup scores were
not affected by the time after the illness. This result may be related
to the presence of prolonged COVID-19 symptoms. Furthermore, it suggests
that menstrual symptoms may also consider as an ongoing symptom of
COVID-19.
Our study has some limitations. Since the menstrual cycle duration,
menstrual volumes and sexual activity of the individuals were not
evaluated. Therefore the relationship between increased menstrual
symptoms after COVID-19 and these variables could not be explained.
Since our participants were aged 18–45 years, our results may not be
applicable to women beyond that age range who had been diagnosed with
COVID-19 and are actively menstruating. The retrospective assessment of
pre-COVID-19 menstrual symptoms is another limitation of our study.
In conclusion, we observed worsened menstrual symptoms, fatigue, and
menstrual pain severity in women after diagnosis of COVID-19. In
addition, we found that age at menarche, fatigue, and menstrual pain
severity changes determined the changes in menstrual symptoms after
COVID-19 diagnosis. Menstrual symptoms were more severe in women with
prolonged fatigue, dyspnea, muscle–joint pain, and gastrointestinal
symptoms. We examined the effects of COVID-19 on menstrual symptoms and
determined the factors associated with menstrual symptom changes. We
believe that the relationship between menstrual symptoms and menstrual
cycle characteristics and long COVID-19 symptoms should be further
examined in future studies with long-term follow-up periods.