Coronavirus Disease 2019 (COVID-19)–Related Stress and Menstrual Changes : Obstetrics & Gynecology

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Original Research

Coronavirus Disease 2019 (COVID-19)–Related Stress and Menstrual Changes

Anto-Ocrah, Martina PhD, MPH; Valachovic, Tori BS; Chen, Michael PhD; Tiffany, Kimberly BA; DeSplinter, Lindsey BA; Kaukeinen, Kimberly BS; Glantz, J. Christopher MD, MPH; Hollenbach, Stefanie MD, MS

Author Information
Obstetrics & Gynecology: October 27, 2022 - Volume - Issue - 10.1097/AOG.0000000000005010
doi: 10.1097/AOG.0000000000005010
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In March of 2020, the World Health Organization characterized the coronavirus disease (COVID-19) as a global pandemic.1 At the time of this study, May 2021, more than 3.5 million deaths worldwide had been attributed to COVID-19, with more than 500,000 deaths recorded in the United States alone.2 The Centers for Disease Control and Prevention cites just more than 1,000,000 U.S. deaths from COVID-19 as of August 2022.3 The harrowing loss of life due to this global pandemic along with the ensuing public health interventions and indirect economic effects have resulted in unprecedented societal disruption, which has led to a spike in emotional distress and psychiatric symptoms.4 In the United States, women have shouldered more childcare duties during the pandemic5 and find COVID-19–induced changes to daily activities, along with the potential risk of COVID-19 illness, significantly more stressful than men.6

High stress levels have been associated with aberrant menstrual changes in women.6–10 Disruptions in women's menstrual cycles, such as amenorrhea, can not only be detrimental to reproductive goals,11 but they have been associated with undesired mental health,12 respiratory,13 and cardiovascular outcomes.14 Although reports suggest greater effects of COVID-19–related stress on women than men during the pandemic,15,16 little research has been conducted on the relationship between COVID-19–related stress and women's menstrual cycles, an important indicator of overall well-being.

In this study, we evaluated how stress related to the COVID-19 pandemic has affected women's menstrual cycle length, duration, and flow and frequency of spotting between cycles. We hypothesized that women with high levels of COVID-19–related stress will report changes in all four menstrual parameters (cycle length, duration, flow, and spotting) compared with prepandemic times.

METHODS

Because it was important to reach a geographically and racially diverse population of women across the United States, we used a cross-sectional study design to recruit a sample of U.S. adult women between the ages of 18–45 years using Dynata, a survey sampling company that maintains a demographically diverse web panel of survey takers across the United States.17–19 Dynata's panel members are randomly routed to available surveys based on eligibility criteria of open surveys and receive participation rewards based on Dynata's incentive system.17–19 Our recruitment plan involved the use of soft quotas, aligned with U.S. Census data to ensure geographic, racial, and ethnic diversity in our sample. In research, soft quotas can mean either an absolute minimum that researchers expect to be exceeded or a quota for which near enough is good enough.20 For this study, using soft quotas in our recruitment and sampling scheme allowed us to monitor the geographic, racial, and ethnic distributions of the study population and modify or target the distribution of subsequent invitations to participate to grossly reflect U.S. Census data.

The title of the survey that was distributed to Dynata's panelists was “Women's Covid-related Stress, Menstrual Health and Wellbeing,” accompanied by a summary detailing that the survey was intended to investigate the effect of COVID-19–related stress on women's menstrual health and overall well-being. Participants completed the anonymous, web-based survey using REDCap (Research Electronic Data Capture, Vanderbilt University). Survey finishers received participation rewards per Dynata's incentive system.17–19

The study's inclusion criteria included: 1) self-identifies as a woman, 2) self-reported age between 18 and 45 years, and 3) resides in a U.S. state or territory. Women older than age 45 years were excluded to avoid the hormonal irregularities associated with the menopausal transition.21–23 To capture naturally cycling women, we excluded women who were menopausal or postmenopausal before the pandemic, had undergone hysterectomy, were currently pregnant, were less than 3 months postpartum, were currently receiving exogenous glucocorticoids, had undergone infertility treatments before the pandemic, or were currently taking hormonal birth control.

All survey questions were reviewed for relevance and context by the research team and pretested with a subsample of women within the target population for face and content validity. Informed consent was obtained from all research participants. The study was approved by the University of Rochester IRB (STUDY00005980).

Menstrual parameters were self-reported based on the following questions:

  • Menstrual cycle length: “Since the COVID-19 pandemic began in March 2020, has the length of your menstrual cycle changed? (the time from day 1 of one cycle until day 1 of the next cycle)”. Response options (randomized): No change/Shorter/Longer/I have not had my period since the pandemic began in March 2020.
  • Cycle duration: “Since the COVID-19 pandemic began in March 2020, has the duration of your periods changed? (days of flow per period)” Response options (randomized): No change/Shorter/Longer/I have not had my period since the pandemic began in March 2020.
  • Cycle flow: “Since the COVID-19 pandemic began in March 2020, has your menstrual flow changed? (amount of bleeding)” Response options (randomized): No change/Lighter/Heavier/I have not had my period since the pandemic began in March 2020.
  • Spotting: “Since the COVID-19 pandemic began in March 2020, have you begun having spotting between periods?” Response options (randomized): Yes/No/I have not had my period since the pandemic began in March 2020.

Participants who selected “no change” or “no” across all four parameters (length, duration, flow, and spotting) were categorized as “no change,” and all others were categorized as “change.” The two groups then were compared in bivariate and multivariable regression analyses.

Participants' COVID-19–related stress levels were assessed with the PSS-10-C (COVID-19 Pandemic-related Perceived Stress Scale).24 The PSS-10-C has 10 items, which are ranked on a 5-point Likert scale of “0-Never” to “4-Always.” Scores range from 0 to 40, with higher scores indicative of greater stress levels. We defined low COVID-19–related stress as PSS-10-C scores lower than 25 and high COVID-19–related stress as scores of 25 or higher, in accordance with the literature.24

Covariates included age, race, ethnicity, educational attainment, marital status, number of living children (younger than age 18 years), and smoking status. Participants were also asked about their prepandemic menstrual functioning, assessed by how many periods they experienced per year before the pandemic, along with comorbidities diagnosed before and during the pandemic. Comorbidities included reproductive or gynecologic conditions (endometriosis, leiomyomas or myomas, polycystic ovarian syndrome, and uterine polyps), thyroid disease, obesity, sexually transmitted infections, and mental health history (anorexia, anxiety, depression, and other mood disorders). We also asked about COVID-19 vaccination status, because preliminary reports suggest an association between psychological stress and vaccination hesitancy.25

We used descriptive statistics (proportions, means, medians, ranges, and standard deviations) to describe the study sample. Pearson's χ2 and t tests were used to compare survey responses in bivariate analyses, to identify important covariates. We used logistic regression models to estimate crude and adjusted effect sizes. In minimally adjusted models, we adjusted only for predictors (variables that were associated with menstrual change only) and confounders (variables that were associated with both COVID-19–related stress and menstrual change). In fully adjusted models, we adjusted for all variables that were statistically significant in bivariate analyses if they had also been adjusted for in previously published menstruation studies. We used the standard P<.05 cutoff to determine statistical significance in all our analyses. Analyses were completed using Stata.

RESULTS

The survey launched on May 4, 2021, and ended on May 7, 2021. A total of 1,037 survey takers (Fig. 1) met the first set of inclusion criteria and consented to participate in the study; 948 (91%) were deemed “completes,” meaning that they proceeded through all questions to the final survey page. The remaining 89 did not make it to the final survey page and were considered “incompletes.” Despite being considered completes, participants may have had missing data and not answered all relevant questions. Thus, we indicate the final sample size for each of the analyses in the tables as appropriate (see Appendix 1, available online at https://links.lww.com/AOG/C930, for comparison of differences between completes and incompletes). The mean age of the completes was 32.62 years (±7.06 SD), and the mean number of children younger than age 18 years for the sample was 1.1 (±1.31 SD). Three hundred seventy-four naturally cycling women met the second set of gynecologic and reproductive inclusion criteria for the menstrual analysis group (ie, not menopausal or postmenopausal before the pandemic, had not undergone hysterectomy, not currently pregnant or less than 3 months postpartum, not currently receiving exogenous glucocorticoids, had not undergone infertility treatments before the pandemic, not currently taking hormonal birth control) and were asked the menstrual-assessment questions (Fig. 1) (see Appendix 1, https://links.lww.com/AOG/C930, for comparison of the excluded nonnaturally cycling women [n=569] with the included naturally cycling women [n=374] on key covariates).

F1
Fig. 1.:
Schematic of study methods. PSS-10-C, Coronavirus 2019 Pandemic-related Perceived Stress Scale.

Our recruitment strategy, modeled on U.S. Census data, resulted in a diverse group of survey participants across each U.S. state and geographic region (Table 1). With regard to race, compared with U.S. Census data, there was an over-representation of Asian individuals, American Indian/Alaskan Native individuals, and those who identified as an unlisted race; there was an under-representation of those of Hispanic heritage. Educational attainment was high compared with U.S. Census data, with about a quarter (23.9%) of all participants having at least a Master's degree. However, among the women who met the second set of gynecologic and reproductive inclusion criteria (Table 1), only 15.3% had Master's-level education, which was close to the U.S. Census rate of 13.0%; there was an over-representation of women with high school–equivalent education or less (44.0%) compared with U.S. Census data (38.0%). Fewer than 5% of participants had been divorced or separated (Table 1). However, because we surveyed only U.S. women between the ages of 18 and 45 years, differences in the study data compared with the larger U.S. Census population should be interpreted with caution, because they are likely due to the age-restricted nature of the study's inclusion criteria.

Table 1. - Demographic Characteristics of Participants
Characteristic Total Study Sample Meeting 1st Set of Eligibility Criteria (N=1,037) Participants Meeting 2nd Set of Eligibility Criteria (n=374) U.S. Census Data
Race 47
 Missing n=141 n=1
 Nonmissing n=896 n=373
 American Indian/Alaska Native 17 (1.9) 9 (2.4) 1.3
 Asian 86 (9.6) 33 (8.9) 5.9
 Black 76 (8.5) 40 (10.7) 13.4
 Native Hawaiian 2 (0.2) 2 (0.5) 0.2
 White 680 (75.9) 270 (72.4) 76.3
 None of the above 35 (3.9) 19 (5.1) 2.8
Ethnicity
 Missing n=154 n=5
 Nonmissing n=883 n=369
 Hispanic 122 (13.8) 51 (13.8) 18.5
 Non-Hispanic 761 (86.2) 318 (86.2) 60.1
Educational attainment 48
 Missing n=140 n=1
 Nonmissing n=897 n=373
 High school or less 310 (34.6) 164 (44.0) 38.0
 Technical training or Associate’s or Bachelor's degree 373 (41.6) 152 (40.7) 50.0
 Master's degree or higher 214 (23.9) 57 (15.3) 13.0
Relationship status 49
 Missing n=141 n=0
 Nonmissing n=896 n=374
 Single or in a relationship but not married 435 (48.6) 217 (58.0) 30.7
 Married 421 (47.0) 140 (37.4) 46.3
 Divorced, separated, other 40 (4.5) 17 (4.6) 23.0
Geographic region*, 47
 Missing n=214 n=30
 Nonmissing n=823 n=344
 Northeast 107 (13.0) 49 (14.3) 19.2
 Southeast 164 (19.9) 79 (23.0) 25.6
 Midwest 122 (14.8) 46 (13.4) 20.6
 Southwest 159 (19.3) 51 (14.8) 12.8
 West 271 (32.9) 119 (34.6) 20.8
Data are n (%) or %.
*Northeast: Maine, Massachusetts, Rhode Island, Connecticut, New Hampshire, Vermont, New York, Pennsylvania, New Jersey, Delaware, Maryland, Washington DC; Southeast: West Virginia, Virginia, Kentucky, Tennessee, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Arkansas, Louisiana, Florida. Midwest: Ohio, Indiana, Michigan, Illinois, Missouri, Wisconsin, Minnesota, Iowa, Kansas, Nebraska, South Dakota, North Dakota. Southwest: Texas, Oklahoma, New Mexico, Arizona. West: Colorado, Wyoming, Montana, Idaho, Washington, Oregon, Utah, Nevada, California, Alaska, Hawaii.

Of the 1,037 participants who met the first set of eligibility criteria, 838 completed the PSS-10-C scale and were dichotomized as high (score 25 or higher on the PSS-10-C, n=93) or low (score lower than 25 on the PSS-10-C, n=745) COVID-19–related stress. As shown in Table 2, women with high COVID-19–related stress were significantly younger than those with low COVID-19–related stress (P=.003) and were more likely to identify as long-term tobacco users or report recent smoking cessations since the pandemic started (P=.034). Additionally, there was a greater prevalence of obesity (P=.006) and mental health history (P<.001) among individuals in the high-stress group compared with the low-stress group. When considering only the women who met our gynecologic and reproductive inclusion criteria, 354 had complete COVID-19–related stress data for bivariate analyses, with 89.5% meeting the cutoff for low COVID-19–related stress (n=317) and 10.5% categorized as high COVID-19–related stress (n=37, Table 2). Women in the high-stress group were still significantly younger than those in the low-stress group (P=.048) and had a greater prevalence of mental health history (P=.001). Mental health was also associated with menstrual change (P<.001, Appendix 1, https://links.lww.com/AOG/C930), as was education (P=.012, Appendix 1, https://links.lww.com/AOG/C930). Thus, age, smoking status, obesity status, mental health status, and education were included as covariates in our multivariable models, mimicking what has been done in other menstruation literature.10,26–28

Table 2. - Characteristics of Survey Participants With Coronavirus Disease 2019 (COVID-19)–Related Stress Data Across COVID-19–Related Stress Levels
Characteristic COVID-19–Related Stress Level P
Low* High
Participants meeting 1st set of eligibility criteria (n=838) n=745 n=93
 Age (y) 32.7±6.84 30.3±7.39 .003
33 (18–45) 30 (18–45)
 Race
  Black 63 (8.5) 10 (10.8) .769
  White 557 (75.5) 69 (74.2) .769
  None of the above 118 (16.0) 14 (15.1)
  Missing 7 (0.9) 0 (0.0)
 Ethnicity
  Hispanic 102 (14.0) 10 (11.0) .434
  Non-Hispanic 628 (86.0) 81 (89.0)
  Missing 15 (2.0) 2 (2.2)
 No. of children 1.13±1.32 1.1±1.32 .631
1 (0–11) 1 (0–8)
 Current marital status
  Single 211 (28.5) 24 (25.8) .596
  In relationship, but not married 149 (20.1) 24 (25.8) .596
  Married 346 (46.8) 42 (45.2)
  Divorced, separated, widowed, other 34 (4.6) 3 (3.2)
  Missing 5 (0.7) 0 (0.0)
 Partner gender§
  Male 362 (88.7) 55 (91.7) .495
  Female 46 (11.3) 5 (8.3)
  Missing or not asked 337 (45.2) 33 (35.5)
 Educational attainment,||
  Less than or equal to high school 259 (35.0) 32 (34.4) .804
  Technical training or Associate's or Bachelor's degree 311 (42.0) 42 (45.2) .804
  Master's degree or higher 170 (23.0) 19 (20.4)
  Missing 5 (0.7) 0 (0.0)
 Smoking status
  Long term tobacco user, even before pandemic 235 (31.8) 40 (43.0) .034
  Recently started smoking since the pandemic 59 (8.0) 5 (5.4)
  Recently stopped smoking 69 (9.3) 13 (14.0) .034
  Has never used tobacco 377 (51.0) 35 (37.6)
  Missing 5 (0.7) 0 (0.0)
 Prepandemic menstrual function (periods/y)
  Amenorrhea (0–3) 27 (8.6) 0 (0.0) .211
  Oligomenorrhea (4–7) 29 (9.3) 2 (5.4) .211
  Normal cycle (8–14) 238 (76.0) 22 (89.2)
  Polymenorrhea (15 or more) 19 (6.1) 2 (5.4)
  Missing or not asked 432 (58.0) 67 (72.0)
 COVID-19 vaccination status
  Vaccinated 344 (46.6) 50 (53.8) .189
  Not vaccinated 395 (53.5) 43 (46.2)
  Missing 6 (0.8) 0 (0.0)
 Reproductive or gynecologic comorbidity#
  Yes 151 (20.4) 19 (20.4) .986
  No 591 (79.6) 74 (79.6)
  Missing 3 (0.4) 0 (0.0)
 Thyroid comorbidity
  Yes 52 (7.0) 8 (8.6) .575
  No 690 (93.0) 85 (91.4)
  Missing 3 (0.4) 0 (0.0)
 Obesity status
  Has obesity 91 (12.3) 21 (22.6) .006
  Does not have obesity 651 (87.7) 72 (77.4)
  Missing 3 (0.4) 0 (0.0)
 Mental health comorbidity || **
  Yes 356 (47.4) 69 (74.2) <.001
  No 386 (52.6) 24 (25.8)
  Missing 3 (0.4) 93 (0.0)
 STI
  Yes 46 (6.2) 6 (6.5) .757
  No 699 (93.8) 87 (93.5)
  Missing 0 (0.0) 0 (0.0)
Participants meeting 2nd set of eligibility criteria (n=354) n=317 n=37
 Age (y) 32.5±7.2 30.4±8.3 .048
33 (0–11) 30 (0–4)
 Race
  Black 35 (11.1) 4 (10.8) .981
  White 226 (71.5) 27 (73.0) .981
  None of the above 55 (17.4) 6 (16.2)
  Missing 1 (0.3) 0 (0.0)
 Ethnicity
  Hispanic 43 (13.7) 5 (13.9) .980
  Non-Hispanic 270 (86.3) 31 (86.1)
  Missing 4 (1.3) 1 (2.7)
 No. of children 0.95±1.3 0.79±1.1 .429
1 (0–11) 0 (0–4)
 Current relationship status
  Single 108 (34.1) 14 (37.8) .595
  In relationship, but not married 75 (23.7) 9 (24.3)
  Married 119 (37.5) 14 (37.8)
  Divorced, separated, widowed, other 15 (4.7) 0 (0.0)
  Missing 0 (0.0) 37 (0.0)
 Partner gender§
  Male 146 (94.8) 20 (100) .297
  Female 8 (5.19) 0 (0.0)
  Missing or not asked 163 (51.4) 17 (46.0)
 Educational attainment
  Less than or equal to high school 143 (45.3) 13 (35.1) .269
  Technical training or Associate's or Bachelor's degree 127 (40.2) 20 (54.1)
  Master's degree or higher 46 (14.6) 4 (10.8)
  Missing 1 (0.3) 0 (0.0)
 Smoking status
  Long term tobacco user, even before pandemic 90 (28.4) 12 (32.4) .119
  Recently started smoking since the pandemic 11 (3.5) 1 (2.7)
  Recently stopped smoking 25 (7.9) 7 (18.9)
  Has never used tobacco 191 (60.3) 17 (46.0)
  Missing 0 (0.0) 0 (0.0)
 Prepandemic menstrual functioning (periods/y)
  Amenorrhea (0–3) 27 (8.7) 0 (0.0) .219
  Oligomenorrhea (4–7) 28 (9.0) 2 (5.4)
  Normal cycle (8–14) 238 (76.3) 33 (89.2)
  Polymenorrhea (15 or more) 19 (6.1) 2 (5.4)
  Missing or not asked 5 (1.6) 0 (0.0)
 COVID-19 vaccination status
  Vaccinated 113 (35.9) 14 (37.8) .814
  Not vaccinated 202 (64.1) 23 (62.2)
  Missing 2 (0.6) 0 (0.0)
 Reproductive or gynecologic comorbidity #
  Yes 41 (12.9) 5 (13.5) 1.00
  No 276 (87.1) 32 (86.5)
  Missing 0 (0.0) 0 (0.0)
 Thyroid comorbidity
  Yes 14 (4.4) 3 (8.1) .403
  No 303 (95.6) 34 (91.9)
  Missing 0 (0.0) 0 (0.0)
 Obesity status
  Has obesity 31 (9.8) 7 (18.9) .089
  Does not have obesity 286 (90.2) 30 (81.1)
  Missing 0 (0.0) 0 (0.0)
 Mental health comorbidity || **
  Yes 128 (40.4) 26 (70.3) .001
  No 189 (59.6) 11 (29.7)
  Missing 0 (0.0) 0 (0.0)
 STI
  Yes 8 (2.5) 1 (2.7) 1.00
  No 309 (97.5) 36 (97.3)
  Missing 0 (0.0) 0 (0.0)
STI, sexually transmitted infection; PSS-10-C, Coronavirus 2019 Pandemic-related Perceived Stress Scale.
Data are mean±SD, median (range), or n (%) unless otherwise specified.
*PSS-10-C (Coronavirus 2019 Pandemic-related Perceived Stress Scale) score lower than 25.
PSS-10-C score 25 or higher.
Included in fully adjusted model.
§Asked only of those who indicated that they had a partner.
||Included in minimally adjusted model.
Asked only of those not using nonhormonal birth control.
#Reproductive or gynecologic diagnoses included endometriosis, leiomyomas or myomas, polycystic ovarian syndrome, and uterine polyps.
**Mental health diagnoses included anorexia, anxiety, depression, and other mood disorders.

Of the women who met the second set of eligibility criteria, 180 reported no changes in their menstrual function (no change group) and 191 reported at least one change in period length, duration, or flow or spotting (change group). Twenty-three of the 191 (12%) women reported a change in all four menstrual parameters (Appendix 1, https://links.lww.com/AOG/C930).

As shown in Table 3, a greater proportion of women in the high-stress group experienced menstrual cycle changes, as hypothesized. High COVID-19–related stress was significantly associated with both shorter and longer period lengths (P=.008), both shorter and longer period durations (P<.001), heavier menstrual flow (P=.035), and increased spotting between cycles (P=.006).

Table 3. - Assessing the Association Between Perceived Coronavirus Disease 2019 (COVID-19)–Related Stress Level and Menstrual Changes (n=354)
COVID-19–Related Stress Level P
Low (n=317)* High (n=37)
Menstrual cycle length (n=353) .008
 No change 224 (70.9) 18 (48.6)
 Shorter 37 (11.7) 7 (18.9)
 Longer 38 (12.0) 11 (29.7)
 No period since pandemic began 17 (5.4) 1 (2.7)
 Missing 1 (0.27) 0 (0)
Period duration (n=354) <.001
 No change 225 (71.0) 18 (48.7)
 Shorter 41 (12.9) 7 (18.9)
 Longer 33 (10.4) 12 (32.4)
 No period since pandemic began 18 (5.7) 0 (0.0)
 Missing 0 (0.0) 0 (0)
Menstrual flow (n=354) .035
 No change 207 (65.3) 19 (51.4)
 Lighter 37 (11.7) 4 (10.8)
 Heavier 59 (18.6) 14 (37.8)
 No period since pandemic began 14 (4.4) 0 (0.0)
 Missing 0 (0.0) 0 (0.0)
Spotting between cycles (n=353) .006
 No spotting 255 (80.7) 25 (67.6)
 Spotting between cycles 43 (13.6) 12 (32.4)
 No period since pandemic began 18 (5.7) 0 (0.0)
 Missing 1 (0.27) 0 (0.0)
Data are n (%) unless otherwise specified.
*PSS-10-C (Coronavirus 2019 Pandemic-related Perceived Stress Scale) score lower than 25.
PSS-10-C score 25 or higher.

Compared with those in the low-stress group, a significantly greater proportion of women in the high-stress group reported shorter (11.7% vs 18.9%, respectively) and longer menstrual cycle lengths (12.0% vs 29.7%, respectively) compared with prepandemic times. In minimally adjusted models, high COVID-19–related stress was associated with twice the odds of changes in menstrual cycle length compared with low COVID-19–related stress (adjusted odds ratio [aOR] 2.15; 95% CI 1.05–4.39; P=.035, Table 4). The odds were even greater in fully adjusted models (aOR 2.32; 95% CI 1.12–4.85; Table 4).

Table 4. - Odds of Change* in Menstrual Cycle Parameters Associated With High Coronavirus Disease 2019 (COVID-19)–Related Stress Levels (Compared With Low) (n=354)
Outcome (vs No Change) Crude Minimally Adjusted Model§ Fully Adjusted Model||
Menstrual cycle length change 2.57 (1.29–5.11) 2.15 (1.05–4.49) 2.32 (1.12–4.85)
Period duration change 2.58 (1.30–5.14) 2.08 (1.02–4.25) 2.38 (1.14–4.98)
Menstrual flow change 1.78 (0.90–3.54) 1.47 (0.72–2.99) 1.61 (0.77–3.34)
Spotting between cycles 2.85 (1.33–6.09) 2.48 (1.12–5.49) 2.32 (1.03–5.22)
PSS-10-C, Coronavirus 2019 Pandemic-related Perceived Stress Scale.
Data are odds ratio (95% CI).
*Change refers to any response other than “no change” across each parameter.
PSS-10-C (Coronavirus 2019 Pandemic-related Perceived Stress Scale) score 25 or higher.
PSS-10-C score lower than 25.
§Adjusted for education and mental health.
||Adjusted for education, mental health, age, smoking status, and obesity status.

With regard to menstrual period duration, a significantly greater proportion of women with high COVID-19–related stress reported that they had experienced shorter periods (12.9% vs 18.9%) and longer periods (10.4% vs 32.4%) since the start of the pandemic. Minimally adjusted models showed that high COVID-19–related stress was associated with 108% greater odds of changes in period duration during the pandemic, compared with low COVID-19–related stress (aOR 2.08; 95% CI 1.02–4.25; P=.04, Table 4). Again, the effect estimates increased in fully adjusted models (aOR 2.38; 95% CI 1.14–4.98; Table 4).

Furthermore, a greater percentage of women with high COVID-19–related stress reported experiencing a heavier menstrual flow during the pandemic (37.8%) as compared with those with low COVID-19–related stress (18.6%, P=.035, Table 3). In regression analyses, however, the effect estimates were not statistically significant, though they were in the hypothesized direction (Table 4).

Similarly, 32.4% of women with high COVID-19–related stress reported spotting between their menstrual cycles during the pandemic, whereas approximately half that proportion of women with low COVID-19–related stress reported this symptom (13.6%, P=.006, Table 3). In regression analyses, high COVID-19–related stress was associated with more than twice the odds of spotting compared with low COVID-19–related stress in both minimally (aOR 2.48; 95% CI 1.12–5.49) and fully adjusted (aOR 2.32; 95% CI 1.03–5.22; Table 4) models.

DISCUSSION

We surveyed a geographically representative and racially diverse sample of U.S. women of reproductive age to evaluate how stress related to the COVID-19 pandemic has affected their menstrual cycles. More than half of the participants who met the study's gynecologic and reproductive criteria and had complete COVID-19–related stress data reported at least one change in their period length, duration, or flow or spotting (n=191), and an alarming 12% of these women reported changes in all four menstrual parameters. We found that high COVID-19–related stress was significantly associated with both shorter and longer period length (P<.008), both shorter and longer period duration (P<.001), heavier menstrual flow (P=.035), and increased spotting between cycles (P=.006). Multivariable analyses showed that high COVID-19–related stress was associated with at least twice the odds of menstrual perturbations in crude, minimally, and fully adjusted regression estimates for period length, duration, and spotting. Although the association between COVID-19–related stress and heavier menstrual flow was not statistically significant in our findings, the clinical relevance of the correlation between the two variables cannot be neglected, because menorrhagia has been associated with anemia29 and the economic costs of menstruation—“the tampon tax”—can be burdensome to individuals.30 Given the economic ramifications that the pandemic has had on populations worldwide, for women who experience abnormal bleeding, changes in cycle length or duration, and intermenstrual spotting, the burden of the additional tampon tax could be mentally burdensome and financially prohibitive.

Our findings align with early indications of COVID-19–related menstrual disruptions in the emerging literature. Initial reports from a study on Australian Olympic trainees showed that 19.6% and 24.7% of hormonal contraceptive users and natural cyclers, respectively, have reported changes to their menstrual cycles since the onset of the pandemic, a marked increase from the percentage of natural cyclers who reported changes before the pandemic.11 Emerging research from the National Institutes of Health and the Centers for Disease Control and Prevention also indicates that females with long COVID-19 (lingering COVID-19 symptoms that can last up to months after the initial illness) report a range of menstrual changes, including cycle irregularities, abnormal clotting, and severe premenstrual syndromes.11,31

Stress pathways are known to interact with and modulate the menstrual cycle, which is regulated by the hypothalamus-pituitary-ovarian axis through hormonally mediated feedback loops.32,33 Epidemiologic studies have long pointed to an association between stressful events and menstrual perturbations. Menstrual cycle irregularities have been documented in women experiencing war7 and psychological stress in the workplace.10,34 Additionally, high incidence of amenorrhea was reported in active-duty females and army nurses in the British and American camps during World War II9 and documented in women who were enslaved during the era of the trans-Atlantic slave trade.35–37

To our knowledge, the role of COVID-19–related stress in relation to menstrual cycle changes has yet to be fully elucidated. In contrast to our findings, Nguyen et al did not find an association between COVID-19–related stress and menstrual changes.38 A potential contributor to this discrepancy could be the fact that the authors of that article used a two-question Likert-style assessment to query COVID-19–related stress rather than a validated questionnaire such as the PSS-10-C to more accurately assess stress associated with the pandemic. Unlike Nguyen et al, two other studies have pointed to an association between COVID-19–related stress and menstrual changes. A recent study of female health care professionals in Turkey concluded that reported COVID-19–related stress was a significant predictor of menstrual irregularities, although the type of menstrual disturbances was not specified.39 Similarly, Ozimek et al observed that women with high perceived stress levels during the pandemic were more likely to experience a longer duration of menses and heavier bleeding during menses compared with those with moderate stress levels.40 However, unlike ours, their study sample was not reflective of the U.S. Census in multiple demographic factors, including race, socioeconomic status, and geographic distribution.

Our findings demonstrate an association between high COVID-19–related stress and menstrual changes on a granular level and within a more diverse group of women across various educational, racial and ethnic, and regional backgrounds in the United States. Because we report menstruation parameters as discrete categories of cycle length, period duration, menstrual flow, and spotting changes, the findings can be pinpointed to specific menstrual parameters, such as cycle length, which is known to be clinically relevant to future health risks.14 Additionally, our sampling scheme allowed us to sample U.S. women exposed to varying degrees of COVID-19 illness rates, restrictions, mandates, and policies and to understand what aspects of their menstrual cycles have been affected by COVID-19–related stressors.

Our study has some limitations, however. The first is the potential for recall bias in participant survey responses, where participants may have over-reported or under-reported the observed changes in their menstrual cycle throughout the pandemic. However, the validity of self-reports of women's reproductive history, compared with the gold standard of medical records, has been reported to be in the range of 92.9–100%,41 implying that the probability of biased reporting in this study is low. Future studies should validate participants' self-reports with objective assessments of menstrual functioning, such as hormonal biomarkers, which could be combined with prospective menstrual logs to provide researchers with long-term assessments of menstrual disruptions secondary to COVID-19–related stress. The online nature of the survey could have resulted in a sampling or selection bias favoring individuals with internet access and ample time for research participation, a potential explanation for why the education level of the sample is higher than national averages. However, a comparison of survey completers and noncompleters showed very few differences between the two and even highlighted more participation by Black individuals than would be expected. Additionally, the research was limited to participants who self-identify as women, thus excluding individuals from gender minority groups who may not identify as women but do menstruate. Future studies should be more inclusive of not only racially diverse participants but also of individuals from sexual and gender minority groups, because emerging reports have highlighted the disproportionate effects of the pandemic on these individuals' mental health and well-being.42,43

In this study, we found that high COVID-19–related stress levels are associated with increased risk of changes in multiple menstrual cycle parameters. Menstrual outcomes provide insight into numerous aspects of women's overall well-being, including cardiovascular,14 endocrinologic,44 reproductive,45 and menopausal health outcomes.46 Given the importance of the menstrual cycle as an indicator of women's overall well-being, reproductive health care professionals should be attuned to COVID-19–related stress levels as a potential factor affecting their patients' menstrual health.

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