Regular menstrual cycles result from the delicate interaction between different organ systems and hormonal response in the female body. The proper functioning of the hypothalamic–pituitary–ovarian axis plays the major role in achieving normal regular menses.1 Menstrual irregularities can result from organic diseases, but more so from endocrinologic as well as psychologic causes.1 Stress, whether physical, emotional or psychologic has been shown to cause menstrual perturbations.2–4
Many epidemiologic studies tackled the association between chronic stressful conditions and menstrual aberrations. Environmental stresses can vary from mild changes in life conditions to severe, drastic ones like periods of war. Difficult life conditions,5 changes in occupation,6 stressful jobs,4 school examinations,7 and midlife changes,3 were all associated with menstrual irregularities.
War times are among the most stressful conditions that people face. Very old reports showed the association between long periods of war and menstrual dysfunction. Before the time of execution,8 and during World War II, many imprisoned women suffered from amenorrhea.9,10 The more recent literature dealing with the effect of war times on the menstrual cycle is scarce. During the Desert Storm war in 1996 in Iraq, many women soldiers experienced menstrual irregularities.11,12
Although long periods of war might affect menstrual cycles, the effect of a short period of war on these cycles has not been evaluated. In this study, the menstrual aberrations in women subjected to a short period of war are reported.
MATERIALS AND METHODS
The study was approved by the Institutional Review Board at the American University of Beirut, and it targeted civilian women living in small towns and villages in southern Lebanon that were subjected to 16 days of shelling and bombardment from April 11–27, 1996. Those women either stayed in their villages or were displaced into safer areas. The reason for the displacement was fear of death and the availability of dwellings in safer places.
Six months after cessation of the war, social workers went to those villages and interviewed nonpregnant and nonlactating women, aged 15–45 years, and completed a questionnaire related to their menstrual history. The interviews took place throughout November 1996. A random sample of approximately 50 women from each village, representing 10–20% of the population of these villages, was targeted based on a list of names provided by each village’s moukhtar (mayor). The majority of women approached agreed to participate in the study. Criteria used for exclusion from the study, applied directly by the social workers or later after data analysis, included irregular cycles before the war, pregnancy, lactation, chronic medical disease, use of oral contraceptives, and inability to recall menstrual history. Chronic medical diseases included diseases that affected the well being of patients or necessitated chronic medication intake that had direct or indirect effect on their menstrual history, eg, thalassemic patients with anemia, diabetics on insulin, those with renal disease on medications, psychologic problems, etc.
The questionnaires were completed by the women with the help and explanation of the social workers. The questions asked related to the menstrual history (whether regular or irregular) before the war, 3 months after, and 6 months after the war. It included the age, weight, height, marital status, and past medical history. After data analysis, subjects were divided into two main groups as follows: group A included women who stayed in the war zone throughout the 16 days or between 3–16 days, and group B included women who left the area within 1–2 days after the start of the war. The same questionnaire was also completed by a group of women who were living in a safe area not exposed to war in southern Lebanon and served as controls (group C).
Menstrual cycles were considered irregular when cycle-to-cycle interval variations exceeded 6 days, and when cycles were either short (less than 21 days) or long (more than 38 days). In the questionnaire, the menstrual cycles were recorded as either regular or irregular.
The data obtained from the questionnaires were collected and analyzed to check the effect of a short war on the menstrual cycles of women in the study groups (groups A and B). The variation in the menstrual cycles was analyzed with respect to the duration of exposure to war (in terms of staying in or leaving the towns exposed to war) and the long-term sequelae of this exposure. Also this variation was compared with the variation in menses in the control group (group C) over a 6-month period. For statistical analysis, comparison of women’s characteristics was done by either performing χ2 tests if the variables were categorical or analysis of variance for continuous variables. Within-group changes were compared using the McNemar χ2. A P value of<.05 was considered statistically significant.
A total of 769 women completed the questionnaire, 123 in group A, 377 in group B, and 269 in group C. Six hundred sixty-one women met the inclusion criteria: 102 in group A, 325 in group B, and 234 in group C.
Table 1 shows the demographic data of women included in the analysis. The three groups were similar with respect to the mean age, height, weight, age at menarche, and proportion of married women.
Table 2 shows the changes in the menstrual pattern among the three groups 3 months and 6 months after the war. At the time of war all women in the three groups had regular menstrual cycles (inclusion criterion), but 3 months later 35.3% of group A, 10.5% of group B, and 2.6% of group C had menstrual irregularities. These values were significantly different, indicating that exposure to war did lead to menstrual aberrations, especially in those exposed to prolonged periods of war. Six months later, spontaneous resumption of regular cycles occurred in many women in the two groups exposed to war. The 4.3% menstrual irregularity reported in group B after 6 months was not different from the 3.9% noted in group C, but both were statistically different from the 18.6% menstrual aberration found in group A. Women in groups A and B had a higher incidence of irregular cycles at 3 months compared with 6 months with P=.031 and P=.006, respectively. This did not hold true for women in group C.
This is one of the few reports in the literature showing that exposure to a short period of war leads to abnormal menstrual cycles in up to one third of women (MEDLINE, January 1980 to October 2006, English language; keyword “war” and search terms “menses,” “menstrual cycle,” “menstrual period,” “menstrual irregularity,” “ menstrual aberration,” or “amenorrhea”). In addition, approximately 20 % of women will continue to have irregular cycles up to 6 months after cessation of war.
The literature about the effect of war on menstrual cycle is very scarce and is limited mainly to veterans. During World War II, many women who became prisoners had sudden onset of amenorrhea that lasted for long periods of time.9,10 This was a form of chronic stress those imprisoned women were facing. Women soldiers during Desert Storm, living the chronic stressful conditions of a prolonged war, suffered most from dysfunctional uterine bleeding,11 such as having heavier cycles or skipping their menses, especially during combat periods.12 Although the duration of war in our study was only 16 days, simulating an acute stressful condition, it caused menstrual aberrations that lasted for a considerable period of time.
The mechanism through which war affects menstrual cycles is not clear. Psychologic stress is believed to play an important role. Most previous studies have indicated that different types of stress have a negative effect on the menstrual cycle. Environmental stresses can vary in severity. Before execution, almost all women became amenorrheic.8 Unusual menstrual patterns were reported among desert-dwelling hunter–gatherer women facing difficult living conditions.5 Changes in occupation were associated with changes in menstrual cycles.6 Women in stressful jobs had more than double the risk for short cycle length compared with women not in stressful jobs.4 Among schoolgirls, 15.8% claimed that there was a correlation between school examinations and irregular menses.7 Even in midlife women, psychological distress was associated with irregular menses.3
This relationship between the psychosocial status of women and aberrations in menstrual cycles cannot be demonstrated in all cases exposed to stress.13 This difference in response to stress may be explained by differences in population characteristics, study design, and differences in the assessment of psychosocial factors. The mechanism through which chronic stress can lead to menstrual irregularities is believed to be secondary to inhibition of the normal pulsatile gonadotropin-releasing hormone secretion due to excessive hypothalamic activity of corticotrophin-releasing hormone in response to stress.1
Menstrual irregularities were present more and lasted longer in women who were exposed to war for longer periods of time (group A). Women who were exposed only to 1–2 days of war and were later displaced to safer zones (group B) had significantly lower incidence of irregular menses compared with group A, but higher incidence of menstrual problems compared with women who were initially living in safe areas (group C). This may be related to the direct effect of the war experience even though it was limited to 1 or 2 days only. In addition, the deterioration in the physical infrastructure and socioeconomic conditions associated with the displacement also might have contributed to this difference.
The mechanism through which acute stress associated with war affects menstrual cycles is not clear. Ennian Xiao et al14 tried to elucidate the response to a short stressful insult of the menstrual cycle of Rhesus monkeys in both the follicular and the luteal phases. Their studies showed that acute stress can, by way of adrenal axis activation, alter menstrual cyclicity for one or two cycles.
A limitation of this study is its reliance on the memory of those women trying to recall their menstrual histories over a 6-month period. Also, the study cannot determine the longest duration for menstrual irregularity since, by design, we limited the follow-up to 6 months postwar.
In conclusion, this study reports on the effect of a short period of war on menses. It shows that an acute stressful condition will disturb menses for a period that goes beyond the period of stress, but in a rather reversible manner. In such cases, only observation and reassurance of those women may be necessary.
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