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.