ABSTRACT
Background:
Several symptoms are typically experienced after a coronavirus disease 2019 (COVID-19) infection. Worldwide, a lot of women are reporting irregularities in their menstrual cycles post-COVID-19 infection. The purpose of this study is to investigate the prevalence of menstrual pattern among young girls during the second wave of COVID-19 pandemic and to determine the risk factors related to lifestyle among young girls.
Methods:
A cross-sectional study was conducted using a self-designed questionnaire encompassing details of the menstrual pattern, features of hyperandrogenism, lifestyle, and comorbidity among young girls aged 16-24 years.
Results:
The data from 508 girls fulfilling the inclusion criteria were analyzed. The prevalence of irregular menstrual cycle was found to be 29.1%. Further analysis revealed that a significant percentage of girls with irregular menstrual cycle suffer from depression (14.9%) and are often staying stressed (40.5%) in comparison to the girls having regular menstrual cycle. Also, a total of 58 girls out of 508 were diagnosed with polycystic ovary syndrome (PCOS). Among various comorbid conditions, obesity was found in 60% of girls having PCOS followed by an eating disorder.
Conclusions:
A significant increase in irregular menstrual cycle in young girls was found during the second wave of COVID-19. The risk factors for causing the irregular menstrual cycle were found to be insomnia, stress, and depression
Keywords: COVID-19, menstrual cycle, polycystic ovary syndrome (PCOS), reproductive health, young girls
Introduction
Regular menstruation is an indicator of women’s reproductive health and well-being.[1] Any change in the pattern of the menstrual cycle in terms of regularity, frequency, duration, and intermenstrual bleeding is defined as irregular menstruation. Also, irregular menstruation is one of the major manifestations of anovulation along with decreased ovarian steroid production and secretion.[2] Many studies have shown the adverse longer effects of the irregular menstrual cycle in women leads to the risk of developing cardiovascular disease, diabetes mellitus, chronic renal failure and also infertility, premature menopause, breast, and ovarian cancer.[3,4] The collective global prevalence of irregular menstrual cycle based on age, occupation, and country of residence, varies between 5% and 35.6%.[5,6]
A variety of factors affects the pattern of the menstrual cycle, the most important is the dysregulation of the hypothalamic-pituitary-adrenal axis (HPA).[7] In addition to physiological factors, mental health conditions such as anxiety, stress, and depression also affect the menstrual cycle as shown by previous studies.[8,9] The women mostly in their reproductive years (aged 18-44 years) are more likely to be affected by endocrine disorders. In a worldwide estimate, the most common endocrine disorder, that is, polycystic ovary syndrome (PCOS) affects 5-15% of the women population.[10]
An outbreak of severe acute respiratory syndrome disease (SARS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in Wuhan, China, in December 2019 and has now spread all over the world, swiftly leading to global risk to public health crisis.[11] On March 11, 2020, World Health Organization (WHO) declared the outbreak as global pandemic, and the disease was named coronavirus disease 2019 “COVID-19”.[12] In India, 345 million people have already been infected and more than 0.4 million had died due to COVID-19 as on November 22, 2021. A recent study has reported the prevalence of stress, psychological distress, anxiety, depression, and sleep disturbances in the Indian population during COVID-19 are 61%, 43%, 34%, 33%, and 27%, respectively, posing a significant threat to psychological well-being.[13] The correlation between various lifestyle factors and the menstrual cycle has been discussed earlier, however, there is no previous data available on the magnitude or prevalence of irregular menstrual cycle and its associated factors in young girls during an outbreak of a severe second wave of COVID-19 disease in India.
Young girls who are having irregular periods for a longer time are at greater risk of developing gynecological problems resulting in an increased risk of PCOS and other reproductive diseases.[14] The reproductive health problems in young girls tend to aggravate anxiety and depression that brings major psychological morbidity and worsens their later life by increasing the risk of depression, stress, and low self-esteem. Therefore, finding out the prevalence of irregular periods among young girls and determining various risk factors related to lifestyle during the COVID-19 pandemic that affects the menstrual problems are required to ensure their healthy reproductive life to restore self-esteem. The emotional and financial strain could also be prevented if the reproductive problem is treated at an early stage. Therefore, the present study aimed to investigate the prevalence of menstrual pattern among young girls during the second wave of COVID-19 pandemic and to determine the risk factors related to lifestyle among young girls.
Methods
A non-experimental questionnaire-based survey form was used to find out the prevalence of irregular periods among young girls and risk factors affecting the menstrual cycle. The cross-sectional study was conducted among the girl students of the University of Delhi, India during the academic year 2020-2021. All students were enrolled in the study, after obtaining written and informed consent from them. The data collection procedure was carried out in the months April to May during the second wave of COVID-19, in the year 2021.
Menstrual pattern, inclusion, and exclusion criteria
As per WHO definitions, 3 to 5 bleeding episodes within a 90-days reference period (RP) are considered to be a normal frequency of “menses” or bleeding episodes. Amenorrhea was defined as no bleeding or spotting within a 90-days’ time interval.
The young girls between the age group 16-24 years studying in University of Delhi, India, were included in the present study. Girls who submitted incomplete forms were excluded from the study.
Survey study
A self-designed questionnaire was used to assess the young girl’s background information regarding independent variables such as subjects studied in the college, parental education, and age. The questionnaire also includes questions based on the lifestyle of students to find out the risk factors that might have a role in affecting the menstrual cycle. The girls, who volunteered to participate in the study, were asked to fill up a questionnaire asking about details of the menstrual pattern, features of hyperandrogenism, lifestyle, and comorbidity. The data was collected from 530 girls from the months April to May 2021. The responses were analyzed by GraphPad prism 5 software and the groups were divided on the basis of irregular or regular menstrual cycle [Schematic Figure 1] to find out the parameters that affect the menstrual pattern. Any duplicity of data was checked and deleted.
Figure 1.
A schematic diagram showing the methodology
Statistical analysis
For all statistical analyses, the Chi-square test and Fisher’s exact test were used. All data analyses were carried out by GraphPad Prism 5 software and a P value less than 0.05 was considered statistically significant for any difference.
Results
Demographic characteristics of participants
The data from 508 girls fulfilling the inclusion criteria were analyzed for the study. Around 70.9% girls had a regular menstrual cycle while 29.1% girls had irregular menstrual cycles [Figure 2]. Irregular menstrual cycle is one of the hallmarks of women’s reproductive health; therefore, we divided all cases into two groups based on menstrual pattern for further evaluation for the menstrual-related factors such as body mass index (BMI), level of bleeding, length of bleeding, acne presence, and hair growth [Table 1]. Both the groups had similar mean age (P > 0.05). The Chi-square analysis reveals that BMI was not significantly differ in girls having regular and irregular menstrual cycle; however, a total of 6.8% of girls had BMI over 30 kg/m2 along with menstrual irregularities indicating the high percentage of obesity in comparison to the girls who had regular menstrual cycles. Further analysis showed a significant difference in the level of bleeding, length of bleeding, acne presence, and hair growth association between regular and irregular groups. About 79.1% of girls had irregular menstrual reported changes in menstrual cycle length of longer than a week. There was a significant association found for the presence of acne. In addition, 43.9% of girls showed significant association of hirsutism with irregular menstrual cycle. Also, around 80% of girls with irregular menstrual cycle reported having the premenstrual syndrome (PMS) in comparison to 67% of girls having a regular menstrual cycle.
Figure 2.
Distribution of menstrual pattern among young girls during COVID-19
Table 1.
Demographic characteristics of the participants and association with menstrual pattern
| Variables | No. (%) | P | |
|---|---|---|---|
|
| |||
| Girls with regular periods N=360 (70.9%) | Girls with irregular periods N=148 (29.1%) | ||
| Age | |||
| (Age±S.D) | 18.89±1.19 | 18.85±1.17 | 0.819 |
| BMI | |||
| Under weight (<18.5 Kg/m2) | 95 (26.4) | 35 (23.7) | 0.208 |
| Normal weight (18.5-24 Kg/m2) | 206 (57.2) | 83 (56.1) | |
| Overweight (25-29.9 Kg/m2) | 49 (13.6) | 20 (13.5) | |
| Obese (>30 Kg/m2) | 10 (2.8) | 10 (6.8) | |
| Heavy bleeding | |||
| Yes | 99 (27.5) | 70 (47.3) | 0.0001 |
| No | 261 (72.5) | 78 (52.7) | * |
| Period longer than a week | |||
| Yes | 345 (95.8) | 117 (79.1) | 0.0001 |
| No | 15 (4.2) | 31 (20.9) | * |
| Acne presence | |||
| No | 188 (52.2) | 50 (33.8) | 0.0002 |
| Yes | 172 (47.8) | 98 (66.2) | * |
| Hair growth | |||
| No | 278 (77.2) | 83 (56.1) | 0.0001 |
| Yes | 82 (22.8) | 65 (43.9) | * |
| PMS | |||
| No | 119 (33.1) | 30 (20.3) | 0.0038 |
| Yes | 241 (66.9) | 118 (79.7) | * |
BMI, body mass index; PMS, premenstrual syndrome; S.D, standard deviation; P, probability value; P value under 0.05 indicates a significant outcome
Lifestyle factors associated with menstrual pattern
Among lifestyle factors, the maximum number of girls from both groups had adopted a moderate lifestyle in comparison to light, sedentary, and vigorous activity [Table 2]. Similarly, there was no significant difference observed in memory between the two groups. Further analysis revealed that a significant percentage of girls with irregular menstrual cycle suffered from depression in comparison to the girls having regular menstrual cycle. Likely, there was a statistically significant (P = 0.001) association found for the factor ‘staying stressed’ between the girls with regular and irregular menstruation. Results have shown that the girls with irregular menstruation showed higher percentage for often staying stressed than the girls with regular menstrual cycle. In support of it, a higher percentage (55.8%) of the girls with a regular menstrual cycle reported ‘staying happy’ than the girls with irregular menstruation. A significant (P < 0.05) association was found for the factor ‘sleep 6-8 hrs daily’ between the regular and irregular menstruation groups. However, other lifestyle factors like doing exercise did not show any association between the groups.
Table 2.
Lifestyle factors associated with regular and irregular periods in young girls during COVID-19
| Variables | Girls with regular periods N=360 (70.9%) | Girls with irregular periods N=148 (29.1%) | P |
|---|---|---|---|
| Lifestyle Activity | |||
| Light | 116 (32.2) | 54 (36.5) | 0.647 |
| Moderate | 199 (55.3) | 76 (51.4) | |
| Sedentary | 37 (10.3) | 13 (8.8) | |
| Vigorous | 8 (2.2) | 5 (3.4) | |
| Sharp Memory | |||
| No | 45 (12.5) | 27 (18.2) | 0.241 |
| Yes | 157 (43.6) | 60 (40.5) | |
| Sometimes | 158 (43.9) | 61 (41.2) | |
| Depression | |||
| No | 184 (51.1) | 49 (33.1) | 0.0007* |
| Yes | 32 (8.9) | 22 (14.9) | |
| Sometimes | 144 (40.0) | 77 (52.0) | |
| Staying Stressed | |||
| Always | 22 (6.1) | 14 (9.5) | 0.0011* |
| Never/rarely | 65 (18.1) | 60 (40.5) | |
| Often | 90 (25.0) | 60 (40.5) | |
| Sometimes | 183 (50.8) | 14 (9.5) | |
| Happiness | |||
| No | 49 (13.6) | 22 (14.9) | 0.0003* |
| Yes | 201 (55.8) | 55 (37.2) | |
| Sometimes | 110 (30.6) | 71 (48.0) | |
| Sleep 6-8 hrs daily | |||
| Always | 235 (65.3) | 75 (50.7) | 0.0028* |
| Often | 83 (23.1) | 53 (35.8) | |
| Rarely | 6 (1.7) | 7 (4.7) | |
| Sometimes | 36 (10.0) | 13 (8.8) | |
| Exercise | |||
| No | 135 (37.5) | 54 (36.5) | 0.331 |
| Yes | 109 (30.3) | 54 (36.5) | |
| Sometimes | 116 (32.2) | 40 (27.0) |
P, probability value; P value under 0.05 indicates a significant outcome
Effect of usage of plastics on menstrual cycle
There was no significant difference found among the factors such as drinking water from the plastic bottles, using plastic containers for eating, storage, and heating food, between the girls who had regular or irregular menstruation [Table 3]. Further, we raised the question related to the awareness about the harmful effects of plastics on health and environment. As shown in Figure 3, majority of girls who had regular and irregular menstrual cycle, respectively, are already aware of the harmful effects of plastics on health. Similarly, a significant percentage of girls who had a regular and irregular menstrual cycle, are cognizant of the destructive effects of plastics on the environment.
Table 3.
Plastics usage and awareness associated with regular and irregular periods in young girls during COVID-19
| Variables | Girls with regular periods n=360 (70.8%) | Girls with irregular periods n=148 (29.1%) | P |
|---|---|---|---|
| Drink water from plastics bottles | |||
| No | 116 (32.2) | 48 (32.4) | 0.445 |
| Yes | 133 (36.9) | 62 (41.9) | |
| Sometimes | 111 (30.8) | 38 (25.7) | |
| Using plastics containers for storage | |||
| No | 65 (18.1) | 30 (20.3) | 0.523 |
| Yes | 172 (47.8) | 75 (50.7) | |
| Sometimes | 123 (34.2) | 43 (29.1) | |
| Using plastic container for food warming | |||
| No | 270 (75.0) | 109 (73.6) | 0.528 |
| Yes | 26 (7.2) | 15 (10.1) | |
| Sometimes | 64 (17.8) | 24 (16.2) | |
| Use of plastic ware for eating | |||
| No | 298 (82.8) | 130 (87.8) | 0.167 |
| Yes | 62 (17.2) | 18 (12.2) |
Abbreviations: P, probability value; P value under 0.05 indicates a significant outcome
Figure 3.
Distribution of awareness about the adverse effects of plastics among girls having regular and irregular periods
Prevalence and clinical characteristics of PCOS
Since we found a high prevalence of girls having irregular menstrual cycle, we also cross-checked the presence of PCOS as comorbidity among girls of both the groups. A total of 58 girls out of 508 were diagnosed with PCOS, among these, 85.7% girls were aged 16-20 years and 14.3% girls were aged 20-24 years. BMI measurements revealed that a large proportion of the girls had normal BMI while 20.7% were overweight, whereas only a few (5.2%) were morbidly obese [Table 4]. A total of 53.4% girls reported their onset of periods at the age of 12-16 years while 46.6% of girls reported to have menarche onset at the age of 10-12 years. Among the total PCOS girls, 25.9% reported PCOS with other gynecological or endocrine disorders while 74.1% girls reported to have PCOS alone. Figure 4 represents the distribution of comorbidity among girls suffering from PCOS. Among various comorbid conditions, majority of girls had obesity followed by eating disorder and other diseases such as diabetes, thyroid, clotting factor disorder, cardiovascular disease, hypoglycemia, and low blood pressure.
Table 4.
Demographics variables of girls with PCOS (n=58)
| Demographics variables | Frequency, n (%) |
|---|---|
| Age-wise PCOS (Years) | |
| 16-20 | 48 (85.7) |
| 21-24 | 8 (14.3) |
| BMI | |
| Underweight (<18.5 Kg/m2) | 10 (17.2) |
| Normal weight (18.5-24 Kg/m2) | 33 (56.9) |
| Overweight (25-29.9 Kg/m2) | 12 (20.7) |
| Obese (>30 Kg/m2) | 3 (5.2) |
| Menarche onset | |
| 10-12 years | 27 (46.6) |
| 12-16 years | 31 (53.4) |
| Major disease | |
| PCOS | 43 (74.1) |
| PCOS with other disorders | 15 (25.9) |
Abbreviations: PCOS, polycystic ovary syndrome; BMI, body mass index; %, percentage
Figure 4.
Distribution of comorbidity among PCOS girls
Table 5 represents the clinical characteristics of young girls having PCOS. Regarding the cardinal symptoms of PCOS, 75.9% girls had irregular menstrual cycle while others had regular menstrual cycle. Furthermore, depression was stated by 58.6% of girls. Interestingly, 27.6% of girls with PCOS had family history of PCOS. However, a higher percentage of girls reported to have diabetes as family history of disease followed by thyroid, obesity along with other diseases like cardiovascular diseases, cancer, and infertility.
Table 5.
Clinical characteristics of young girls with PCOS (n=58)
| Clinical characteristics | Frequency, n (%) |
|---|---|
| Menstrual cycle | |
| Regular | 14 (24.1) |
| Irregular (Oligomenorrhea) | 44 (75.9) |
| Menstrual flow | |
| Normal | 29 (50.0) |
| Heavy | 29 (50.0) |
| Hirsutism | |
| Yes | 34 (58.6) |
| No | 24 (41.4) |
| Acne | |
| Yes | 34 (58.6) |
| No | 24 (41.4) |
| Depression | |
| Yes | 34 (58.6) |
| No | 24 (41.4) |
| Continues weight gain | |
| Yes | 20 (34.5) |
| No | 38 (65.5) |
| Waistline more than 35 cm | |
| Yes | 13 (22.4) |
| No | 45 (82.8) |
| Family diagnosed with PCOS | |
| Yes | 16 (27.6) |
| May be | 7 (12.1) |
| No | 35 (60.3) |
| Family history of disease | |
| PCOS | 16 (27.6) |
| Diabetes | 31 (53.4) |
| Thyroid | 19 (32.8) |
| Obesity | 9 (15.5) |
| Cardiovascular diseases | 7 (12.1) |
| Cancer | 6 (10.3) |
| Infertility | 5 (8.6) |
| Others | 8 (13.8) |
PCOS, polycystic ovary syndrome; %, percentage
Discussion
The present study determining the impact of the second wave of COVID-19 outbreak on the magnitude of menstrual pattern, its characteristics and association with the lifestyle factors of young girls of metropolitan city (Delhi) is the pioneer study of its kind. Our findings revealed a significantly higher prevalence (29.1%) of irregular menstrual cycle among young girls of North India in comparison to earlier study done by Verma et al.,[15] reported 11.47% prevalence of irregular menstrual cycle. However, an earlier study before the pandemic reported by Taneja et al.,[16] showed 24.8% irregular menstruation among young women of Delhi. A recent study during COVID-19 pandemic on Turkish women healthcare workers aged 18-40 years showed 28.7% prevalence of irregular menses[17] reasserting the role of pandemic in inducing psychological stress, anxiety, and depression leading to irregular menstrual cycles. In contrary, a study by Sharma et al.[18] reported 64.2% of school going girls aged 14 years showed irregular menstruation as most of the girls were within two years of their menarche that can be irregular initially and normal menstrual cycles occur around the age of 19-20 years. Hence, our study was focused on the age group of 16-24 years girls to avoid such discrepancy. In the present study, we did not find any significant association between BMI and irregular menstruation in agreement to the study carried out by Tang et al.[19] though, 6.8% girls with irregular menstruation had high BMI than the girls who had regular periods (2.8%).
Further, study on menstrual characteristics among young girls revealed that around 20.9% of girls with irregular menstrual cycle, also had abnormal duration of menstruation of less than a week in comparison to the girls who had regular menstruation. Alternatively, a study on a menstrual pattern among adolescents observed that the majority 88.8% had a normal duration of menstruation of up to 4-5 days.[20] In addition, a significant number of girls with irregular (78.1%) and regular (95.8%) menstrual cycle are suffering from menorrhagia. Around 47.3% girls with irregular menstruation reported to have heavy bleeding; however, an earlier study reported 31.2% abundant blood loss in adolescent girls.[21] The cause of heavy menstrual bleeding can be dysfunctional uterine bleeding related to anovulation;[22] therefore, it was expected to be higher in the girls with irregular menstrual cycle. Another noteworthy result of the present study was a significant rise in the percentage of girls (79.7%) suffering from PMS that includes irritability, suffocation, nervousness, mood swings, etc. A recent systematic review study reported that more than 50% of adolescent girls are suffering from PMS in India.[23]
Further, we had also considered the lifestyle factors associated with the irregular menstrual cycle. Depression, staying stressed and the lack of sleep were found to be the most significant factors associated with the girls having irregular menstruation during COVID-19. Earlier studies have shown that the global or local crisis are associated with traumatic stress, emotional well-being and menstrual-related problems in young girls. A recent study by Takmaz et al.[17] has also shown that COVID-19 induced anxiety, stress, and depressive symptoms are linked to increased prevalence of menstrual irregularity among healthcare workers. In addition, several studies have well documented the positive correlation between the stress, depressive symptoms, and abnormal or irregular menstrual cycle. The studies by Jung et al.[24] and Nillni et al.[3] also showed that the women having irregular menstrual cycle reported the perceived stress and depressive symptoms. Moreover, our results revealed that COVID-19 linked depression, lack of sleep, and stress are the major predictors of irregular menstrual cycle among young girls. The hypothalamic–pituitary– adrenal (HPA) axis plays a key role in regulating the body’s stress. Any environmental, social, and physical stressors cause the release of various hormones and are linked to dysregulation of HPA axis activity which further leads to disruption of the normal functioning of hypothalamic-pituitary-gonadal (HPG) axis resulting in abnormal menstrual abnormal menstrual cycle or disturbance in other reproductive mechanisms.
A well-known fact about harmful effects of plastics is that the plethora of chemicals leached out from the plastics is known to mimic various hormones and act as endocrine disrupting chemicals (EDCs);[25] therefore, we have also raised the question whether the irregular menstrual cycle is associated with the usage of plastics. We did not find any significant association between the usage of plastics and abnormal irregular cycle. This could be due to awareness among the majority of the girls (98.9%) about the adverse effects of plastics and hence usage of plastic was limited to few participants only (7.2%).
Since the persistent imbalance of hormones or irregular menstrual cycle leads to formation of multiple cysts ultimately resulting in the development of PCOS.[26] Therefore, we had also asked the questions related to comorbidity such as PCOS in young girls. Surprisingly, 11.41% (n = 58) girls already had PCOS out of which 75.9% (n = 44) were having irregular menstrual cycle and 24.1% (n = 14) were having regular menstrual cycle. In addition, 25.9% of girls were having PCOS along with other diseases like obesity followed by eating disorder, diabetes, thyroid, etc., [Figure 4]. It has been well documented that metabolic and psychological comorbidity are associated with women having PCOS.[27] In the present study, the most common comorbidity among girls having PCOS was obesity that includes android weight distribution. This may be due to the fact that a high prevalence of hyperinsulinemia and insulin resistance in adolescent girls lead to excessive androgen production in the ovary resulting in hyperandrogenism that is an associated risk factor with PCOS girls.[28] Further, we looked at the clinical characteristics of young girls having PCOS. Both acne and hirsutism were significantly higher in PCOS girls, which is the most common clinical manifestation of PCOS.
Conclusion
The present study showed a significant increase in irregular menstrual cycle in young girls during the second wave of COVID-19. The risk factors for causing the irregular menstrual cycle were found to be insomnia, stress, and depression. These results emphasize the need for improvement in the lifestyle of young girls for the well-being of their reproductive health.
Limitations of the study
As indicated in the current study, the COVID-19 pandemic may have an impact on the menstrual cycle, although there is a chance that the association is the result of several sorts of bias. Due to increased health awareness and diligent health monitoring following COVID-19 infection, menstrual cycle variations may have been apparent and reported compared to pre-COVID-19 times.
Financial support and sponsorship
Nil.
Conflicts of interest
The authors declare that there are no conflicts of interest for publication of this article. The views expressed in this article are of the authors alone and do not necessarily represent the views of their organizations.
Acknowledgments
We acknowledge Prof. Savita Roy for her logistic support and undergraduate students’ volunteers Ms. Shramana, Ms. Ashi, Ms. Kashish, Ms. Khushi, Ms. Prerna, and Ms. Vaishali who helped in collecting survey forms.
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