Клинический разбор в общей медицине №3 2025

Original Article

Evaluation of menstrual cycle changes among women in shahrekord during the COVID-19 pandemic

Mozhdeh Asgari, Masoumeh Moezzi, Lobat Jafarzadeh, Soheila Banitalebi

Shahrekord University of Medical Sciences, Shahrekord, Iran

Abstract
Background and Aim. COVID-19, a global pandemic, has impacted the world and caused various health issues. This study was conducted to evaluate the effects of COVID-19 on menstrual cycle changes. 
Materials and methods. In this cross-sectional study, 314 women aged 18 to 45 who resided in Shahrekord City, Iran, from 2022 to 2023 were enrolled. A researcher-designed questionnaire including demographic information, vaccination history, COVID-19 infection history, and menstrual cycle characteristics was designed, and data was gathered through social media. After data collection, the data were entered into SPSS version 22 and analyzed using descriptive and analytical statistical methods. 
Results. Among patients, 62.7% of participants reported no change in menstrual bleeding volume after contracting COVID-19. In comparison, only 23% of individuals reported an increase or decrease in their bleeding volume after the infection. Regarding the number of menstrual days, 71.3% of participants had no change in the duration of their period after contracting COVID-19. There was also a significant difference between the amount of menstrual bleeding (p=0.005), the number of menstrual days (p=0.006), spotting (p=0.013), interval between menstrual cycles (p=0.0001), menstrual pain (p=0.001), and premenstrual symptoms (p=0.0001). 
Conclusion. The findings of the present study show that COVID-19 severity is significantly relationship with alteration in the menstrual cycle.
Keywords: menstruation, menorrhagia, COVID-19, vaccine, shahrekord. 
For citation: Asgari M., Moezzi M., Jafarzadeh L., Banitalebi S. Evaluation of menstrual cycle changes among women in shahrekord during the COVID-19 pandemic. Clinical review for general practice. 2025; 6 (3): 91–96. DOI: 10.47407/kr2024.6.3.00585

Introduction

The COVID-19 pandemic is the result of a virus belonging to the Coronaviridae family, a group of single-stranded RNA viruses. This coronavirus, the seventh known member of its family, typically infects animals such as birds and mammals, often resulting in mild respiratory illnesses like the common cold in humans. However, certain coronaviruses can lead to severe outbreaks in human populations [1]. COVID-19 symptoms can range from mild to severe and can vary significantly among individuals. Common symptoms include fever, persistent cough, muscle aches (myalgia), tachycardia and headache. Some patients may also experience gastrointestinal issues such as diarrhea, nausea, and vomiting. Respiratory symptoms are prevalent, often manifesting as cough, dyspnea, chest pain, and sputum production. Other symptoms may include sore throat, nasal congestion, rhinorrhea, and fatigue. Additionally, it resulting in anosmia and ageusia. In more severe cases, it may lead to hemoptysis (coughing up blood), skin rashes, and neurological symptoms, including impaired consciousness and seizures [2, 3]. In addition, COVID-19 imposes heavy healthcare (mainly hospital beds/day) costs on the society [4]. Some studies suggest that women who contracted COVID-19 have experienced changes in their menstrual cycles, including a worsening of premenstrual symptoms, higher levels of irregular periods, amenorrhea, and an increase in menorrhagia [5–7]. Moreover, women with COVID-19 have experience more ovarian injury, such as reduction in reproductive endocrine disorder and ovarian reserve [5].
Recently, public concerns have emerged about potential disruptions to menstrual cycles due to COVID-19 vaccines, contributing to issues related to menstrual health, vaccine hesitancy, and anxieties surrounding vaccination's effects on fertility [8, 9]. Some women have reported menstrual irregularities following vaccination, such as menorrhagia, frequent bleeding episodes (metrorrhagia or polymenorrhea), and even postmenopausal bleeding. One possible underlying factor may be vaccine-induced thrombocytopenia [10]. Despite the ongoing publication of new research on COVID-19, the limited studies addressing the relationship between COVID-19 and menstrual health underscores a significant gap in medical research in this area. So, this study was designed to determining menstrual cycle changes in women of Shahrekord city during the COVID-19 pandemic during 2021–2022.

Material and methods

Study design and population. This research was carried out using a cross-sectional study design. The target population included women aged 18 to 45 with natural menstrual cycles, residing in Shahrekord, Iran, from 2022 to 2023.
Inclusion and exclusion criteria. The study's inclusion criteria specified that participants needed to be women aged between 18 and 45 who were not currently taking hormonal medications, thyroid drugs, or oral contraceptives. Additionally, if vaccinated, participants must have received at least two doses of the same vaccine. Women with no prior history of hematologic disorders, polyps, or similar health issues were eligible for the study.
On the other hand, the exclusion criteria ruled out pregnant or breastfeeding women, those with a history of corticosteroid use, individuals diagnosed with diabetes, smokers, and women with known mental health disorders.
Sample size and sampling method. To estimate a proportion in a cross-sectional study, the sample size can be determined using the following formula:

       Z2.P.(1 – P)
n= 
              d2 
Confidence Level (Z): 95%, so Z = 1.96 
Estimated Proportion (p): if unknown, use p = 0.5 
Margin of Error (d): 5% (0.05)
The final sample size would be approximately 384. However, we slightly higher margin of error or different assumptions for p and a total of 314 participants ultimately included in the study. The sampling method was convenient sampling.
Data collection method and questionnaire. A preliminary questionnaire was designed and tested in a pilot study with 50 eligible participants (They excluded from the study). After analyzing the responses, faculty members from obstetrics, social medicine, and infectious diseases revised the questionnaire by removing, modifying, or adding specific questions. The revised questionnaire was then reviewed for face validity by three faculty members and tested for reliability.
The questionnaire's face validity was confirmed by three faculty members. Reliability was assessed using the split-half method (Guttman split-half coefficient). The reliability coefficient was 0.81 and showed very good reliability. 
Study procedure. Following approval from the Research and Technology Deputy and obtaining the necessary permits, eligible women aged 18 to 45 were recruited according to inclusion criteria. The electronic questionnaire was created on Porsline. To ensure inclusion criteria were met, exclusion criteria were listed within the questionnaire; responses that met any exclusion criteria were excluded during data analysis.
The finalized researcher-designed questionnaire contained 40 questions, covering demographic information, vaccination history, COVID-19 infection history, and menstrual cycle characteristics. It was distributed online via social media platforms such as WhatsApp and Instagram. Prior to participation, individuals received an explanation of the study's purpose and questionnaire content.
During data analysis, 99 participants were excluded due to incomplete responses or meeting exclusion criteria. After collecting all responses, those not meeting inclusion criteria (e.g., those using hormonal or thyroid medications, age outside 18–45, or having certain health histories) were also excluded. The remaining data were entered into SPSS version 26 for descriptive and analytical statistical analysis.
Data analysis. The data were analyzed with SPSS software (version 26). Categorical variables were presented as mean±standard deviation, while categorical variables were expressed as frequencies and percentages. Chi-square test were used, with a significance level of P (<0.05).
Findings. This study aimed to investigate changes in the menstrual cycles of women in Shahrekord (Southwest Iran) during the COVID-19 pandemic. A total of 314 women participated, with a mean age of 21.32±15.7 years. In this study, 74.8% of participants were married, 22.6% were single, and the rest were divorced or widowed. The majority of participants (52.2%) were housewives and had university education (58.6%). Most of the women (35.7%) used natural methods of contraception, and 35% had no history of pregnancy (table 1).
In this study, 92.7% of the participants had received the COVID-19 vaccine. Regarding COVID-19 infection, 44.6% of the participants had affected the virus before receiving the vaccine, 25.8% after receiving the vaccine, and 29.6% had been infected in both cases. Concerning the frequency of COVID-19 infection, the majority of participants had affected the virus only once (46.5%), while the rest had been infected twice or more. The infection severity among participants was categorized as mild in 28.3%, moderate in 47.1%, severe in 6.4%, a combination of mild and moderate in 15.3%, and a combination of moderate and severe in 2.9% (table 2).
Based on the findings in table 3, 62.7% of participants reported no change in menstrual bleeding volume after contracting COVID-19, while only 23% of individuals reported an increase or decrease in their bleeding volume after the infection. Regarding the number of menstrual days, 71.3% of participants had no change in the duration of their period after contracting COVID-19. Spotting after COVID-19 infection was reported by only 12.4% of participants. In this study, 66.9% of individuals had no change in the menstrual cycle interval after contracting COVID-19, while 16.9% reported a variation in the cycle length. Menstrual pain after COVID-19 infection remained unchanged for 65.3% of participants, whereas 20.1% reported an increase in pain. Symptoms before menstruation were unchanged for 58.3% of participants, while 28.6% reported an increase in premenstrual symptoms. Regarding menstrual changes, 30.9% of participants experienced changes in their menstrual cycle after contracting COVID-19 and receiving the vaccine. Regarding menstrual complications, 47.5% of participants stated that they developed menstrual issues after their first COVID-19 infection. In this study, 31.2% of participants believed that the severity of COVID-19 infection was related to changes in the menstrual cycle.
Regarding the relationship between menstrual disorders and the severity of COVID-19, as shown in Table 3, there is a significant difference in various menstrual characteristics post-COVID-19 infection based on the severity of the disease. These include the amount of menstrual bleeding (p=0.005), the number of menstrual days (p=0.006), spotting (p=0.013), interval between menstrual cycles (p=0.0001), menstrual pain (p=0.001), and premenstrual symptoms (p=0.0001).

Discussion

This study was designed to determining menstrual cycle changes in women of Shahrekord city during the COVID-19 pandemic during 2021–2022. COVID-19 infection was associated with significant changes in menstrual characteristics, including bleeding volume, the number of menstrual days, incidence of spotting, interval between cycles, menstrual pain, and premenstrual symptoms. In this regard, the study by Taskaldıran et al. showed that out of 241 women with COVID-19, 86 (35.7%) reported experiencing various changes in their menstrual patterns during the first three cycles following the infection. They also indicated various menstrual irregularities within their study population, which differed among women. Some women reported shortened or delayed menstrual cycles, while others experienced heavier or lighter bleeding [11]. The study by Phelan et al. reported changes in women's menstrual cycles, such as increased menstrual bleeding, more painful periods compared to pre-pandemic levels, and missed cycles that had not occurred before the infection [12]. In the study by Muharam et al., following the infection, delayed cycles were reported in 19.6% of patients, and shortened cycles in 15.2% of patients. Additionally, 33% of patients experienced heavier bleeding, and 11.4% reported longer menstrual durations [13]. The occurrence and nature of the changes in our study align with recent studies. Various mechanisms may contribute to menstrual changes following COVID-19 infection, with stress being one of the underlying mechanisms. It has been shown that COVID-19 is a significant source of stress, anxiety, and depression [14, 15]. Studies have shown that the changes in the female hormone levels are associated with health behaviors, obesity, and stress [16, 17]. Stress can cause menstrual irregularities by disrupting the hypothalamic-pituitary-gonadal (HPG) axis, which may lead to impaired ovulation and hormonal imbalances [18]. Additionally, prior research has demonstrated that stress can interfere with the LH surge that typically occurs prior to ovulation, which disrupts the normal ovulatory process and contributes to menstrual irregularities. This disruption in hormonal regulation can lead to a range of reproductive health issues, further highlighting the impact of stress on the menstrual cycle [19]. Moreover, one potential cause of menstrual irregularities is the direct impact of the virus itself. The coronavirus gains entry into cells by binding to the Angiotensin-converting enzyme 2 (ACE2) receptor, which was initially believed to be present solely in the respiratory system. However, subsequent research has revealed that the virus also affects the ovaries and endometrium. The ACE2 receptors in the ovaries are essential for the proper maturation of follicles and the process of ovulation, suggesting that viral interference with these receptors could disrupt normal reproductive function and contribute to menstrual disturbances [20]. Evidence have demonstrated that cytokines such as interleukin-6, interleukin-8, and tumor necrosis factor-alpha (TNF-α), which are pivotal mediators of the inflammatory response in COVID-19, can induce a procoagulant state. This dysregulated coagulation cascade may contribute to alterations in menstrual patterns, including changes in bleeding volume, subsequent to infection [21]. Moreover, ovarian damage, such as reduced ovarian reserve and reproductive hormonal imbalances, has been observed in women with COVID-19. However, there were no significant differences in menstrual timing, menstrual bleeding volume, menstrual cycle phases, or history of dysmenorrhea between women with severe and non-severe COVID-19 [5]. A systematic review revealed that Alterations in menstrual volume and cycle length have been observed as consequences of COVID-19 infection, with the latter being the most commonly reported menstrual irregularity in the studies reviewed. Women primarily reported reduced menstrual volume and longer cycle durations. The results also suggest that the severity of COVID-19 does not impact changes in the menstrual cycle [6]. In this study, 92.7% of the participants had received the COVID-19 vaccine. Regarding menstrual changes, 30.9% of participants experienced changes in their menstrual cycle after contracting COVID-19 and receiving the vaccine. Changes in the menstrual cycle following COVID-19 vaccination have been reported to exceed these levels. For example, in the study by Taskaldıran et al., 15% of participants experienced changes in their menstrual patterns after vaccination, with this figure rising to 43.3% after the second dose. Various changes were reported, with the most common being menstrual delay (late periods) [11]. Menstrual changes following COVID-19 vaccination may also be attributed to immune processes [13, 22].
The lack of examination of the long-term effects of COVID-19 and vaccination on the menstrual cycle, as well as the failure to examine confounding factors such as mood and metabolic problems, were limitations of this study.

Conclusion

The results of this study indicate that the severity of COVID-19 infection was associated with significant changes in menstrual characteristics, including bleeding volume, the number of menstrual days, incidence of spotting, interval between cycles, menstrual pain, and premenstrual symptoms. These findings highlight the importance of recognizing the broader social and psychological effects of the pandemic on women’s health, underscoring the need for attention and intervention in this area.

Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.
Conflict of interests. The authors declare that there is not conflict of interests.

Acknowledgment. The authors would like to thank the Clinical Research Development Unit, Hajar Hospital, Shahrekord University of Medical Sciences, Shahrekord, Iran for their support, cooperation and assistance throughout the period of study.
Ethical Approval. This study was conducted after obtaining an ethics code from the Shahrekord University of Medical Sciences with ID: IR.SKUMS.MED.REC.1401.030. No interventions were performed, and specific ethical considerations were observed.
Author contributions. All authors reviewed and approved the final version of the manuscript.
Data availability statement. All data presented in this study will available free of charge for any researcher upon reasonable request from the corresponding author.
Funding. The author (s) reported there is funding associated with the work featured in this article Grant number: 6323. Shahrekord University of Medical Sciences.

Информация об авторах
Information about the authors

Мождех Асгари – отделение акушерства и гинекологии, Отдел клинических исследований и разработок, Больница Хаджар, Шахрекордский университет медицинских наук

Mozhdeh Asgari – Department of Obstetrics and Gynecology, 
Clinical Research Development Unit, Hajar Hospital, Shahrekord University of Medical Sciences
Масуме Моэззи – отделение общественной медицины, Медицинский факультет, Центр социального здоровья, Шахрекордский университет медицинских наук

Masoumeh Moezzi – Department of Community Medicine, School of Medicine, Social Health Determinate, Shahrekord University of Medical Sciences
Лобат Джафарзадех – доцент каф. акушерства и гинекологии, Отдел клинических исследований, Больница Хаджар, Шахрекордский университет медицинских наук

Lobat Jafarzadeh – Assoc. Prof., Department of Obstetrics and Gynecology, Clinical Research Development Unit, Hajar Hospital, Shahrekord University of Medical Sciences
Сохейла Баниталеби – специалист по клиническим исследованиям, больница Хаджар, Шахрекордский университет медицинских наук

Soheila Banitalebi – Clinical Research Development Unit, Hajar Hospital, Shahrekord University of Medical Sciences

Поступила в редакцию: 09.02.2025
Поступила после рецензирования: 18.02.2025
Принята к публикации: 20.02.2025

Received: 09.02.2025
Revised: 18.02.2025
Accepted: 20.02.2025