COVID-19 and Menstruation

The coronavirus disease 2019 (COVID-19) pandemic has taken four million lives or more, worldwide. Caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the respiratory and systemic manifestations of severe disease have overshadowed the other potential effects of the virus on human physiology. One such area is female menstruation.

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Background

There are over 800 million people who undergo menstrual cycles and therefore need to have access to safe and hygienic menstrual products. Despite making up over half the world’s population, COVID-19-related research in this field is lacking.

It is well established that the ability to manage one’s menstrual cycles is often linked to socioeconomic status and the region in which one lives. Poverty is a major driver of menstruation-related ill-health, and so are wars and natural catastrophes that drive large-scale migrations and refugee movements.

Power Plays

Even without menstruation-related needs, 2.2 billion and 4.2 billion people do not have access to potable water and sanitary services. In fact, one in three people worldwide lives in an area where water has to be rationed much of the time. When applied to menstruation, the difficulty of maintaining hygiene and convenience becomes more acute.

Displaced people and the disabled characteristically face huge difficulties in gaining timely, affordable, and convenient access to menstrual products and clean water. Refugee camps typically have crowded bathrooms, which means menstruators may not have water, sanitation, and hygiene (WASH) facilities that are essential for menstrual management with health and dignity.

In the pandemic situation, the competition for resources is obvious: should the water and money be used for the menstruating female’s needs, which are all too often ignored, or for hand and face hygiene, and other urgent functions involved in preventing the spread of COVID-19?

Once again, menstruation moves down the list, intensifying inequities in this area at the cost of worsening the physical and mental health of menstruating females. Not only this, but this also leaves them unable to avail themselves of social and economic opportunities.

Stigmatizing Menstruation and COVID-19

The need to care for another family member with COVID-19 may affect menstruation symptoms, both in terms of the anxiety induced by the illness and the need to cope with menstrual needs in a still more exacting scenario.

The emotional toll of COVID-19 becomes higher with misinformation such as the alleged link between menstruation and COVID-19. This can further reduce the social value of menstruators, which is especially toxic when these persons are already oppressed or marginalized because of their race, religion, disability, or other factors.

The stigma surrounding menstruation has led to many women waiting until late at night for their turn to visit the common bathroom, which leaves them open to violence, as well as the ill-health consequent on undue delay in changing their sanitary pads. This is besides the intense discomfort of wearing soaking wet pads.

Restricted Access

Lockdowns and school closures, as well as the difficulty of gaining access to health services at the primary level, have led to reduced availability of menstrual supplies and information regarding this area. In fact, even with schools open, one study estimated that well over 330 million girls attended schools without facilities for hygienic changes of sanitary pads.

Quarantines and curfews restrict access to such supplies still further. While some women may resort to making their own supplies, using blankets or old clothes, others in the family often resent this use, viewing it as a waste of useful resources.

This may lead to domestic violence. Moreover, reusable products require enough water and soap to maintain them in a hygienic condition, failing which, both ill-health and humiliation are more likely.

Shortage of Supplies and Money

All these inequities are further compounded by the financial pressure, supply chain disruptions, and panic buying, triggered by COVID-19. As a result, some scientists estimate that over 8 of 10 women in such regions worried that they would not have access to necessary menstrual hygiene supplies.

Women, who do not typically control household expenditure, may lose what access they have to such supplies.

The repercussions of this on safe menstrual hygiene management can be drastic, with food or utilities prioritized over purchasing menstrual hygiene materials, an acute issue for those who use disposable materials each month. Without easy access to sanitary supplies, women and girls may be forced to trade sex for supplies, or for the money to buy supplies.”

COVID-19 has thus raised the barriers to menstrual hygiene by enhancing the difficulty in gaining safe access to necessary resources. Unfortunately, menstruation has no virtual alternative. Changes in Cycle Length and Volume

Menstrual Cycle Changes

One in five female athletes reported a change in menstrual cycles after the onset of the pandemic. The reasons may range from tapering workload, through anxiety and stress, to disease-linked inflammation and immune alterations.

Both stress and energy deficit are known to alter the hypothalamic-pituitary-ovarian (HPO) axis, which regulates the menstrual cycle. Large energy deficits can disrupt the luteal phase, cause ovulation to stop, and lead to scanty infrequent periods, or oligomenorrhea.

Since the pandemic has led to immense mental and emotional strain and distress, and because anxiety is associated with higher menstrual scores. A significant proportion of cycle complaints may be due to this link

Some scientists have performed menstrual cycle evaluations to identify and examine such changes occurring in reproductive-age women. One such study carried out in May 2020 shows that among a group of women with a mean age of 26 years, menstrual periods became shorter and lighter compared to pre-pandemic periods.

It is estimated that more than a third of regularly menstruating women developed irregular cycles during the pandemic, with associated depression, anxiety, and stress.

Another study indicates that among patients with confirmed COVID-19, a quarter have altered bleeding. Despite the fact that systemic complications were, expectedly, higher in severe COVID-19, disease severity was not linked to menstrual volume changes.  

Conversely, over a fifth with severe COVID-19 had long cycles, vs a tenth with mild disease. On individual analysis, as many as one in five patients report that their cycles became prolonged following infection, but 3% said they had shortened cycles.

Transient Changes

No significant alterations have been found in sex hormone levels and anti-Mullerian hormone levels, compared to age-matched controls, indicating that the infection does not leave any permanent effect on these hormones. Systemic disease is known to be a risk factor for cycle prolongation, perhaps explaining these transient effects.

The findings suggest a transient and self-limited suppression of ovarian function due to the infection. Follow-up showed that volume changes persisted through the study period in about one in seven women, but almost all cycle length changes normalized, within two months.  

Temporary derangements of the cycle may be managed at home, once pregnancy is excluded.

What are the Implications?

Thus, while COVID-19 does not disrupt menstruation significantly in the medical sense, its social effects in this area are deep. Further steps must be taken as part of an integrated, inclusive, and participatory COVID-19 management policy to redress these inequities.

Any pandemic response MUST include menstrual hygiene facilitation protocols, especially in regions and communities where such needs are marginalized. This should include information about this female event, with potential pandemic-related changes, and list menstrual goods as essential items, while supporting local manufacturers and vendors to ensure an uninterrupted and inexpensive supply.

School curricula should include understandable information about periods so those girls who have their first period during the pandemic are able to identify what is happening and respond appropriately and safely.

All care workers dealing with disabled girls and women must ask if their menstrual needs are being met, and about other related issues. Finally, women and girls must be shown and informed on how to prevent virus transmission during this time.

References:

• Demir, O. et al. (2021). Triangle of COVID, Anxiety, and Menstrual Cycle. Journal of Obstetrics and Gynecology. doi: 10.1080/01443615.2021.1907562.  https://pubmed.ncbi.nlm.nih.gov/33955327/
• Takmaz, T. et al. (2021). The Impact Of COVID-19-Related Mental Health Issues on Menstrual Cycle Characteristics of Female Healthcare Providers. Journal of Obstetrics and Gynecology Research.  DOI: 10.1111/jog.14900. https://pubmed.ncbi.nlm.nih.gov/34137123/
• Ingraham, R. F. et al. (2021). Menstrual Health During COVID-19: How Water, Sanitation, and Hygiene Can Improve Equity (Online).  http://info.primarycare.hms.harvard.edu/blog/menstrual-health-hygiene (Accessed on 11 August 2020).
• McNamara, A. et al. (2020). Menstrual Cycle Change During COVID-19. Sharing some early results. Blog on British Journal of Sports Medicine. https://blogs.bmj.com/bjsm/2020/11/20/menstrual-cycle-change-during-covid-19/.
• Li, K. et al. (2021). Analysis of sex hormones and menstruation in COVID-19 women of child-bearing age. Public Health Emergency Collection. https://dx.doi.org/10.1016%2Fj.rbmo.2020.09.020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522626/

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.