Association between psychological stress and menstrual cycle characteristics in perimenopausal women

Assessment of App-Based Versus Conventional Survey Modalities for Reproductive Health Research in India, South Africa, and the United States: Comparative Cross-Sectional Study

BACKGROUND

There is a widely acknowledged global need for more research on reproductive health (including contraception, menstrual health, sexuality, and maternal morbidities) and its impact on overall well-being. However, several factors-notably, high costs, considerable effort, and the sensitivity of these topics-impede the collection of the necessary data, especially in less accessible and lower-income populations. The burgeoning ownership of smartphones and growing use of menstrual tracking apps (MTAs) may present an opportunity to conduct reproductive health research with fewer impediments than those associated with conventional survey methods.

OBJECTIVE

The main objective was to ascertain the feasibility, potential usefulness, and limitations of conducting reproductive health research using a mainstream MTA.

METHODS

In each of the 3 countries, we evaluated questionnaire responses from (1) current users of an MTA (Clue) and (2) participants surveyed using conventional survey modalities (in-person interviews, SMS text messaging, and web-based questionnaires). We compared these responses with published data collected from large nationally representative benchmark samples (the United States Census and the Demographic and Health Surveys for South Africa and India).

RESULTS

Given a sufficiently large user base, app-distributed surveys were able to quickly capture large samples on par with other methods and at low cost, with the additional advantage of being able to deploy remotely and simultaneously across countries. In each country, neither the app nor the conventional modality sample emerged as a consistently closer match to the distributions of the demographic attributes and the patterns of contraceptive use reported for the respective benchmark sample. Despite efforts to obtain representative samples, the conventional modality samples sometimes over- and other times underrepresented some subgroups (eg, underrepresentation of married persons in the United States and overrepresentation of rural residents in India). In all 3 countries, app users were younger, more educated, more likely to be urban residents, and more likely to use nonhormonal rather than hormonal contraceptive methods compared with the respective national benchmark. App users, compared with the conventional modality samples, consistently reported being more comfortable discussing their menstrual periods with other persons (eg, family, friends, and health care providers), suggesting that MTA users may be more likely to respond truthfully to questions on sensitive or taboo health topics. The app samples' consistency across countries regarding users' demographic profiles, contraceptive choices, and personal attitudes toward menstruation supports the validity of making cross-country comparisons of survey findings for a given app's users.

CONCLUSIONS

MTAs such as Clue can provide a quick, scalable, and cost-effective method for collecting health data, including on sensitive topics, across a wide variety of settings and countries. With expanding global access to technology and the increasing use of these tools, consumer MTAs can be a viable survey modality to strengthen reproductive health research.

Shift work and menstruation: A meta-analysis study

Background

Shift work is a potential risk factor for women's reproductive health. Evidence suggests that shift work is associated with menstrual disorders, reproductive disturbances, and adverse pregnancy outcomes. However, previous studies did not systematically examine the results of menstrual irregularities, dysmenorrhea, and early menopause at the same time.

Objective

To determine the relationship between shift work and women's menstrual characteristics (e.g., irregular menstruation, dysmenorrhea, and early menopause).

Methods

Four databases (PubMed, Embase, Cochrane, and Web of Science) were searched up to December 2022. The study characteristics and risk assessment values of the literature were extracted from 21 studies that met the criteria. Odds ratios (ORs), relative risks (RRs), hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated to assess the relationship between shift work exposure and menstruation. The included studies were evaluated for heterogeneity, publication bias, sensitivity analysis, and subgroup analysis.

Results

A total of 21 studies with 195,538 female participants, including 16 cross-sectional studies and 5 cohort studies, were included in this meta-analysis. According to the quality evaluation, the included research had high methodological quality. The overall ORs of shift work for the likelihood of irregular menstruation and dysmenorrhea were 1.30 (95% CI, 1.23-1.36) (I2 = 41.9%, P < 0.05) and 1.35 (95% CI, 1.04-1.75) (I2 = 73.0%, P < 0.05), respectively. There was a significant positive association between shift work and the risk of early menopause (HR = 1.09, 95% CI, 1.04-1.14), without significant heterogeneity (I2 = 0.0%, P > 0.05).

Conclusions

This meta-analysis indicated that shift workers have significantly higher odds of menstrual disorders, dysmenorrhea, and early menopause. This study focuses on female reproductive health and has broad implications for adjusting optimal working hours and shift schedules for female workers.

The impact of SARS-COV-2 infection on menstruation

BACKGROUND

Recent study has demonstrated that the GnRH system in patients with post-COVID syndrome may be influenced by SARS-CoV-2. However, the impact of COVID-19 infection on women's menstruation is still unknown.

OBJECTIVE

We aimed to investigate the the relationship between coronavirus disease 2019 (COVID-19) and menstruation in premenopausal women.

METHODS

This was a retrospective cohort study. Pre-menopausal women were invited to participate in the online questionnaire on wechat. Participants were divided into four groups according to whether they were infected with severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) and whether they had menstrual changes during the pandemic. Sociodemographic characteristics, history of COVID-19, menstruation and menstrual changes of the participants were collected. Statistical analyses were performed using SPSS, version 25.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

A total of 1946 women were included in the study. 1800 participants had been or were currently infected with SARS-COV-2, and 146 people had not been infected. Among 1800 patients with COVID-19, 666 (37.0%) had changes in menstruation, and 1134 (63.0%) did not, which was significantly higher than the uninfected participants (c2 = 12.161, P = 0.000). The proportion of participants with menstrual cycle changes (450/67.6%) is larger than that of uninfected participants (c2 = 6.904, P = 0.009). COVID-19 vaccination was associated with lower odds of menstrual cycle change (OR, 0.855; 95% CI, 0.750-0.976). Participants who reported chest pain (OR, 1.750, 95% CI, 1.209-2.533) and dyspnea (OR, 1.446; 95% CI, 1.052-1.988) during infection had greater odds of changes to their menstrual cycle compared with the participants who did not.

CONCLUSIONS

The association between the COVID-19 and increased prevalence of menstrual cycle irregularity. COVID-19 vaccination is a protective factor in the long term, and participants with chest pain and dyspnea are more likely to develop AUB.

Menstrual irregularities associated with COVID-19 vaccines among women in Saudi Arabia: A survey during 2022

Some changes appeared in women's menstrual cycle after receiving the coronavirus disease 2019 (COVID-19) vaccine, but the information about the pattern and characteristics of these symptoms was unclear. This study was conducted to estimate the prevalence of menstruation change and evaluate the association between COVID-19 vaccination and the occurrence of such disturbance. An online web-based survey was conducted during March-April 2022 that targeted 729 COVID-19 vaccinated women aged between 18 and 45 years in the Jazan region of Kingdom of Saudi Arabia. The tool collected demographic information, psychological data, and COVID-19 post-vaccination side effects. The overall prevalence of menstrual change among the women was 60.9% (95% CI 57.3-64.4). 66.3% and 64.1% of women, respectively, in the age group of 25-34 and 35-45 years were more affected. Most of the detected abnormalities were related to delayed menstruation and changes in pain intensity. Menstrual disturbances that occur after immunization are transient and have no long-term implications. Menstrual disorders are prevalent before vaccination, but there is a considerable increase following vaccination. Because there is no apparent cause for these post-vaccine disturbances, and their effects are difficult to anticipate, it is preferable to warn those concerned and encourage them to learn more about the biological changes causing these problems.

How Lifestyle Changes during the COVID-19 Global Pandemic Affected the Pattern and Symptoms of the Menstrual Cycle

This research investigated the implications that the COVID-19 pandemic had on the menstrual cycle and any contributing factors to these changes. A questionnaire was completed by 559 eumenorrheic participants, capturing detail on menstrual cycle symptoms and characteristics prior to and during the COVID-19 pandemic lockdown period. Over half of all participants reported to have experienced lack of motivation (61.5%), focus (54.7%) and concentration (57.8%). 52.8% of participants reported an increase in cycle length. Specifically, there was an increase in the median cycle length reported of 5 days (minimum 2 days, maximum 32 days), with a median decrease of 3 days (minimum 2 days and maximum 17 days). A lack of focus was significantly associated with a change in menstrual cycle length (p = 0.038) reported to have increased by 61% of participants. Changes to eating patterns of white meat (increase p = 0.035, decrease p = 0.003) and processed meat (increase p = 0.002 and decrease p = 0.001) were significantly associated with a change in menstrual cycle length. It is important that females and practitioners become aware of implications of environmental stressors and the possible long-term effects on fertility. Future research should continue to investigate any long-lasting changes in symptoms, as well as providing education and support for females undergoing any life stressors that may implicate their menstrual cycle and/or symptoms.

Chronic Stress and Ovulatory Dysfunction: Implications in Times of COVID-19

Stress is known to be associated with adverse health outcomes. The COVID-19 pandemic and its associated lockdowns are examples of chronic stressors. Lockdown measures inadvertently caused significant psychological distress and became a powerful source of anxiety/stress, sleep disturbances, nutritional changes and weight gain. Stress is known to impact women's health specifically, through hypothalamic-pituitary-gonadal (HPG) axis dysfunction and resultant ovulatory dysfunction. Such dysfunction may manifest in menstrual irregularities and/or infertility due to hypothalamic hypogonadism. Here, we review the key physiological mediators of stress and associated ovulatory dysfunction. The kisspeptinergic system is comprised of sets of neurons located in the hypothalamus, the rostral periventricular region of the third ventricle (RP3V) and the arcuate nucleus (ARC). This system links nutrition, reproductive signals and stress. It plays a key role in the function of the HPG axis. During chronic stress, the kisspeptinergic system affects the HPG axis, GnRH pulsatility, and, therefore, ovulation. Leptin, insulin and corticotrophin-releasing hormone (CRH) are thought to be additional key modulators in the behavioral responses to chronic stress and may contribute to stress-related ovulatory dysfunction. This mini-review also summarizes and appraises the available evidence on the negative impact of chronic stress as a result of the COVID-19 pandemic lockdowns. It proposes physiological mechanisms to explain the observed effects on women's reproductive health and well-being. The review suggests areas for future research.

Understanding the cross-talk between mediators of infertility and COVID-19

COVID-19 is the ongoing health emergency affecting individuals of all ages around the globe. Initially, the infection was reported to affect pulmonary structures. However, recent studies have delineated the impacts of COVID-19 on the reproductive system of both men and women. Hence, the present review aims to shed light on the distribution of SARS-CoV-2 entry factors in various reproductive organs. In addition, impacts of COVID-19 mediators like disrupted renin angiotensin system, oxidative stress, cytokine storm, fever, and the mental stress on reproductive physiology have also been discussed. For the present study, various keywords were used to search literature on PubMed, ScienceDirect, and Google Scholar databases. Articles were screened for relevancy and were studied in detail for qualitative synthesis of the review. Through our literature review, we found a multitude of effects of COVID-19 mediators on reproductive systems. Studies reported expression of receptors like ACE-2, TMPRSS2, and CD147 in the testes, epididymis, prostrate, seminal vesicles, and ovarian follicles. These proteins are known to serve as major SARS-CoV-2 entry factors. The expression of lysosomal cathepsins (CTSB/CTSL) and/ neuropilin-1 (NRP-1) are also evident in the testes, epididymis, seminal vesicles, fallopian tube, cervix, and endometrium. The binding of viral spike protein with ACE-2 was found to alter the renin-angiotensin cascade, which could invite additional infertility problems. Furthermore, COVID-19 mediated cytokine storm, oxidative stress, and elevated body temperature could be detrimental to gametogenesis, steroidogenesis, and reproductive cycles in patients. Finally, social isolation, confinement, and job insecurities have fueled mental stress and frustration that might promote glucocorticoid-mediated subnormal sperm quality in men and higher risk of miscarriage in women. Hence, the influence of COVID-19 on the alteration of reproductive health and fertility is quite apparent.

Triangle of COVID, anxiety and menstrual cycle

This study aimed to examine whether the menstrual cycles of women with regular cycles have been affected by the COVID 19 pandemic. This cross-sectional online survey study evaluated the menstrual cycle characteristics of women in the reproductive phase of their lives during the COVID-19 pandemic in May 2020. Changes before and after COVID-19 were evaluated with a paired sample t-test and chi-square test. A Pearson correlation test was used to show the relationships between variables. The study was completed with 263 participants in total. The average age of the participants was 26.3 ± 6.9 (18-45). Participants' duration of period (p = .003) and pads used per day (p = .002) decreased compared to their experience before the COVID-19 outbreak. The mean total MSQ score was 3.1 ± 0.8 (0-4), mean STAI-1 score was 45.1 ± 9 (20-78) and mean STAI-II score was 43.3 ± 5.9 (30-69). It was found that STAI-I and STAI-II scores showed a positive correlation with MSQ-Somatic subgroup scores(r = 0.153, p = .013; 0.190, p = .002) and MSQ-Total scores (0.144, p = .020; 0.175, p = .004). With the COVID-19 pandemic, increased anxiety scores increased women's menstrual symptoms while the length of periods and the number of pads used decreased.Impact statementWhat is already known on this subject? The COVID 19 pandemic, has caused enormous psychological distress potentially resulting in the development of posttraumatic stress disorder. The menstrual cycle is a process that can be affected by psychological stress.What do the results of this study add? This is the first study to examine the relationship between stress caused by the COVID-19 pandemic and the menstrual cycle. The increases in the degree of anxiety and stress as a result of the COVID-19 outbreak was found to be high enough to affect the characteristics of the menstrual cycle in the women surveyed.What are the implications of these findings for clinical practice and/or further research? In a prospective study intended to be carried out after the outbreak ends in the future, it will be possible to evaluate whether the menstrual cycle parameters return to their former order and consequently this hypothesis will be able to be more definitively confirmed.

Perceived Stress and Fecundability: A Preconception Cohort Study of North American Couples

While some epidemiologic studies support the hypothesis that stress can adversely affect fertility, few prospective studies have assessed the association in couples from the general population. We used data from Pregnancy Study Online, a web-based preconception cohort study of pregnancy planners from the United States and Canada (2013-2018), to examine the association between women's and men's perceived stress levels prior to conception and fecundability. Women (aged 21-45 years) and their male partners (aged ≥21 years) who were attempting conception without fertility treatment were eligible. We measured perceived stress using the 10-item Perceived Stress Scale (PSS). We ascertained pregnancy information using bimonthly follow-up questionnaires of female participants. We followed 4,769 couples until self-reported pregnancy, initiation of fertility treatment, loss to follow-up, or 12 menstrual cycles of attempt time, whichever came first. We used proportional probabilities regression models to estimate fecundability ratios and 95% confidence intervals, adjusting for potential confounders. Higher PSS scores among the women were associated with slight reductions in fecundability (comparing PSS scores of ≥25 vs. <10, fecundability ratio = 0.87, 95% confidence interval: 0.74, 1.02). PSS scores among the men were not substantially associated with fecundability.

Differences in ovarian hormones in relation to parity and time since last birth

OBJECTIVE

To examine ovarian function in relation to parity and time since last birth.

DESIGN

Cross-sectional study.

SETTING

Health-care program in California.

PATIENT(S)

346 naturally cycling women, aged 18 to 39 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mean follicular urinary estradiol metabolite concentration (E1C) (cycle days -8 to -1), mean luteal progesterone metabolite concentration (PdG) (days 0 to +10), and cycle phase lengths in ovulatory cycles.

RESULT(S)

After the women had collected daily urine samples for up to eight menstrual cycles, we measured the E1C and PdG using enzyme-linked immunoassay. The cycle phase lengths were calculated from the hormone profiles and daily diaries. Women who had given birth within the previous 3 years had lower E1C than the nulliparous women and women who last given birth >3 years earlier. Among the parous women, E1C was positively associated with the time since last birth. Women who last gave birth >3 years earlier had longer follicular phases than the nulliparous women. There were no associations between parity and PdG or luteal phase length.

CONCLUSION(S)

Our cross-sectional data suggest that ovarian function differs in nulliparous and parous women and is positively associated with the time since last birth. Longitudinal research is needed to explore within-woman changes in ovarian function prepartum and postpartum.

Predictors of psychological well-being and stress among Jordanian menopausal women

PURPOSE

The aim of this study was to investigate purpose in life, self-acceptance, perceived stress levels, and menopausal symptoms among Jordanian women.

METHODS

A descriptive, correlational design with a convenience sample of 193 women aged 40-55 years was employed.

RESULTS

The average age at menopause for the current sample was 47.4 years, and menopausal status did not significantly affect purpose in life, self-acceptance, or perceived stress levels. Negative correlations were found between purpose in life and perceived stress, and between self-acceptance and perceived stress (r = -0.49; p = 0.01 and r = -0.58; p = 0.01, respectively). Menopausal symptoms were found to be a strong negative predictor of purpose in life, self-acceptance, and perceived stress levels. In addition, higher health rating was significantly associated with higher psychological well-being and lower perceived stress levels. Perimenopause was found to be a vulnerable stage for severe menopausal symptoms particularly psychological complaints. However, vasomotor symptoms and loss of sexual interest became more intense among postmenopausal women. Although women in the current study had low psychological well-being and high perceived stress, these were not affected by their menopausal status.

CONCLUSION

The study showed the importance of including both physical and psychological symptoms during encounters with health professionals, besides considering women's expectations about menopause to help ease their menopausal transition and improve their well-being.

An exploratory dimensional approach to premenstrual manifestation of obsessive-compulsive disorder symptoms: a multicentre study

OBJECTIVE

In women with obsessive-compulsive disorder (OCD), symptom severity appears to fluctuate over the course of the menstrual cycle. The objective of this paper was to compare female OCD patients with and without premenstrual worsening of obsessive-compulsive symptoms (OCS), in terms of the clinical characteristics of OCD.

METHODS

This was a cross-sectional study involving 455 women with OCD, of whom 226 (49.7%) had experienced premenstrual OCS worsening and 229 (50.3%) had not (PMOCS-worse and PMOCS-same groups, respectively). Data were collected with the original and dimensional versions of the Yale-Brown obsessive-compulsive scale, as well as with the Beck Depression Inventory (BDI) and Beck anxiety inventory (BAI).

RESULTS

We found significant differences between the PMOCS-same and PMOCS-worse groups, the latter showing a higher frequency of suicidal ideation (P<.001), suicide attempts (P=.027), current use of selective serotonin reuptake inhibitors (P=.022), lifetime use of mood stabilisers (P=.015), and sexual/religious obsessions (P<.001; OR=1.90), as well as higher scores on the BDI (P<.001) and BAI (P<.001).

CONCLUSION

Underscoring the fact that OCD is a heterogeneous disorder, there appears to be a subgroup of female OCD patients in whom the premenstrual period is associated with a higher frequency of sexual/religious obsessions, depression, anxiety, and suicidality. This might be attributable to hormonal fluctuations. Further studies are warranted in order to investigate this hypothesis by evaluating such patients at different phases of the menstrual cycle, as well as measuring hormonal levels.

Association of past and recent major depression and menstrual characteristics in midlife: Study of Women's Health Across the Nation

OBJECTIVE

The aim of this study was to examine the association of a history of major depression (MD) with menstrual problems in a multiethnic sample of midlife women.

METHODS

Participants were 934 women enrolled in the Study of Women's Health Across the Nation, a multisite study of menopause and aging. The outcomes were menstrual bleeding problems and premenstrual symptoms in the year before study entry. The Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders was conducted to determine recent and past psychiatric diagnoses. Covariates included sociodemographic, behavioral, and gynecologic factors.

RESULTS

One third of the participants reported heavy bleeding, 20% reported other abnormal bleeding, and 18% reported premenstrual symptoms. One third had past and 11% had recent MD. Past MD was associated with an increased likelihood of heavy bleeding (odds ratio, 1.89; 95% CI, 1.25-2.85), adjusting for recent MD, menopause status, and other covariates. Past MD was not associated with other abnormal bleeding or premenstrual symptoms in the final analysis that adjusted for recent MD.

CONCLUSIONS

Midlife women with a history of MD are more likely to report heavy bleeding.

Work and family stress is associated with menstrual disorders but not with fibrocystic changes: cross-sectional findings in Chinese working women

OBJECTIVES

To explore the separate and combined effects of work and family stress on menstrual disorders and fibrocystic changes in Chinese working women.

METHODS

Data were obtained from a cross-sectional study of 1,642 female railway workers. The Effort-Reward Imbalance Questionnaire and Family Stress Scale were used to measure work stress and family stress, respectively; the menstrual and breast conditions were evaluated by gynecologic interview and a medical examination. Multivariate log-binomial regression was performed to analyze the associations.

RESULTS

Menstrual disorders were found in 59.3% of female workers, and 54.8% had fibrocystic changes. The risk of menstrual disorders was significantly elevated with respect to work and family stress. The highest risk was found in the group with combined exposure to both work and family stress (RR with 95% CI 1.33 (1.18-1.49)). No significant association between stress and fibrocystic changes was observed.

CONCLUSIONS

Menstrual disorders were associated with stress from work and family life, but not fibrocystic changes, in working women. Tailored intervention measures reducing the burden of stressful psychosocial work and family environment are needed to improve women's reproductive well-being.

Stress and reproductive failure: past notions, present insights and future directions

PROBLEM

Maternal stress perception is frequently alleged as a cause of infertility, miscarriages, late pregnancy complications or impaired fetal development. The purpose of the present review is to critically assess the biological and epidemiological evidence that considers the plausibility of a stress link to human reproductive failure.

METHODS

All epidemiological studies published between 1980 and 2007 that tested the link between stress exposure and impaired reproductive success in humans were identified. Study outcomes were evaluated on the basis of how associations were predicted, tested and integrated with theories of etiology arising from recent scientific developments in the basic sciences. Further, published evidence arising from basic science research has been assessed in order to provide a mechanistic concept and biological evidence for the link between stress perception and reproductive success.

RESULTS

Biological evidence points to an immune-endocrine disequilibrium in response to stress and describes a hierarchy of biological mediators involved in a stress trigger to reproductive failure. Epidemiological evidence presents positive correlations between various pregnancy failure outcomes with pre-conception negative life events and elevated daily urinary cortisol. Strikingly, a relatively new conceptual approach integrating the two strands of evidence suggests the programming of stress susceptibility in mother and fetus via a so-called pregnancy stress syndrome.

CONCLUSIONS

An increasing specificity of knowledge is available about the types and impact of biological and social pathways involved in maternal stress responses. The present evidence is sufficient to warrant a reconsideration of conventional views on the etiology of reproductive failure. Physicians and patients will benefit from the adaptation of this integrated evidence to daily clinical practice.

Mind over matter: psychological factors and the menstrual cycle

PURPOSE OF REVIEW

Increasingly, gynaecologists are becoming aware of the impact of psychosocial factors on women's health generally, and on the menstrual cycle in particular. This review highlights developments in this field in the last triennium.

RECENT FINDINGS

Stress impairs the ovarian cycle through activation of the hypothalamus pituitary adrenal axis. The effect of psychological stress on the menstrual cycle is mediated by metabolic factors. Stress-induced impairment of ovarian function may not necessarily manifest as menstrual irregularity, and the effects of stress may persist beyond the cycle in which the stress episode occurred. Response to stress may be determined not so much by the nature of the stress as by the intrinsic neuronal attributes of the individual.

SUMMARY

Interventions to address underlying stress should be part of the management regime for women with menstrual cycle abnormalities.

Variability in the Phases of the Menstrual Cycle

OBJECTIVE

To determine variability in the phases of the menstrual cycle among healthy, regularly cycling women.

DESIGN

A prospective descriptive study of a new data set with biological markers to estimate parameters of the menstrual cycles.

PARTICIPANTS

One hundred forty one healthy women (mean age 29 years) who monitored 3 to 13 menstrual cycles with an electronic fertility monitor and produced 1,060 usable cycles of data. MEASURES AND OUTCOMES: Variability in the length of the menstrual cycle and of the follicular, fertile, and luteal phases, and menses. The estimated day of ovulation and end of the fertile phase was the peak fertility reading on the monitor (i.e., the urinary luteinizing hormone surge).

RESULTS

Mean total length was 28.9 days (SD = 3.4) with 95% of the cycles between 22 and 36 days. Intracycle variability of greater than 7 days was observed in 42.5% of the women. Ninety-five percent of the cycles had all 6 days of fertile phase between days 4 and 23, but only 25% of participants had all days of the fertile phase between days 10 and 17.

CONCLUSIONS

Among regularly cycling women, there is considerable normal variability in the phases of the menstrual cycle. The follicular phase contributes most to this variability.