European Journal of Cardiovascular Medicine

effects on female reproductive physiology, Reis and colleagues confirmed an Angiotensin-ACE2 axis and ACE2 markers in all stages of follicle maturation in the human ovary (6) ACE2 expression was also found in epithelial cells and stromal cells in the endometrium and this expression of ACE2 changed with the phases of menstrual cycle, being more abundant in the secretory phase than the proliferative phase (7).Castillo et al. performed a systematic literature review to study the impact of the SARS-CoV-2 infection on the endometrium. Although they found TMPRSS2 expression was moderate and ACE2 was low but they also found that certain other markers were highly expressed throughout the menstrual cycle, with most enhanced expression at the secretory phase (8).Deficiency of Anti Mullerian hormone detected in post COVID period depicts the decreased ovarian reserve due to COVID 19 which might ultimately result in infertility.  Angiotensin II is essential for regular menstrual cycles and alteration in the receptors of angiotensin II may thus lead to dysfunctional uterine bleeding and hyperplasia of the endometrium (9).The COVID 19 pandemic has not only adversely affected the physical well being of the population at large but has also adversely affected the mental well being of masses.

In a U.S. based study it was found that women are most prone to the psychological distress caused by COVID 19 pandemic (10). It’s a well known fact that undue psychological stress can affect women’s menstrual health. Stressful triggers can activate the hypothalamic-pituitary-gonadal (HPG) axis and dysregulate the gonadotropin releasing hormone (GnRH) secretion which results in functional hypothalamic amenorrhoea (FHA) and chronic anovulation not attributing to any organic cause (11).Psychological distress is also associated with exaggerated pre-menstrual symptoms (PMS) ,dysmenorrhoea, menorrhagia and lower libido along-with missed periods.(12) Phelan et al. performed an anonymous digital survey, 46% reported a change in their menstrual cycle since the beginning of the pandemic, 53% reported worsening premenstrual symptoms, 18% reported new menorrhagia and 30% new dysmenorrhea compared to before the pandemic. 9% reported new missed periods with median number of missed periods as 2(1–3). Almost half of women reported heavier and painful periods.  Alterations were found in the minimum and maximum cycle length. These shorter or longer menstrual cycles were mostly anovulatory, thus making it difficult for conception or end up in spontaneous abortion if even conceived (12).

Khan S. et al 2022 described the menstrual cycle changes among the SARS-CoV-2 positive participants (n 127), 16% reported changes in their menstrual cycle. These participants also reported a greater number of COVID-19 symptoms compared to those who did not have any change in their Menstrual Cycle (8.6 vs 6.1). They were more likely to be overweight or obese (60% vs 44.9%). However, these comparisons did not reach the threshold of statistical significance. The most common COVID-19 symptom in these participants was fatigue (13).

Not only does the COVID infection causes menstrual irregularities but studies have also found that COVID vaccination too causes menstrual irregularities (14)  Muhaidat et al investigated the prevalence and impact of menstrual abnormalities after the COVID-19 vaccine among females in the Middle East and North Africa region. They found that about 66.3% of participants reported menstrual symptoms post-vaccination, of which 46.7% experienced them after their first dose. These abnormalities mainly being longer menstruation duration and increased menstrual cycle lengths and cramps. Self resolution of symptoms occurring within 2 months in 93.6% of participants (14).

Laganà A et al., 2022, investigated menstrual irregularities after the first and second doses of the COVID-19 vaccine. They found that about 50–60% of reproductive age women reported menstrual cycle irregularities after receiving the first dose of the COVID-19 vaccine and 60–70% after the second dose. After both the doses most women had menstruation 1 –5 days earlier than expected also heavier menstruation than usual. These irregularities spontaneously resolved in approximately half the cases within two months (15).On the other hand  Emily R. et al, assessed whether COVID-19 vaccination is associated with changes in cycle or menses length and found only a difference of 1 day in cycle length and no change in menses length(16).Women who menstruate constitute approximately 49% of the total number of confirmed cases of COVID-19 infection [17].Wang Y-X et al., points out that the features of menstrual cycle are now being recognized as ‘vital signs’ determining overall health & well-being of women. Irregular and long menstrual cycles have been associated with a greater risk of premature mortality (18) and high risk of developing ovarian endometrial cancer [19] and lifestyle diseases like PCOS and insulin resistance (20). Li et al. analyzed sex hormones levels and menstruation in a cohort of reproductive age women hospitalized for COVID-19. They divided patients into those with mild or severe symptoms and compared their hormonal levels to those of healthy women (controls). Patients who experienced menstrual changes during the SARS-CoV-2 infection were more likely to have decreased menstrual volume and longer cycles (prolonged to 8–14 days). After 3 months of follow up, their menstrual cycles had returned to normal. Sex hormones (FSH, LH, Estrogen E2, progesterone, and testosterone) and the Anti-Mullerian hormone concentrations also did not differ between women with COVID-19 and the controls (21). Nguyen BT et. al., (2021) detected potential changes in ovulation, cycle length, menstrual duration and self-reported perceived stress during the pandemic. They found that COVID-19 pandemic did not induce population-level changes to ovulation and menstruation among women using a mobile app to track menstrual cycles. Approximately 7.7% and 19.5% of users recorded an-ovulatory cycles and abnormal cycle lengths during the pandemic, respectively. 32.0% Women self-reported more stress during the pandemic. (22)

The existing literature search have conflicting reports , also the present studies were performed mostly within a few months time frame of COVID 19 infection , thus possibly missing the long term effects of COVID infection on reproductive  health of women. Our  study was designed to study the short as well as long term  effects of COVID 19 infection on the very less researched menstrual cycle in Indian females to better understand the implications of COVID infection on reproductive health of  North  Indian Women. The spread duration of data collection in our study was vast (spanning all three phases of COVID and a year after that)

The study was conducted at S.N. Medical College Agra for a period of 12 months, in accordance with the Declaration of Helsinki. The data was collected using an online-based questionnaire created through Google Forms® online survey development software, from May 2023 to April 2024 This study was created to ensure that the ethical standards of voluntary participation were followed, that it was not emotionally distressing, and that the participants’ rights to privacy, anonymity, and self determination were protected. An informed consent was obtained from all participants on the first page of the study’s questionnaire, it explained the aims of the study and emphasized on the confidentiality of the data collected. Inclusion Criteria : Women in the reproductive age group (18-45 years of age) , infected with COVID 19 infection at-least once, with regular menstrual cycles prior to the COVID 19 infection Exclusion Criteria: • Women with irregular menstrual cycles • Women not infected with COVID 19 virus • Pregnant or lactating women • Women who were using assisted reproductive techniques for conception The data was collected by circulating the google form among various college going students (medical and non medical) and other groups of all ages and occupation/no occupation during the year 2023-2024 and 108 responses were gathered. Data collection confined to minimum 12th pass subjects.

The data was collected using an online-based questionnaire created through Google Forms® online survey development software, from May 2023 to April 2024. The average age of the study group was calculated to be 22.59 years. The survey was in the form of Questions and are presented here in that form with following being the observations

1) When were you infected with COVID 19:

Out of the 108 participants 79.6% were infected only once during the 3 waves, 15.7% were infected twice and only 4.6% were infected during all the three phases of COVID 19 infection.

2) Did you suffer from symptomatic disease or asymptomatic ?

82.4 % had Mild symptomatic disease . Only 1 subject suffered from severe symptomatic disease and required hospitalization with ICU/O2 therapy

3) Was your menstrual cycle regular before the covid infection ?

Before the COVID only 11.1% women had irregular periods with 50.9% subjects having average duration of 26-30 days, 20.4 % had an average duration of 20-25 days and 28.7 % had more than 30 days as average duration.

4) Did you feel any change in the menstrual cycle after COVID infection ?

Women complaining of changes in the Menstrual cycle almost doubled i.e. 20.4% (11.1% previously) after suffering from COVID Infection/Illness.

5) Did the duration of the flow days change after the infection/illness

76.9% women did not report any change in the length of the menstrual cycle whereas 13% reported longer (average increase of 2-3days) than normal duration and 10.2% reported shorter (average reduction by 2 days) than before menstrual cycle duration.

6) 12% women reported an abnormal passage of clots (which never happened earlier) after the COVID 19 infection.

7) 20% women reported a more permanent change (change for more than 3 months) in the cycle length after the infection.

8) 22.2% subjects had to take medical intervention as treatment and 2 required hospitalization for the severity of symptoms.

9) About 20% subjects felt that their overall reproductive health may have suffered negatively because of the COVID infection.

10) Were you vaccinated with COVID vaccine when you got infected ?

The most interesting finding is 40.7% subjects were fully vaccinated with both the doses at the time of infection,10.2% were vaccinated with a single dose and 49.1% were not vaccinated at all.

11) 20% felt their Pre menstrual symptoms worsened after the infection and 5% felt it got better , whereas 75% felt no change in PMS

12) Almost all the subjects complained of Long Covid syndrome and the most frequent complaint was fatigue followed by coughing , anosmia and muscle pains etc.

Our results show that COVID 19 has affected the reproductive health of most of the females. Though some regained the normalcy within few months but 22.2% women required medical intervention as treatment and still 20% women reported having suffered a more permanent change in their menstrual cycles which has negatively affected their overall well being

We found that nearly 1/3rd of women had changes in the menstrual cycle duration and about 20% felt the change to be permanent (more than 3 months ). The changes reported by us are in accordance with Li K., et al 2021 who in their retrospective cross sectional study reported a menstrual volume decrease or cycle prolongation in nearly one fifth of patients (21)

Though we could not perform the hormonal levels of these women but our results indicate that due to these changes, these women may be at risk of ovarian suppression which may lead to infertility as well. This has been reported by others as they found inappropriately high concentrations of follicle stimulating hormone (FSH) and luteinizing hormone (LH) in patients with COVID 19, pointing towards COVID 19 induced ovarian suppression (23)

In our study 12% women reported abnormal passage of clots post COVID 19 which is distressing both physically and mentally. Phelan N et al in 2021 performed a digital survey and stated that The COVID 19 pandemic has severely impacted the reproductive health of women (14)

20% of women reported a worsening in the premenstrual syndrome, in our data which agrees with the work of Phelan et al 2021 who reported 53% women had worsened premenstrual symptoms during and after the COVID 19 infection (14).While a significant proportion of women described the negative impact of the pandemic on their menstrual cycle, there were a few (5 subjects) who described their PMS improved after the COVID pandemic. In their review article Madaan S, et al.(2022) concluded that patients of COVID 19 should be evaluated for fertility after recovery as SARS CoV 2 may infect the ovary, uterus, and vagina through ubiquitous expression of ACE 2, leading to disturbed menstruation and thus leading to infertility (24).

In an opinion letter Gemma C Sharp, et.al. 2021, reviewed multiple papers and raised several outstanding questions, one of which is “The effect of COVID-19 illness on menstrual cycle features” which we have addressed in our study (25).There are several limitations to this observational study. The first is that the study recorded self-reported data, which is subject to bias. Second is the number of participants , which is limited, more the number of participants , better is the data. The majority of the subjects belong to the same social class, there is lack of data from poor/un educated women who may have more serious effects on their reproductive health.  Also, the quantification of hormonal levels (FSH and LH) would have strongly substantiated the present data.