key: cord-0818665-wx46y6tl
authors: Bruinvels, G.; Goldsmith, E.; Blagrove, R.; Martin, D.; Shaw, L.; Piasecki, J.
title: How lifestyle changes within the COVID-19 global pandemic have affected the pattern and symptoms of the menstrual cycle.
date: 2021-02-03
journal: nan
DOI: 10.1101/2021.02.01.21250919
sha: e86aa121ae625d4f7b08e81a9a1854c1721fa951
doc_id: 818665
cord_uid: wx46y6tl

Background: The coronavirus 2019 (COVID-19) pandemic has caused significant changes to homes, working life and stress. The purpose of this research was to investigate the implications that the COVID-19 pandemic has had on the menstrual cycle and any contributing factors to these changes. Methods: A questionnaire was completed by 749 participants, whom ranged from physically active to elite, in their training status. The questionnaire captured detail on menstrual cycle symptoms and characteristics prior to and during the COVID-19 pandemic lockdown period, as well as lifestyle, stress, exercise and nutrition. Descriptive statistics and frequency distribution were reported and decision tree analysis performed. Statistical significance was assumed at p<0.05. Results: Fifty-two point six percent of females experienced a change in their menstrual cycle during the lockdown period. Psychosocial symptoms had changed in over half of all participants. Participants who reported increased stress/worry in family and personal health were significantly associated with changes in menstrual symptoms. Similarly, job security stress was associated with increases in bleeding time (p<0.05). Conclusions: It is important that females and practitioners become aware of the implications of stressful environments and the possible long-term implications on fertility, particularly given the uncertainty around a second wave of the global pandemic.

The menstrual cycle is a natural process for most females that occurs in the 46 reproductive years between puberty and menopause. A 'normal' (eumenorrheic) menstrual 47 cycle lasts 22-35 days (Fehring, Schneider and Raviele, 2006) and is characterised by a 48 cyclical fluctuation of sex hormones mediated by the hypothalamic-pituitary axis, which is 49 essential for maintenance of bone health and fertility. Whilst oestrogen and progesterone are 50

the key sex hormones involved in the reproductive system, they are also vital in the 51 regulation of other physiological systems and maintaining holistic health. In particular, 52 oestrogen is a key regulator of bone resorption (Chen, Wang and Huang, 2009 ) and also has a 53 cardioprotective role (Iorga et al., 2017) . Therefore, continuous oestrogen exposure through 54 the menstrual cycle post-puberty and pre-menopause could also reduce risk of other health 55 conditions such as osteoporosis and cardiovascular disease (Bae, Park and Kwon, 2018; 56 Mumford et al., 2012) . 57

A eumenorrheic menstrual cycle can be used to indicate that the body is in an 58 adaptive physiological state, and not subject to excess stress. Therefore, from a physical 59 performance perspective, it can be used to guide readiness and adaptation. Dysregulation of 60 this process may be multifactorial; often occurring as a result of perturbation of the 61

The second section captured detail about the participants' working status prior to and during the COVID-19 pandemic lockdown, information around children and if 146 applicable, how this affected their working routine. This section also included Likert scales to 147 detail how financial status and job security affected worry and stress. The third section 148 requested detail on exercise behaviour changes that may or may not have occurred for the 149 participant during lockdown. There were ten different categories of training in which the 150 participants could answer with one of the following options: 1; about the same, 2; increased, 151 3; decreased, 4; I never do this. The fourth section contained questions concerning the 152 menstrual experiences of the participants, based on previous work by co-author's xxx. The 153 same options used in section three applied here for 28 different symptoms associated with the 154 menstrual cycle. Participants were also asked about the length of their cycle and bleeding 155 patterns in a multiple-choice format (increased, decreased, stayed the same), with an 156 opportunity to elaborate on coping mechanisms for any symptoms that may have arisen 157 during the COVID-19 lockdown. The final section of the questionnaire focused on the 158 general health of the participant. This included Likert scales regarding worry around personal 159 and family health, and whether the participants have been previously diagnosed with, or have 160 been assumed to have/had, COVID-19. The final element of the survey captured aspects of 161 nutritional intake that may have changed during the lockdown using the previously 162 mentioned scale (1-4) from sections 3 and 4. Data processing is shown in Fig. 1 . 163 164 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in were removed from the dataset. Data was then coded to categorised responses and then 170 frequency analysis was carried out. Data are represented as mean ± standard deviation (SD), 171 frequencies and percentages. Statistical significance was set at p ≤ 0.05. Further analysis was 172 carried out using R Statistical Software. Decision trees were created using the rpart 173 (Therneau and Atkinson, 2019) and rpart.plot (Milborrow, 2019) packages to explore 174 possible connections between changes in menstrual symptoms since the onset of COVID-19 175 and specific lifestyle changes covered in the questionnaire. These trees were pruned using 10-176 fold cross-validation to prevent over-fitting. Potential relationships between changes in 177 symptoms and lifestyle identified by the decision trees were then tested using Fisher's exact 178 test. 179 180 181 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in they had experienced some symptoms of COVID-19 and had therefore had to self-isolate. 186

Ten percent reported that someone in their household had experienced symptoms and in turn 187 they were required to self-isolate. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in 

Prior to COVID-19 >75% of our sample were in full-time employment. During 220 COVID-19 lockdown half of the respondents reported to be working full-time at home and 221 17% were working part-time at home. Only 54 participants indicated they had been 222 furloughed at either 80% or 100% pay. Distribution of working status prior to and during 223 COVID-19 is shown in Fig. 2 . 224

The stress experienced by participants is displayed in table 2. The majority of those 225 with children expressed that their children caused higher levels of daily stress. When 226 considering other possible sources of stress and worry such as financial stress, job security 227 and stress regarding menstrual symptoms, most participants (>50%) did not report being 228 overly worried or stressed (1-3 on Likert scale) by such parameters ( preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250919 doi: medRxiv preprint

Most changes to menstrual symptoms experienced during the COVID-19 pandemic 249 were psychosocial in nature (Fig. 3) . Over half of all participants reported to have 250 experienced lack of motivation (59.3%), focus (53.1%) and concentration (54.9%). Similarly, 251 symptoms of mood changes, irritability, emotional feeling, worry and being distracted were 252 all reported in over half of all participants. There were minimal differences in this pattern 253 when dividing participants between those who were hormonal contraceptive users or not. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250919 doi: medRxiv preprint likely than other women to experience reduced sex drive, constipation, reduced focus, 266 reduced motivation, feeling emotional and lower back pain. 267

Changes in nutritional and exercise patterns can be found in Table 4 

Of the 28 symptoms listed in Fig. 3, women pre-COVID-19 at three or higher (see Table 2 ) increased to 11 during the lockdown period 282 and this score increased to 13 if additional stress concerning family health was given the 283 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250919 doi: medRxiv preprint highest rating. Among the women with lower levels of stress about personal health, the 284 average increase in symptoms was 7.8 but this score only stayed low among women who 285 maintained or increased their fruit and vegetable intake (7.3). Among those who did not, an 286 average of 11 symptoms increased. 287

The cross-validated decision tree process did not identify any factors significantly 288 related to blood-loss changes but did show that high levels of stress regarding job security 289 whether cycle length had changed. Amongst the 558 of women that were not using hormonal 304 contraception, 58% noticed a change in cycle length, compared to 41% of the 187 who did 305 use hormonal contraception (Table 3) , which was a significant difference (p<.001). 306 307 308 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in here has shown that whilst the cycle length of a hormonal contraceptive user may not change 332 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250919 doi: medRxiv preprint as readily in relation to the external environment, symptoms and side effects may still be 333 present and can be affected by environmental changes. 334

There were some differences in the symptoms reported between elite and sub-elite 335 athletes, compared to non-elite respondents. Fifty-four percent of elite female athletes 336 indicated that bloating was a symptom they had increasingly experienced during COVID-19 337 lockdown, which was significantly higher than the reported prevalence of bloating amongst 338 the other participants. This proportion is higher than previously reported amongst elite Simpson and Stakes, 1987) . It was also reported that higher level competitors may have been 349 less likely than other women to experience reductions in; sex drive, focus and motivation and 350 increases in; constipation, feeling emotional and lower back pain, compared to non-351 competitive athletes, however this was not significant. Whilst elite sport competition has 352 been cancelled or postponed during the COVID-19 pandemic lockdown, it is likely that these 353 athletes will have access to various additional support networks (Bowes, Lomax and 354 Piasecki, 2020) and thus are able to manage rapidly changing environments more so than 355 their non-elite counterparts. 356 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The greatest contributor towards changes in symptoms was stress. There was a 377 significantly greater increase in symptoms when participants reported high levels of worry 378 about personal and family health. Similarly, bleeding time was more likely to have changed if 379 high level of stress regarding job security was reported. Interestingly, fruit and vegetable 380 intake were able to off-set some changes in cycle length associated with stress, and high 381 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250919 doi: medRxiv preprint intensity training was able to regulate stress regarding job security. Clearly, the current 382 climate surrounding COVID-19 has been a stressful event for many 383 Rehman et al., 2020; Odriozola-González et al., 2020) . This data highlights the great impact 384 that such stress can have on female physiology, not solely on mental health and well-being. 385

Current education around such possible influencers on the menstrual cycle is quite limited 386 amongst the female population (Ayoola, Zandee and Adams, 2016; Larsen et al., 2020) . 387

Given that the current climate is likely to continue for the foreseeable future, it is important 388 that females become aware of the influence that stress will have on the menstrual cycle and 389 are able to manage/control these changes to the best of their ability. It is deemed that long- As with all research, there are limitations with this study that should be 400 acknowledged. The data herein comes from a range of countries in which there were a range 401 of rules and regulations, and therefore experiences, with regards to lockdown, therefore 402 possibly influencing the participants differently. However, the countries assessed in the study 403 all documented some degree of change in lifestyles and working environments. Our sample 404 also included hormonal contraceptive users as well as non-users. The regularity of cycles 405 when utilising combined oral contraceptives, due to exogenous hormones that they contain, is 406 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in can also contribute to symptoms experienced which we were able to document in both 411 hormonal contraceptive users and non-users. Finally, our data only provides a small insight 412 into the changes experienced by females during the COVID-19 pandemic and does not 413 provide any longitudinal data that could document the rise and fall of symptom exacerbation 414 or the degree of severity that the females may have been affected by such environmental 415 changes. 416

In conclusion, lifestyle changes experienced by females throughout the COVID-19 418 pandemic lockdown period can impact menstrual cycle length and symptoms. Over half of all 419 females reported a change in their cycle length and over a third experienced changes in 420 bleeding patterns. The most substantial changes arise in psychosocial symptoms, which is 421 somewhat expected given previously reported links between the pandemic lockdown period 422 and mental health. The stress caused by the pandemic is the most significant contributor to 423 menstrual cycle changes. This is important and highlights the potential for long-term stress to 424 influence female fertility and other health consequences. With the current uncertainty of the 425 COVID-19 pandemic, and a possibility of a second wave during the northern hemisphere 426 winter season, menstrual cycle changes could become a serious consequence. It is therefore 427 important to educate females about the influence of stress as well as to ensure clinicians are 428 fully aware of the reasons why menstrual cycle changes may arise. 429 430 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in Triad Coalition risk assessment tool is an evidenced-based tool that is reliable and well-531 described', J Sports Sci, pp. 1-4. 532 533

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Caparello, G., Barrea, L., Scerbo, F., Esposito, E. and perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250919 doi: medRxiv preprint

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