Determining the Effect of COVID-19 on the Menstrual Cycle Among Women of Reproductive Age Group in the Jazan Region: A Cross-Sectional Study

Background: The coronavirus disease 2019 (COVID-19) pandemic has gravely affected the world in various ways. COVID-19 is a major health crisis, with long-term physical and mental health consequences. Many women reported menstrual irregularities during and after the pandemic. The study aimed to assess the effects of COVID-19 on menstrual cycles in females of reproductive age in the Jazan region. Methodology: A descriptive cross-sectional research design was utilized to conduct the study in Jazan, Saudi Arabia. A structured questionnaire was used to collect data from 346 women aged 18-44 years who had normal menstrual cycles for more than a year before the outbreak and had a history of COVID-19 infection. Result: The questionnaire was completed by 346 women. Only 144 (41.6%) of the study's respondents were aged 25-34 years. Of the respondents, 283 (81.8%) were university students, and 219 (63.3%) were married. The majority of women (337, 97.4%) were vaccinated against COVID-19. A total of 301 (87.0%) were healthy. Before being infected with COVID-19, 19.70% of the responders had irregular periods, which increased to 59.50% during infection and 33.20% after getting better. There was a relationship between the regularity of menstrual periods during COVID-19 infection and the duration of menstrual periods after COVID-19 (p = 0.035); the frequency of menstrual periods before (p = 0.001), during (p = 0.009), and after (p = 0.001) COVID-19; menstrual period regularity before (p = 0.001) and after (p = 0.001) COVID-19 infection; and pain severity level during (p = 0.001) and after (p = 0.004) COVID-19 infection. Regarding the perception of the impact of COVID-19 on menstrual changes, there was an association between COVID-19 infection and variation in days during two consecutive menstrual cycles (p = 0.001), changes in the duration of menstrual cycles (p = 0.022), delayed or absent menstruation (p = 0.019), and menstruation stopping (p = 0.023). Conclusion: The research demonstrated the COVID-19 pandemic is an international health problem that affects women, leading to changes in regularity, duration, frequency, and severity of pain. These changes may have a long-term impact on women's reproductive health.


Introduction
Coronavirus disease 2019 (COVID-19) is a dangerous pandemic illness that has shattered the world with various negative effects. Acute respiratory syndrome coronavirus 2 was first detected in December 2019 in Wuhan, Hubei province [1]. It is considered the seventh human coronavirus. Since then, the virus has spread rapidly over a short period of time to become the most dangerous health problem on a global scale, with varying degrees of burden, severity, psychological consequences, and social effects [2,3]. COVID-19 has had a major effect on people's lives throughout the world, particularly women of reproductive age. The disease itself and control protocols like social distancing and quarantine lead to increased loneliness, anxiety, and depression. This psychological stress during the pandemic has greatly affected female reproductive health [4]. According to a study, the mental state in the United Kingdom has worsened to the end of 2020 compared to the prior COVID-19 outbreak [5].
According to research in the US, the percentage of adult psychological suffering in 2020 was higher than in 2018. In this research, women aged 18-24 years had the most psychological discomfort. Stress may influence women's menstrual cycle [6]. According to the International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB system 1), the normal menstrual cycle has a duration of 24-38 days with a normal amount

Study sample
Women aged 18-44 years who had normal menstrual cycles (according to the FIGO standard) for more than a year prior to the outbreak with a history of COVID-19 infection were recruited in the study.

Tools for data collection
A cross-sectional survey using a modified version of three surveys was used. The first survey included two parts. Part 1 included a structured questionnaire sheet with demographic characteristics such as color, educational level, marital status, nationality, and residence. Part 2 included participants' clinical characteristics, such as medical data and medical histories, such as the presence of chronic disease and the status of COVID-19 vaccination. The second survey contained the assessment sheet for the effect of COVID-19 on the duration, regularity, pain severity, frequency of menstrual periods, and amount of blood loss; each question was answered with either "yes" or "no." The third survey was conducted to learn about women's perceptions of the effect of COVID-19 on menstrual changes. It was classified according to the level of agreement (strongly disagree, disagree, neutral, agree, and strongly agree).

Pilot study
A pilot study was carried out to evaluate the viability, objectivity, clarity, and application of study instruments and was conducted on 10% of the study sample. The necessary alterations were made and were removed from the study sample.

Data collection process
Three surveys were prepared with the structured questionnaire after reviewing the related literature. The access link was prepared and distributed to participants who gave their consent via online platforms. The link had also been distributed directly to women. The tools were tested for reliability using Cronbach's alpha coefficient.

Statistical design
After the data were gathered, they were reviewed, coded, and entered into a computer for analysis. The Statistical Package for the Social Sciences (SPSS) for Windows (IBM Corp., Armonk, NY) was used for data analysis. All continuous variables were converted to categorical variables. Frequency and percentage were used to express categorical data. The chi-square test was utilized to compare variables using categorical data. The probability was set at 0.05.

Ethical consideration
The proposal was accepted by Jazan University's Standing Committee for Scientific Research with the number REC-44/03/323. Online informed consent was collected in Arabic. Subjects were told that their involvement was entirely voluntary and that the information would be processed secretly and anonymously.

Results
The study included 346 participants between the ages of 18 and 44 years who had previously been infected with COVID-19.   Figure 1).

FIGURE 1: Regularity and irregularity of menstruation prior to, during, and after COVID-19 infection
Our findings reveal that the regularity of menstrual periods during COVID-19 infection is not related to the number of pregnancies (p = 0.361) or abortions (p = 0.734). There is a relationship between the regularity of menstrual periods during COVID-19 infection and the duration of menstrual periods after COVID-19 (p = 0.035); frequency of menstrual periods before (p = 0.001), during (p = 0.009), and after (p = 0.001) COVID-19; regularity of menstrual period before (p = 0.001) and after (p = 0.001) COVID-19 infection; and pain severity level during (p = 0.001) and after (p = 0.004) COVID-19 infection ( Table 2).

TABLE 3: The impact of COVID-19 on the occurrence of menstrual cycle bleeding and missing
Regarding the perception of the impact of COVID-19 on menstrual changes, there was a relationship between the regularity of menstrual periods during the COVID-19 infection and changes in the number of days between two menstrual cycles (p = 0.001), changes in the length of menstrual cycles (p = 0.022), delayed or absent menstruation (p = 0.019), and menstruation stopping (p = 0.023) ( Table 4).

TABLE 4: Perception of the effects of the COVID-19 infection on menstrual changes
Of the respondents, 83 (24.0%) strongly agreed that COVID-19 caused changes in the number of days between two menstrual cycles, while 77 (22.3%) women strongly agreed that COVID-19 infection caused changes in the amount of blood lost during the menses. Furthermore, 49 (14.2%) women strongly agreed when asked whether COVID-19 caused bleeding between periods. A total of 65 (18.8%) study participants strongly agreed that COVID-19 caused a delay or absence in the menstrual cycle ( Table 4).

Discussion
COVID-19 is a dangerous pandemic disease that has a detrimental impact on everyone in the world. During the COVID-19 pandemic, women faced stressful times that have been shown to impact their menstrual cycles [4]. Therefore, the objective of the current study was to evaluate the effects of the COVID-19 epidemic on women's reproductive health and menstrual cycle. Our findings revealed that the menstrual cycles changed during and after COVID-19, in terms of the number of days between successive cycles, the quantity of blood, or menses length. This may be attributed to the psychological disorders that influence these irregularities in the menstrual cycle, particularly the severe stress and sadness resulting from COVID-19. In terms of duration or length, the current study found that the duration of the menstrual cycle changes during COVID-19 infection compared to before COVID-19. This result is in line with a previous study, which reported that among women in their study, the cycle's median duration had not changed, but that its range had grown noticeably larger and the minimum and highest recorded cycle lengths had shrunk [4]. This study has shown that the COVID-19 pandemic has had a significant negative impact on the reproductive health of the female population aged 18 to 44 years. This is in line with the previous study [4].
According to prevalence, 19.70% of the respondents reported abnormal menstrual cycles before COVID-19, 59.50% during infection by COVID-19, and 33.20% after healing from COVID-19. This result is in agreement with a study conducted in Turkey, which reported that more than one-fourth of women experienced irregular menstrual cycles during COVID-19 [11]. COVID-19 infection leads to irregular menstrual cycles. Previous research reported that the incidence of menstrual regulation was more than one-tenth lower during the pandemic [12]. Regarding the severity of pain associated with menses, the current result revealed half of the women experienced moderate pain levels before COVID-19, and this percentage increased statistically during COVID-19 and decreased after COVID-19. This result is in harmony with the report that the studied sample had experienced more painful periods during COVID-19 [4].
The current study found that during and after the COVID-19 infection, women had less bleeding between periods than they did before the infection. According to research performed in Iraq and Jordan, 18.8% of women had bleeding between periods during COVID-19 [13]. Regarding missed periods, the current study showed that fewer women had experienced missed periods during and after COVID-19 compared to before COVID-19. This result contrasts with a previous study that reported that the number of missed periods increased significantly as a result of COVID-19 [4].
The current study identified a link between the increase in the prevalence of menstrual cycle irregularity in women and the COVID-19 pandemic. To protect a person's reproductive health, these results show how important it is to take steps to improve their physical and mental health during an outbreak.

Limitations
First, the design of the study was cross-sectional; therefore, it cannot demonstrate a causal link. Second, because the study was limited to the Jazan region, the findings cannot be generalized to the whole country.
Third, because the study was conducted after women were infected with COVID-19 and we asked them some questions before they were infected, some women may not recall some information. Finally, the study did not investigate the effects of stress and anxiety on menstruation.

Recommendations
Insufficient quality study on COVID-19 and menstrual, despite the fact that new studies on the topic are constantly being published, is a reflection of the general direction of research not concerned with women's health, particularly pregnancy, so there is a need to conduct further research in women's reproductive health. Future research should include ongoing multimodal evaluation at various intervals throughout the pandemic, including measurements of body mass index, hormone levels, and ovulation, as well as validated ongoing assessments of mental health. Continuous educational programs for women on how to deal with this new virus should teach women how to maintain proper adherence to preventive measures to avoid any further infection. There is a need to conduct online emotional support sessions to reassure affected women and provide them the chance to obtain medical advice during their illness and isolation period.

Conclusions
The study showed that the COVID-19 pandemic is considered one of the most serious health crises and has a significant impact on women's health, leading to many negative changes for all people, especially women of reproductive age. These changes can negatively affect the menstrual cycle, leading to an increased prevalence of irregularity, increased severity of pain, increased length, a change in the number of days between successive cycles, and a change in the quantity of blood loss. All of these changes can have serious long-term effects on reproductive health. Therefore, we need to look for solutions to menstrual cycle irregularity due to COVID-19 infection, and we need prospective research to validate these results and assess the duration of these menstrual abnormalities.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Standing Committee for Scientific Research, Jazan University issued approval REC-44/03/323. Standing Committee for Scientific Research, Jazan University (HAPO-10-Z-001) issued approval (Reference No.: REC-44/03/323). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.