April 7, 2021 -- Following a recent article in The Guardian, the internet erupted with tales of periods gone awry. The stress and loss of normalcy over the last year appears to have altered cycles and amplified the premenstrual syndrome (PMS) symptoms many women experience. And after the piece published, many responded on social media with the same sentiment: "So, it's not just me?"
Women have experienced the loss of their period, excessive and prolonged bleeding, severe mood swings, and irritability, according to The Guardian article. London-based gynecologist Anita Mitra, MBChB, PhD, took an informal survey and found that 65% of 5677 respondents had noticed a change in their menstrual cycle, The Guardian reported. Another survey, which was posted on medRxiv but hasn't been peer reviewed yet, found 53% of the 749 respondents had noticed a change in their menstrual cycle, including increased cycle length.
"The pandemic in itself has made more stress for women," said Karen Carlson, MD, obstetrician and gynecologist at Nebraska Medicine. There's preliminary evidence that the cycling progesterone and estrogen experienced by reproductive age women actually offers a protective effect against COVID-19, which is good news. But Carlson said that because they are less likely than men and the elderly to become seriously ill, many women have taken on a lot of the additional responsibilities brought on by the pandemic. They often juggle homeschooling and elder care in addition to the ubiquitous stressors of isolation and concerns around personal health.
"Abnormal bleeding is the most common reason people present to the gynecologist," Carlson said in an interview. But in recent months, Carlson said she's seen a slight uptick in these issues, and there might have been even more women presenting to their physicians if the pandemic hadn't also suppressed access to care.
Stress, or rather the cortisol it causes the body to produce, is the culprit for disrupted cycles. It can suppress pituitary hormones that stimulate ovulation. "Some women don't feel right because they are stuck in the one phase of the cycle," Carlson said. They may go months without a period and when they do eventually shed their uterine lining, the bleeding goes on for a while.
Some irregularity in a person's cycle is a normal response to stress and even likely, given the last year. However, bleeding for more than 2 weeks or irregularity for more than 3 months could point to something more serious like an infection or cancer, Carlson said. Getting a clear history so you know when you need to do blood and hormone workups is critical.
Anxiety and Depression Amplified
For some women it's not bleeding that's a problem, rather their PMS has become crippling. And some of their significant others have noticed drastic changes in their mood. In The Guardian article, one woman said she'd gone from feeling withdrawn during her period to being totally unreachable and experiencing intense anxiety.
Maureen Whelihan, MD, a gynecologist in Palm Beach, Florida, said that, for the majority of her patients under 39 years of age, these feelings aren't a hormone issue, but a stress and neuroreceptor issue. She says she's seen approximately a 30% increase in mood disorders since the start of the pandemic. Even though many of her patients are cycling relatively normally, their anxiety and depression have been amplified.
Caroline Gurvich, PhD, a neuroscientist at Monash University in Melbourne, attributes this to the loss of typical coping mechanisms. "Having changes to the support system and routine and things that would keep them mentally healthy can exacerbate PMS," she said in an interview. Gurvich's advice is to build routines into the pandemic lifestyle. Normal wake and sleep times, healthy eating, and practices that bring happiness can be "crucial to keeping those PMS systems as controlled as possible."
Telehealth has made it much easier to access some patients struggling with PMS and offer them the medication or counseling they need, Carlson said. But that approach doesn't work for everyone. "I feel like there are a lot of silent sufferers," she said.
This is where screening practices like the Patient Health Questionnaire-9 are so critical, according to Whelihan, who screens every patient as part of their routine iPad check-in process. Even in a normal year, "I think one third of gynecology is psychiatry," she said in an interview. She finds many of the patients struggling with excessive PMS symptoms, both during the pandemic and before, benefit from a child-sized dose of antidepressant. This may allow them to get to a place where they can make impactful routine decisions about exercise or sleep, and then taper off the antidepressant.
It may also be important for clinicians to help patients make the initial connection between their worsening mood or cognitive function and their period. Knowing their feelings of stress, irritability, fogginess, or being withdrawn are linked to their hormone cycle and possibly worsened by the stress of the pandemic can be helpful, Gurvich said. "If they become conscious of how they are feeling, it can be helpful for management of these stressful symptoms," she said.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.