The last months have been difficult, isolated from friends and family, learning how to work from home or perhaps working face to face seeing patients with COVID. Job losses and a shortage of work and income. For those with caring responsibilities, trying to juggle these with work. Just a trip to the shops feels like planning an epic adventure.
We have all struggled, but there has been a challenge during this time which is unique to women who have a uterus and ovaries that came to my attention through personal and then professional circumstances.
I am now going to overshare. I had presumed COVID beginning on 17th March. I had a grim period at the time and remember thinking that this double whammy really didn’t seem fair. Since then……….nothing. Not a peep. Some significant PMDD symptoms, but no bleeding.
This was weird, so I took to social media a few weeks ago, to see if other people were noticing this, either personally or in their working lives as HCP. The huge numbers of people responding, and the resulting feedback was significant.
- Women and HCPs reported all sorts of menstrual cycle disturbance
- Women having very late periods or even entire missed cycles. This seemed more frequent in those who had been poorly
- Women having more than one bleed per cycle
- Women suffering from significant breast pain
- Postmenopausal women having bleeds for the first time in months/years
- Women having much more severe PM
- Women having more severe period pain, particularly those with endometriosis
- One woman with no ovaries and on HRT having extra dysfunctional bleeding
As we increase the understanding of this virus, we know it seems to be a disease of the blood vessels. As yet, we do not know if there is a direct effect on the hypothalamic-pituitary axis (HPA) and the hypothalamic—adrenal-gonadal axis (HPG) that controls the menstrual cycle.
What we do know and have known for many years (although interestingly there isn’t a huge amount of formal research) is that stress does have a significant effect on these hormonal pathways. And goodness knows, this has been a time of huge stress – that horrible gnawing feeling that just sits in your head and the effect it has on your body.
The mechanism for stress affecting the menstrual cycle seems to be that high levels of glucocorticoids released in response to prolonged stress, predominantly cortisol in humans, impact all levels of the female reproductive system. The most significant effect seems to be that it suppresses GnRH release and thus LH release, suppressing ovulation and therefore the second half of the menstrual cycle. It is likely to also, therefore, be an effect on progestogen and oestrogen balance which will, in turn, cause a variety of symptoms.
The more one learns about women’s health, the more one realises the massive variety of symptoms that women experience as part of their menstrual cycle. This holds true for this time as well. What, however, is really important, is that we don’t fail to differentiate the deeply unpleasant but not dangerous symptoms, from those that need urgent assessment and act accordingly.
As always, make sure a proper history is taken including:
- The timing of symptoms and bleeding
- the type and amount of bleeding
- what contraception is on board
- the risk of pregnancy
- the risk of STI
- abnormal discharge
- pelvic pain
- Vulval symptoms
It is also very important to ask questions about
- the possibility of domestic abuse
- associated symptoms such as mood disturbance, which can be very serious
- breast pain, acne etc.
Depending upon the above, you will need to decide whether you need to bring a patient in for a face to face. This would be highly recommended for pelvic pain, post-coital bleeding, post-menopausal bleeding, severe breast pain, and new vulval symptoms.
I would caution against asking for any genital or breast photographs to be sent during remote consulting as there are significant potential legal issues and absolutely never accept or ask for any genital pictures of children, even in this clinical context. It is illegal. These patients would be better-assessed face to face.
Patients should be seen with PPE as advised for all face to face consultations currently.
The distress amongst those who responded to my social media questions was significant. The fear of pregnancy, the fear of serious illness, debilitating pain, the added difficulty of managing severe mood disturbance during an already stressful time and the inconvenience of extra bleeding, especially at a time when it’s harder to shop, particularly if relying on others to do it for you.
At a time of such huge uncertainty, being aware of the effects of stress and possibly COVID illness on the wellbeing of women and their menstrual cycles is really important. We need to ensure we don’t miss significant pathology whilst being reassuring about the huge variety of symptoms that can be caused by stress.
Stephanie De Giorgio