The European Journal of Contraception & Reproductive Health Care ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iejc20 The global pandemic and changes in women’s reproductive health: an observational study Liya Haile, Niels van de Roemer, Kristina Gemzell-Danielsson, Josep Perelló Capó, Iñaki Lete Lasa, Silvia Vannuccini, Martin C. Koch, Thomas Hildebrandt & Joaquim Calaf To cite this article: Liya Haile, Niels van de Roemer, Kristina Gemzell-Danielsson, Josep Perelló Capó, Iñaki Lete Lasa, Silvia Vannuccini, Martin C. Koch, Thomas Hildebrandt & Joaquim Calaf (2022) The global pandemic and changes in women’s reproductive health: an observational study, The European Journal of Contraception & Reproductive Health Care, 27:2, 102-106, DOI: 10.1080/13625187.2021.2024161 To link to this article: https://doi.org/10.1080/13625187.2021.2024161 © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Published online: 18 Jan 2022. Submit your article to this journal Article views: 2736 View related articles View Crossmark data Citing articles: 3 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iejc20 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 2022, VOL. 27, NO. 2, 102–106 https://doi.org/10.1080/13625187.2021.2024161 RESEARCH ARTICLE The global pandemic and changes in women’s reproductive health: an observational study  Capo Liya Hailea , Niels van de Roemerb, Kristina Gemzell-Danielssonc , Josep Perello d, In ~aki Lete Lasae , f g h i Silvia Vannuccini , Martin C. Koch , Thomas Hildebrandt and Joaquim Calaf a Independent Contractor, Arlington, VA, USA; bValley Electronics AG, Z€urich, Switzerland; cDepartment of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden; dDepartment of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine and Public Health, Hospital de Sant Pau, Barcelona, Spain; eDepartment of Obstetrics and Gynecology, Araba University Hospital, Jose Atxotegui s/n, Vitoria-Gasteiz, Spain; fDepartment of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy, Florence, Italy; gDepartment of Obstetrics and Gynecology, Anregiomed Ansbach Klinikum, Ansbach, Germany; h Frauenklinik, Universit€atsklinikum Erlangen, Universitaetsstrasse 21-23, Erlangen, Germany; iDepartment of Paediatrics, Obstetrics and Gynaecology, Preventive Medicine and Public Health, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain ABSTRACT ARTICLE HISTORY Objective: The COVID-19 global pandemic has led to the death of millions around the world and Received 5 November 2021 impacted the overall health of many people. In this article we aim to compare reproductive health Revised 22 December 2021 indicators in the first 6 months of 2020 to the prior year, as well as explore stress and quality of Accepted 27 December 2021 life during this time. KEYWORDS Methods: This retrospective observational study examined the menstrual cycles of 1159 women Pandemic; COVID-19; who were using a fertility tracking device to record their menstrual cycle and BBT data. We utilised reproductive health; a supplemental mobile application to administer a supplemental survey to collect data on stress menstrual cycle; fertility and quality of life. Descriptive analyses were conducted with t-tests for two-group comparisons. pandemic; coronavirus Results: Study participants from 15 countries contributed to a total of 13,194 cycles. 23.1% (268/ menstruation 1159) responded to the survey focussed on assessing psychosocial distress. 44.4% (119/268) of the study participants reported that they had noticed a change in their menstrual cycle, temperature curve, or menstruation in the past 12 months. Cycle analysis found the average cycle length and pre-ovulation phase length was longer in the first 6 months of 2019, while the average days of menstruation was slightly longer in 2020. Discussion: Our findings indicate that menstrual cycle indicators changed only slightly in the first 6 months of 2020 but were still statistically significant. We were also able to understand that these study participants had some level of awareness of changes to their menstrual health. Introduction Besides the imminent threat of the virus on people’s health, women were also impacted by several factors dur- The global research community accelerated efforts to ing the pandemic such as increased risk of gender-based understand the coronavirus (COVID-19) as it rapidly spread violence [8], financial insecurity [9], stress, and a multitude across the globe, creating dire public health demands. of other stressors. There have been several studies that However, one of the most important yet understudied pub- examined women’s reaction to stress, change in schedules, lic health impacts of this pandemic is reproductive health. and mental health during the pandemic and the stages of From the extensive research that has been conducted, lockdown [6,10]. These studies found that a multitude of external stimuli highly impacts the reproductive health sys- factors such as anxiety and lack of sleep all had an impact tem. Research has shown that stress, diet, exercise, age, on menstrual cycle health and symptoms [11]. and other inputs affect ovulation and the menstrual cycle In a small sample study of women (n ¼ 59) aged 20–54, [1–4]. Current research is minimal on the impacts of an 100% of study participants reported experiencing changes upper respiratory infection like COVID-19 on a woman’s in their menstrual cycle, with 25 participants experiencing menstrual health. Most studies looking at the impact of a delay in menstruation between 2 and 5 or more days COVID-19 on women’s bodies are cross-sectional or limited [10] A slightly larger study of 263 women compared cycle in only understanding the perceived consequences of the changes of women before and after COVID-19, and found pandemic [5,6]. One recent study found that women that women experienced more menstrual cycle symptoms recorded more anovulatory cycles and abnormal cycle during the pandemic, although the length of their men- lengths during the COVID-19 pandemic. Although this struation and use of sanitary pads had decreased [12]. study did not report population level changes to ovulation Menstrual changes were also observed in another study of and menstruation, changes in menstrual cycle health bio- over 700 women who were physically active and reported markers were observed [7]. that 35.6% of study participants experienced a change in CONTACT Liya Haile hailelt@alumni.vcu.edu Independent Consultant, Arlington, VA, USA ß 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc- nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 103 bleeding patterns [7]. This study also found that one of the indicates ‘infertile’, red indicates ‘possibly fertile’ and yellow main contributing factors to changes in the menstrual cycle indicates ‘unknown’ (Figure 1). The colours are indicative of was stress and managing family life. Interestingly, this a woman’s fertility determined by the amount of data pro- study did not find that financial insecurity and job insecur- vided by the users. Consistently measuring BBT lowers the ity impacted menstrual symptoms for more than 50 partici- amount of ‘red’ of ‘possibly fertile’ days as the device caters pants [6]. to the user’s individual menstrual cycle. The device is also Although these studies provide insight into perceived accompanied by an optional free mobile application (app) changes of the menstrual cycle, they lack real time data to called DaysyDay. The app allows users to visualise their data support the reported changes. In this study, we aim to ana- in real time. Daysy fertility device users provide their consent lyse the menstrual cycles of women that were using a fer- to use their unidentifiable data strictly for research purposes tility tracking device during the COVID-19 pandemic and in the terms and conditions upon using the device. We uti- the same period of the preceding year to better under- lised a supplemental mobile application associated with the stand how the pandemic impacted various reproductive Daysy fertility device to administer this survey. Women health indicators like cycle length and variability, and basal received this survey directly on their Daysy application. They body temperature (BBT) as well as reported quality of life. provided consent directly on their mobile device. The study aimed to answer the following questions: Sociodemographic data as well as other measures were collected between June and August 2021. The survey ques- A. Is there a difference in the measurable markers of tions were either multiple choice or based on a likert scale of menstruation (menstrual cycle length variables, etc.) 1–10, with 1 being the lowest and the 10 being the highest. between the period before and during the pandemic This questionnaire with an additional consent process was (primary outcome – data of total sample based on fer- developed and uploaded to a survey software (TypeForm) tility tracker data)? and a link to the survey was generated. This link was B. Is there a difference in the subjectively experienced embedded into a pop-up message in the DaysyDay mobile psychosocial distress between the period before and application and sent exclusively to the study sample. Upon during the pandemic (secondary outcome: Data from subgroup answering questionnaire in addition to fertil- receiving the pop-up notification, study participants were ity tracker menstruation related data)? asked if they would be interested in participating (anonym- C. Is there an association between the subjectively expe- ously) in this study and then further asked for their consent. rienced distress and menstrual cycle changes (second- Once consented, women were asked to complete the survey, ary outcome: Data from subgroup answering although none of the questions were required in order to questionnaire in addition to fertility tracker menstru- submit the survey. In addition to analysing BBT data collected ation related data)? through the fertility device, we also collected data on stress factors such as change in perceived stress level, relationship, and job security to understand the impact the COVID-19 pan- Materials and methods demic had on women’s bodies. In the appendix, you will find Materials the list of questions sent to study participants. The study was conducted in accordance with the declar- ation of Helsinki and approved by the institutional ethics committee at FAU Erlangen (21-402-ANF). Menstrual cycle and BBT data were collected through a Methods fertility tracker (Daysy), a medical device based on fertility awareness. The device records women’s BBT and uses a This was an observational study of women who were using modified calculothermal method to analyse and provide a the Daysy fertility device from 1 January to 30 June 2020 fertility output to users on a daily basis. To receive this infor- and also reported data during the same period in 2019 (see mation, women must record their daily BBT measurements Figure 1). Study participants (n ¼ 1159) were randomly every morning immediately after waking up and also con- selected from a pool of Daysy users who met the study firm menstruation/bleeding. The device displays the user’s inclusion criteria. To be included in the study sample, users estimated fertility status through LED lights, in which green must have used the device for at least 90 days prior to 1 January 2019 and recorded data for at least 80% of their cycle. Each data set contained six cycles from these women in 2019 and six cycles in the same time period for 2020. Study participants were from 15 different countries (Andorra, Australia, Canada, Colombia, Estonia, Germany, Israel, Latvia, Netherlands, Romania, Spain, Sweden, Switzerland, United Kingdom, and the United States). Each study participant was identified with a specific study number. Data were analysed in August 2021 using GraphPad Prism (v. 9.2.0) and Microsoft Excel. One sample t-tests were used for two-group comparisons. Data are repre- sented as mean ± standard deviation (SD), frequencies, and Figure 1. Study design. percentages. Statistical significance was set at p  0.05. 104 L. HAILE ET AL. Table 1. Socio demographic characteristics. Characteristic Categories % (n ¼ 268) Age (years) 18–24 10.4% (28) 25–29 36.9% (99) 30–34 31.7% (85) 35–39 13.1% (35) 40–45 5.6% (15) Older than 45 2.2% (6) Relationship Status Married 38.1% (102) Separated 3.0% (8) Single (without a Partner) 8.6% (23) Long Term relationship (> 3 Month) 48.1% (129) Short Term relationship (< 3 Month) 1.5% (4) Dating but not in a relationship 0.7% (2) Kids Yes 12.3% (33) No 87.7% (235) Working Status before the Pandemic Full-Time 64.9 (175) Part-Time 16.0 (34) Unemployed 2.6 (7) Student 12.7 (34) No information 3.8 (18) Working Status during the Pandemic Full-Time 64.2 (172) Part-Time 19.4 (52) Unemployed 6.3 (17) Student 9.7 (26) No information 0.4 (1) Results Table 2. Data set (n ¼ 1159 Woman) 6 cycles each from 2020 vs. 2019. Mean ± SD The analysis contained data from 1159 women who con- 2020 2019 tributed a total of 13,194 cycles. A total of 23.1% (268/ Average (n ¼ 6607 cycles) (n ¼ 6582 cycles) 1159) of women who were sent the survey responded. Menstrual Cycle Length (d) 28.7 ± 4.58 29.8 ± 6.08 (<0.0001) Of the study participants that completed the survey (5th Pre-ovulation Phase Length (d) 16.2 ± 4.39 17.12 ± 5.96 (<0.0001) of July 2021), 81.7% (219/268) were between 25 and Menstruation Length (d) 3.92 ± 1.22 3.90 ± 1.54 (<0.0001) 39 years old and a majority held a bachelor’s degree or postgraduate degree (see Table 1). Only 12.3% (33/268) reported having children. Table 3. Women (n ¼ 47 out of 268) who reported that their quality of life As indicated in Table 2, in 2019 the average duration had worsened during the pandemic (>5). was longer for the total length of the cycle and for the Mean ± SD pre-ovulation phase. Further, the most noticeable change is 2020 2019 in the days of menstruation, in which on average women Average (n ¼ 522 cycles) (n ¼ 515 cycles) menstruated slightly more in 2020 than they did in 2019. Menstrual Cycle Length (d) 29.2 ± 4.60 30.0 ± 5.47 (<0.0001) Menstruation Length (d) 4.00 ± 1.11 3.87 ± 1.15 (<0.0001) There was a statistically significant difference in the aver- age menstrual cycle length, pre-ovulation phase length, and menstruation length of these women between 2019 (n ¼ 6582 cycles) and 2020 (n ¼ 6607 cycles). who reported that they had noticed a change in their men- 38.1% (102/268) of all women reported being personally strual cycle, temperature curve, or menstruation in the past affected or having had family members that were affected 12 months, we found there to be a significant difference by COVID-19. About 69% (186/268) reported their quality across time for cycle length, pre-ovulation phase length, of life had changed. Of these 186 study participants, 76 and days of menstrual bleeding. We also found that 58.2% reported that their life had either somewhat improved or of all women reported that the pandemic had direct conse- improved (reporting 6–10 on a scale of 1-10). However, of quences for them and their families. the women who were affected or had family that was As shown in Table 4, the most reported direct conse- affected by COVID-19, 46% (47/102) reported that their quences for study participants were limited social contact quality of life worsened in the last 12 months and during and no possibility to practice a hobby. There were very few (reporting a 0–4 on a scale of 1–10). differences regarding perceived changes in the menstrual As shown in Table 3, there was some difference in the cycle, temperature curve, or menstruation in the past menstrual cycle and menstruation length among women 12 months among women who received the vaccine and (n ¼ 47) between 2019 and 2020. The length of menstru- women who did not. Of the 191 who received the vaccine, ation was slightly higher in 2020 among women who 85 reported that they noticed a change in their menstrual reported that their quality of life had worsened during the cycle and/or temperature curve. pandemic. 44.4% (119/268) of the study participants We found that 66.4% (178/268) of women reported feel- reported that they had noticed a change in their menstrual ing sometimes to always stressed because of the pan- cycle, temperature curve, or menstruation in the past demic. We measured stress through different indicators 12 months. This finding was only slightly higher in women reported in the Table 5 below and found that the ‘health who reported being affected or had family that was of the family’ was the biggest stressor for study partici- affected by COVID-19, at 53.9% (50/102). After a sample t- pants. We also found a statistical difference (p < 0.0001) test calculation of over 6000 menstrual cycles of women between menstrual cycle and menstruation length between THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 105 Table 4. Types of direct consequences for women during the pandemic. pandemic. This is similar to a recent study that found Consequence % (n ¼ 156) 45.4% of study participants reported COVID-19 related Reduced work 23.1% (36) stress [7]. Research has shown that significant lifestyle Self-employed existence is at risk 20.2% (18) Loss of job 11.5% (12) changes and social engagement have an impact on stress Moved to home office 27.0% (58) and mental health, all of which have major downstream Children at home 37.2% (28) effects on the hypothalamic–pituitary–gonadal axis [14]. Limited social contact 79.5% (124) No possibility to practice a hobby 46.8% (73) Higher stress levels cause an increase in the glucocorticoid Participants were able to select more than one answer. stress hormone which targets and lowers gonadotropin releasing hormones [15]. This in turn may impact the tim- ing of ovulation and women’s ability to identify when in Table 5. Psychosocial indicators of study participants (n ¼ 268). their cycle they are fertile or infertile. Studies have also % (n ¼ 268) found that high stress levels are associated with menstrual Reported below 5 (Never to Sometimes) cycle irregularities [1–2]. on a scale of 1–10 Felt confident about your ability to handle 13.8% (37) Additionally, our findings show that a majority of study your personal problems participants reported changes in the quality of life during Felt that things were going your way 23.9% (64) the pandemic, 65% (84/129), and of the women who were Felt that you were on top of things 23.9% (64) Reported above 5 (Sometimes to Always) affected or had family that was affected by COVID-19, 27% on a scale of 1–10 (15/55) reported that their quality of life worsened in the Been angered because of things that were 55.2% (148) last 12 months (reporting a 0–4 on a scale of 1–10). outside of your control Felt difficulties were piling up so high 23.8% (64) A strength of the study lies in the characteristics of the that you could not overcome them participants and the way of collecting the data. The data sent Found that you could not cope with all 33.6% (90) the things that you had to do by the participants to the tracker in 2019, well before the onset of the pandemic, had the goal of obtaining faithful feedback on their fertility status. The same happened in 2020 2020 and 2019 for women (n ¼ 95) who reported feeling before being asked for consent. Consequently, the users were stressed during the pandemic (0–2 on a scale of 1–5). interested in its accuracy. Thus, the results on cycle indicators are highly reliable. Moreover, the participants used to be Discussion aware of their menstrual situation and especially sensitive to any change, even subtle, of their cycle characteristics. The objective of this observational analysis was to explore Although this study was able to provide us insight into whether or not women’s menstrual cycles changed in the menstrual cycle changes during the pandemic beyond per- first six cycles of 2020 compared to the same period of the ceived changes, there were several limitations. The first preceding year. We considered menstrual cycle indicators limitation of this study is that the sample reflects the such as menstrual cycle length, pre-ovulation phase length, events in a selected group of women of high educational and menstruation length. Our findings indicate that these level which limits the results generalisability. Secondly the indicators changed only slightly in the first 6 months of sample size is not powerful enough to apply these results 2020 but were still statistically significant. The sample to the general population of fertility awareness users, thus demographics largely reflect women who would typically limiting results to specifically Daysy users or similar fertility use the Daysy device or similar fertility devices, as other device users. Thirdly, study participants were from 15 differ- studies have had similar demographics [7,13]. ent countries and data has shown that the beginning of The study was able to identify whether perceived the pandemic was different in the first 6 months for many changes in the menstrual cycle actually translated to of these countries. Therefore, the first 6 months for a user changes in the menstrual cycle. Of the 50.4% of women in Australia may be very different from the first 6 months who reported feeling a difference in their menstrual cycle of a study participant in Spain. Furthermore, the survey and/or menstruation, we found that menstruation was lon- data is self-reported and may contain recall bias since the ger in the first 6 months of 2020 than it was in 2019. From survey was administered to study participants in July 2021. this we were able to understand that these study partici- Future studies should focus on changes in the menstrual pants had some level of awareness of changes to their cycle in relation to the peaks of the pandemic for study menstrual health. participants based on their location and analyse data based Previous studies have shown that various factors like on targeted information. Analysing the degree of change stress, diet, and exercise have an impact on the menstrual in basal body temperature as well as menstrual cycle indi- cycle [1]. Beyond the fear of contracting the disease, the cators for both 2020 and 2021 may provide more insight COVID-19 pandemic brought unprecedented lifestyle into how women’s menstruations were affected over time changes for women and couples who were impacted by and throughout different pandemic peaks. national lockdowns, occupational changes, and children at home. We found that 57.4% of all women in the study reported that the pandemic had direct consequences for Acknowledgments them and their families. Women reported the biggest con- We thank Johannes Bitzer for critical proof-reading of the manuscript, sequences for them during the lockdown were limited € advice and intellectual support in this work. We thank Jonas Ohrstro€m social contact and no possibility to practice a hobby. for programming the pipeline and preparing the raw data. We thank Furthermore, 69% of study participants reported feeling Tobias Gemperli and Christoph Eck for programming the app and ‘sometimes stressed’ to ‘always stressed’ because of the implementing the survey! 106 L. HAILE ET AL. Disclosure statement [5] Phelan N, Behan LA, Owens L. The impact of the COVID-19 pandemic on women’s reproductive health. Front Endocrinol. The authors declare the following interests: This study was funded by the 2021;12:191. Valley Electronics AG, Zurich, Switzerland. Niels van de Roemer is an [6] Bruinvels G, et al. How lifestyle changes within the COVID-19 internal scientist and employee of the company. Liya Haile is an hon- global pandemic have affected the pattern and symptoms of oured scientific advisor to Valley Electronics LLC. Martin C. Koch is an the menstrual cycle. 10.1101/2021.02.01.21250919v1(2021). honoured medical advisor. All other authors have no conflict of interest. [7] Nguyen BT, Pang RD, Nelson AL, et al. 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