The potential impact of COVID-19 on women’s reproductive and mental health: a questionnaire study

Abstract The pandemic has transformed the social and economic certainties of people’s lives imposing stay-at-home necessities which began in mid-March 2020. This cross-sectional observational study was performed to study the impact of COVID-19 on the reproductive and mental health of women before and after the pandemic. A digital survey form of 50 questions was developed using the Google platform andshared over 4 weeks in August 2021. Paired t-test was used to compare the variables before and after the COVID-19. Of the 450 respondents, 443(98.44%) completed the questionnaire. There was a significant difference in the average duration of menstruation and the proportion of women with a cycle length of 35–45 days increased from 5 to 8% of women after the pandemic. Painful periods (28.5 to 59.5%, p = .002) and weight increased (39.2%, p < .001) after the pandemic. Stress also increased after the pandemic (p < .001). The pandemic has significantly impacted the reproductive and mental health of women. The long-term health significances of this are yet to be determined. Impact Statement What is already known on this subject? The pandemic has transformed the social and economic certainties of people’s lives, mainly women. Women’s health significantly mental health is affected by the lack of adequate domestic and emotional support which may further consequences like the risk of anxiety and depression. What do the results of this study add? Our study shows the effect of COVID-19 on women’s reproductive and mental health before and after the pandemic. Inadvertent forfeits women’s health and well-being and instabilities in reproductive function as raised pressure causes irregularities in the menstrual cycle. What are the implications of these findings for clinical practice and/or further research? Women have suffered from significant mental and reproductive problems during the first and second waves of the COVID-19 pandemic. But, the long-term effects of these are not unknown. Upcoming work should comprise study throughout the pandemic and the long-term impact on women’s health.


Introduction
Severe Acute Respiratory Syndrome coronavirus  or Corona Virus 2019 (COVID-19) is a pandemic of the 21st Century. The pandemic has transformed the social and economic certainties of people's lives. The closely universal imposition of stay-at-home necessities began in mid-March 2020. The several boundaries lasting after that and the extensive commitment to social distancing have led to increasing economic and social uncertainty. COVID-19 appears to reverse the growth towards accomplishing the Bearable Progress Goal, which aims to warrant healthy lives and well-being (Lindberg et al. 2020).
Several aspects are subsidised to limited contact, including interruption of transport services, the shutdown of private services, adaptation of public health amenities into COVID-19 treatment centres, change of medical professionals to COVID-19 emergency response, and contraceptive stock-outs and medical abortion medications due to disruptions in stock chains. The epidemic also saw the rise of fear psychosis, with women desisting to health amenities for the distress of being infested. The study by Roberton et al. 2020, showed that if routine health care is disturbed in cases of health system collapse or deliberate choices made in retorting to the pandemic, the surge in child and maternal deaths will be distressing.
Women are more greatly affected by the Covid-19 pandemic than men, both at the workplace (particularly in the health and community sector) and home, with an increased workload and stress due to lockdown and quarantine actions (Thibaut and van Wijngaarden-Cremers 2020). According to the UN Women Policy Brief (2020), globally, 70% of women comprise the health workforce as frontline health workers (nurses, midwives, and public health workers). Likewise, women make up the maximum health facility service staff (cleaners, laundry, catering).
Women's health (especially mental health) is affected by the lack of adequate domestic and emotional support. This may have further consequences like anxiety and depression and a high risk of post-traumatic stress disorder (PTSD) in women (Yu 2018;Jalnapurkar 2018). In a cross-sectional web survey study, the rate of psychological consequences of the pandemic was much larger than the number of patients clinically affected by the virus, with 50.4% of the entire cohort reporting symptoms of anxiety, 49.1% insomnia, and 25% reported depressive symptoms (Parra-Saavedra et al. 2020). This may have inadvertent forfeits for women's health and well-being, and instabilities in reproductive function, like irregular menstrual cycles, often accompany raised pressure.
Women's reproductive health is affected by the menstrual irregularities caused by stress. The stressors activate the hypothalamic-pituitary-gonadal (HPG) axis, and the neuromodulatory cascade can be altered, which initiates the regulation of gonadotropin-releasing hormone (GnRH) regulation (McGinty et al. 2020). Hypothalamic amenorrhoea (FHA) and chronic anovulation are the outcomes of the change in hormonal regulation cascade, which is not due to a primarily biological cause (Berga and Girton 1989;Williams et al. 2007).
Prenatal care visits were reduced during the pandemic, healthcare set-up was strained, and hypothetically harmful policies were applied with diminutive evidence in high and low/middle-income countries. The societal and monetary impact of a pandemic like COVID-19 on maternal health is noticeable. An increased occurrence of women's mental health complications, such as clinically applicable anxiety and depression, during the epidemic is stated in many countries (Smith et al. 2020;Kotlar et al. 2021).
Our study aimed to document the effect of COVID-19 on women's reproductive and mental health before and after the pandemic and survey the change in lifestyle, health conditions, menstrual cycle, diet and stressors.

Methodology
This was an anonymous cross-sectional study. The survey questionnaire was taken from the Phelan N et al. study with prior permission (Phelan et al. 2021). The Institutional Ethics committee approved the study. A digital survey form was formed using the Google platform (www. Googleforms.com). All women of the reproductive age group were requested to partake in the questionnaire study. An online survey (digital link) was done on social platforms like WhatsApp, Facebook, Twitter, and emails.
Eligible respondents were those who: (a) identified as a woman of reproductive age group, (b) were aged between 15 and 55 years, (c) were Indian citizens. Participants who matched the eligibility criteria and agreed to participate in a research study were asked to complete an online survey. Incomplete questionnaires were excluded from the study. Participants could leave any survey questions and could finish the survey at any time. The survey collected no identifying information, and, to uphold respondents' confidentiality, survey did not share respondents' IP addresses with the research team.
Purposive unknown sampling was used to guarantee a variety of respondents by race and culture, area and age. The survey applied an opt-in sample and was not intended to be fully characteristic of the national population. However, the survey sample broadly mirrors the provincial and ethnic and cultural breakdown of India.
The survey contained 50 questions on demographic information, menstrual history and mental health indications, diet, exercise, and working forms before and since the beginning of the COVID-19 pandemic. It took about 5À 7 minutes to complete the survey. The survey was spread over 4 weeks from August-2021. The study was led and stated according to the best practice guidelines for documenting crosssectional studies (von Elm et al. 2008). The survey answers were downloaded from the server and were checked for completeness. A total of 450 responses from women were collected through the digital link.

Statistical analysis
Values are represented in percentages. Mean ± Standard deviation (SD) for parametric data or median (Interquartile range) [IQR] was used for non-parametric data. Paired t-test was used to compare the variables before and after the COVID-19 pandemic. To compare non-parametric paired data, a Wilcoxon's matched pair test was used. Microsoft Office and SPSS version 16 were used for analysis. p-value <.05 was considered statistically significant.

Results
A total of 450 women responded to the digital questionnaire. Of these, 443 (98.44%) completed the questionnaire, and the remaining 7 (1.56%) were incomplete or declined to respond. The mean age and BMI of the respondents were 32.8 ± 9.3 years with a range of 17-51 years and 24.52 ± 5.8 kg/m 2 ranging between 15.77 and 40.85 kg/m2, respectively (Table  1). All the respondents were Asian Indians (98.5%) and two Indians residing in Canada (0.7%) and Russia (0.7%). Of the 51.8% (n ¼ 228) of women with children, 2.8% were breastfeeding (n ¼ 7).
A total of 44.1% (n ¼ 195) of women were working in the workplace during a pandemic, and 24.3% (n ¼ 107) were made redundant because of the pandemic (Table 1). Among the working women, 40 (35.8%) women had to work more, while 202 (45.5%) women had to look after their children. 60% (n ¼ 265) of the women were home-schooled because of the shutdown.
Most women (96.4%) were not taking/using any contraceptives (Table 2). Among 5.8% (n ¼ 26) trying to get pregnant, 7% (n ¼ 2) of women conceived. 42.1% (n ¼ 187) of women recorded their menstrual cycles, and 26.4% (n ¼ 117) of women noticed a change in the menstrual cycle throughout the pandemic. Weight change was statistically significant (p < .001), where 39.7% (n ¼ 176) of women experienced an increase in weight. Not much difference was observed in libido, PMS, and overall diet.
Among the 443 respondents, 66 (15%) women tested COVID-19 positive, and 40 (9%) women had symptoms but did not get tested (Figure 1). Average menstrual days were significant (p < .001), where the average menstruation days of 35-45 days increased from 5 to 8%, and >45 days increased from 5.2 to 7.6% for women after the pandemic. The maximum menstrual length range increased from 30(28-35) days to 31(28-37) days, but no significant difference was observed. Painful periods increased (28.5% to 59.5%, p ¼ .002) after the pandemic (Table 3). Not much difference was observed in average bleeding days, heavy periods, and missed periods before and after the pandemic.
Among the health indications, women felt lower after the COVID-19 pandemic than before the pandemic (3.9% vs. 7.9%). The paired t-test showed a statistically significant difference, p ¼ .045 (Figure 2). Stress also increased after the pandemic and was statistically significant (6.6% vs. 15.3%, p < .001). There was no significant difference, but an increased percentage of health indicators like increased appetite, lack of sleep, anxiety, binge eating, loneliness, and decreased concentration was observed in women after the pandemic. The percentage of women with a history of PCOS,  'Confinement caused lots of digital dependence leading to less communication between family members, sometimes leading to a strong difference of opinion.' 'Children are suffering as they can't go to school or college.' 'Lost close relatives due to pandemic. Parents recovered from covid. Post covid problems like osteoarthritis in mother.' 'Covid has a high impact on my family income as a business remains shut for a very long period and hence there was no income during a pandemic.' 'Loss of 2 immediate family member due to covid has caused stress in recent � 4 months period.' 'I started working again after my maternity break so my stress has increased so my workout sessions have substantially decreased.'

Discussion
In this unidentified observational questionnaire study, many women have demonstrated difficulties and health disturbances during the SARS-CoV-2 pandemic. These health disturbances are mainly due to lifestyle, work habits, and diet changes. Reproductive function is indicated by the menstrual cycle, in which pressure, restlessness, and depression are the vulnerable factors for process disruptions (Willis et al. 2019;Jang and Elfenbein 2019). We observed a change in the menstrual cycle length with an increased 35-45 days (5.6% vs. 7.6%) and missed periods from 5% to 6%, which can induce stress during the COVID-19 pandemic. Mood disorders like anxiety and depression or women facing stressors are often reported in menstrual cycle differences like amenorrhoea and menstrual changes and PMS in women (Kim et al. 2018;Nillni et al. 2018).
The interconnected nature of the hypothalamic-pituitarygonadal (HPG) and hypothalamic-adrenal axes modulate the stress impacts in the reproductive system of females (Valsamakis et al. 2019). Specified the effects of stress on the HPG axis, outlines and indications of the menstrual cycle are altered by the high levels of anxiety experienced throughout the pandemic, like COVID-19. This would be equivalent to  variations in menstrual cycles that women felt after critical life stressors such as conflict, natural calamities, dislodgment, deprivation, and defection (Kim et al. 2017;Reese Masterson et al. 2014). This study finds that stressors connected to the COVID-19 pandemic may also be a causative factor in menstrual cycle variations. Dysmenorrhoea is associated with the bidirectional association with emotional disorders like anxiety, depression, binge eating, and stress. In a few cases, having these psychological disorders aggravates menstrual pain sternness (Patel et al. 2006). We observed a significant increase in the percentage of women with painful periods (dysmenorrhoea) before and after the pandemic, consistent with other studies (Morales-Carmona et al. 2008;Ibrahim et al. 2015;Abu Helwa et al. 2018).
A systematic review of Latthe et al. reviewed the risk factors associated with chronic pelvic pain, including dysmenorrhoea, dyspareunia, and non-cyclical pelvic pain. Psychological disorders like depression, anxiety, psychoneurosis, and somatic symptom disorder were found more in women in pelvic pain than controls (Latthe et al. 2006). Latthe et al. (2006) also found that females with dysmenorrhoea had a 2.77 times more chance of facing anxiety (95%CI 0.67-11.49) and 2.59 times more chances of getting depression .
No changes in the minimum length of the menstrual cycle were reported, but a change in maximum size with a shortening of average menstrual days and an increase in average menstrual days. Among 26 women who were trying to conceive, only two women conceived. Changes in the menstrual cycles and stress might be the reasons as they are less expected to be ovulatory and more expected to be unprompted abortion (Small et al. 2006).
Approximately 39.7% of the women increased weight in our study. There were increased stress levels during the first wave of the COVID-19 pandemic, and pressure is related to increased cortisol levels. Increased cortisol levels have increased hyper-palatable food intake, high in salt, fat, or both. There is also evidence that our bodies absorb food more slowly under stress. These associations will put women at high risk of type 2 diabetes mellitus and cardiovascular risks (Frates 2021). Around 12.2% of women decrease their weight. This might be because of stress or no hungry or purposeful skipping off in the hoarseness of putting weight. In addition, few people took isolation time as a chance to work out and emphasise their fitness, diet, and sleep. These people are expected to lose weight. It is also likely that people made time for workouts without work travel and cooking healthier mealtimes at home.
There were increased health indications before and after the COVID-19 pandemic. Among different health indications significant difference was observed between feeling low (p ¼ .045) and stress (p < .001). Those who felt low had increased loneliness, anxiety, and stress are more prone to changes in the menstrual cycle. Also, changes in sex hormones increase changes in the sleep cycle (Shechter and Boivin 2010). Sleep deprivation may affect fertility in women, as it is found more pervasive among infertile and reduced ovarian reserve females (Pal et al. 2008).
Among the difficulties faced by the respondents during the COVID-19 pandemic involves stress or change in the job as a significant difficulty (14.7%), followed by financial problems and change in lifestyle (10.3%) and homeschooling challenges (10.3%). These difficulties might have impacted the reproductive and health conditions of the women during the pandemic. These depict how women felt personally but not quantitatively using questionnaires. Our study's key objective was women's reproductive and mental health. Women have suffered from significant mental and reproductive problems during the first and second waves of the COVID-19 pandemic. But, the long-term effects of these are not unknown. Future work assessing changes in hormones, mental health, and ovarian function with a validated questionnaire and biochemical assessment will give a better overview of the impact of a pandemic like COVID-19.
Moreover, our understanding of what might be likely is mainly grounded on experiences in developing countries; the effects of the pandemic and the reply to it will be different. The results cannot be generalised because women of only one nationality were included and that the possible impact of COVID-19 can be modified in the long term. Long-term studies with a bigger sample size may reduce the bias, which is the limitation of this study.

Conclusions
By exposing a tendency for increased menstrual cycle irregularities e before and after the Covid-19 pandemic, this study subsidises our understanding of the pandemic's consequences on women's reproductive health. Although it is clear from this survey that women have agonised considerable disturbance in reproductive health because of the pandemic, the mediumand long-term influences of this are, as yet, unidentified. The expected long-term health consequences include contingent on the pandemic duration and qualms such as the impact on the economy and the delivery of and access to COVID-19 vaccines. Upcoming work should comprise continual multi-modal valuation at different intervals throughout the pandemic and ongoing authenticated mental health assessment and evaluation of body mass index, anthropometric measurements, hormone levels, ovulation, and ovary function.