Abnormal uterine bleeding during the COVID-19 pandemic: a national survey (preprint)

Objective: To evaluate and characterize menstrual changes among COVID-19 vaccinated and infected women. Design A national survey. Setting An online nationwide questionnaire survey, querying about menstrual changes after COVID-19 vaccination or infection. Population Reproductive-age non-pregnant women. Methods The questionnaire was distributed via an online link through social media and directed the participants to an online anonymous Google questionnaire. Results In total, 10,319 women responded, of which 7,904 met the inclusion criteria. Changes in menstrual patterns following the BNT162b2 vaccine were reported by 3,689 (46.7%). Of these, 2,974 women, (80.6%) described excessive bleeding (heavy, prolonged, or intermenstrual) compared with 715 (19.4%) who reported scant bleeding (light, short, or prolonged intervals). Among women who experienced abnormal uterine bleeding (AUB), in most cases (61.1%) it occurred between the vaccination and the ensuing menstrual period. Menstrual disturbances were more common among accurately vaccinated women compared with inaccurately vaccinated by having received a single shot or having undergone a prolonged interval between shots (51% vs 36.6%, P < .001). Menstrual disturbances were similar in type and distribution among the vaccinated and infected women. Conclusions AUB emerged as a side effect of the BNT162b2 vaccine and a symptom of the COVID-19 infection. It was characterized mainly by excessive bleeding. Although the precise incidence could not be determined in this study, the type of bleeding disturbance, as well as the characterization of women at risk, were well defined. The incidence and the long-term consequences of the BNT162b2 vaccine on uterine bleeding warrant further investigation.

COVID-19 infection and women's health; which women are more vulnerable in terms of gynecological health? (preprint)

Background Given gender-specific differences and ACE2 commonly expressed in the ovaries and uterus, it may be important to know which women are at greater risk of COVID-19 infection. Therefore, this study sought to determine which women are more affected by COVID- 19 infection, especially in terms of gynecological pathologies.Methods This retrospective and descriptive study examined the effect and course of COVID-19 in terms of gynecological pathologies in a total of 380 women of reproductive age without systemic disease. General demographics, obstetric and gynecological conditions, and parameters related to COVID-19 were evaluated. All parameters were compared for three groups defined on the basis of COVID-19 severity (mild, moderate, and severe).Results A total of 380 women with a mean age of 35.39 ± 8.94 were included in the study. The mean body mass index (BMI) of the women was 24.35 ± 4.53. The proportion of women with at least one pregnancy history was 69.2%. The mean gravidity of the women was 1.47 ± 1.34 and the parity was 1.16 ± 1.02. Of the women, 112 (29.5%) mild, 207 (54.5%) moderate and 61 (16.0%) severe cases of COVID-19 were seen. The mean age and median BMI of the women were similar in all three groups (p = 0.163, p = 0.127, respectively). Severe disease rates (29.5%) were significantly higher in women with 2 or more cases of COVID-19 than mild disease (14%) (p = 0.018). Severe disease rates (57.4%) in women with at least one pregnancy history were statistically significantly lower than mild disease rates (78.6%) (p = 0.010). The median parity number was significantly higher in the mild disease group than in the moderate disease group (p = 0.021). The most common benign gynecological pathology in women was chronic urinary tract infection (13.2%). Other common pathologies were chronic vaginal infection (12.6%), and polycystic ovary syndrome (PCOS) (11.6%). A history of chronic urinary tract infection was statistically significantly higher in the severe disease group (24.6%), mild (8.9%, p = 0.015) and moderate (12.1%, p = 0.024) disease groups. PCOS, endometriosis (6.3%), abnormal uterine bleeding (AUB) (8.4%), and hormone therapy history (8.2%) were found to be higher in severe disease groups, although not statistically significant (p = 0.596, p = 0.074, p = 0.305, p = 0.059, respectively). The history of leiomyoma (7.1%) was higher in the mild and moderate disease groups than in the severe disease group, but it was not statistically significant (p = 0.794). Benign gynecological operation history (31.3%) was significantly higher in mild (36.6%, p = 0.007), and moderate (33.3%, p = 0.007) disease groups than in the severe group (9, 14.8%).Conclusion Certain obstetric and gynecological conditions are thought to affect COVID 19 susceptibility and severity in women without systemic disease.

COVID-19 Disease and Menstrual-Related Disturbances: A Spanish Retrospective Observational Study in Formerly Menstruating Women (preprint)

After three years of the onset of the pandemic, there is scarce evidence about how COVID-19 disease affect the female reproductive system, and consequently, the menstrual cycle. Since the common causes of secondary amenorrhea are considered as exclusion criteria in the studies about menstrual changes following SARS-CoV-2 infection, the prevalence of this event and the influencing factors in formerly menstruating women remains unknown. A retrospective observational cross-sectional study was conducted on Spanish adult women (N= 17,512), using an online survey; a subpopulation of SARS-CoV-2-infected-formerly menstruating women was included in the present analysis (n= 72). Collected data included general characteristics, medical history, and specific information about COVID-19 disease. 38.9% of the respondents experienced menstrual-related disturbances after suffering from the COVID-19 disease, unexpected vaginal bleeding being the most common (20.8%). Other alterations related with the length – “shorter” by 12.5% − and the flow − “heavier than usual” 30.3% − of the menstrual bleeding were reported. The binary logistic regression showed that being a perimenopausal woman (AOR 4.608, CI 95%, 1.018 – 20.856, p = 0.047) and having heavy menstrual bleeding (AOR 4.857, CI 95%, 1.239 – 19.031, p=0.023) are influential factors. This evidence could help health professionals to provide scientifically up-to-date information to their patients, empowering them to actively manage their reproductive health, especially in those societies where menstrual health is still a taboo.

Relationship between covid-pandemic anxiety and sleep disorder with menstrual disorders among female medical workers.

BACKGROUND: It has been more than 2 years since the 2019 novel coronavirus disease (COVID-19) pandemic destabilized the world, adversely affecting not only physical health, but also mental health. During this time, frontline medical workers were at a greater health risk, especially female medical workers. Changes or abnormalities in the menstrual cycle-an important indicator of women's health-may jeopardize female reproductive functioning. Considering that emotional health and sleep status may be related to the menstrual cycle, this study aimed to investigate the association between menstrual cycle changes, anxiety, sleep dysfunction, and other factors among female medical workers during the COVID-19 pandemic. METHODS: A cross-sectional survey was conducted by distributing online questionnaires to female medical workers in China from February to May 2022. The study included 160 women aged 18-45 years old. The questionnaires covered data related to the participants' sociodemographic characteristics, medical and reproductive history, and lifestyle. The Rating Scale for Clinical Manifestations of Menopathy (SCMM), Self-Rating Anxiety Scale (SAS), and Sleep Dysfunction Rating Scale (SDRS) were utilized. Data were analyzed using chi-square tests, t-tests, and linear regression analysis. RESULTS: A total of 160 female medical staff were randomly selected in this research, of whom seven scored less than 3 points, 85 scored 3-11 points, and 68 scored more than 11 points on the total score of the SCMM. Compared to pre-pandemic scores, scores of dizziness and tinnitus were significantly higher during the COVID-19 pandemic. Scores corresponding to the following clinical symptoms were also higher during the pandemic: Menopathy, including hypaphrodisia, dim complexion, abnormal urination, languidness, dim menstruation, thin menstruation, dysmenorrhea, and empty or saggy lower abdomen (p < 0.05). However, pre-pandemic scores of vaginal bleeding quantity were significantly higher than those found during the COVID-19 pandemic (p < 0.05). Scores of vaginal bleeding quantity were significantly lower in cabin hospitals than other types of hospitals, and a similar finding was observed for vaginal bleeding duration (all p < 0.05). Moreover, the findings of the univariable and multivariable linear regression analysis revealed a link between consistent exercise, the underlying illness, the SDRS score, the SAS score, and the total score of SCMM (p < 0.05). CONCLUSIONS: In this study, we found that menstruation in female medical workers was affected by the COVID-19 pandemic. Furthermore, regular exercise and good physical condition were protective factors, while anxiety and insomnia were risk factors for menstrual abnormalities.

Non-oncological gynecological diagnoses in a women's health care service during the pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2.

OBJECTIVE: Analyze clinical factors and non-oncological gynecological diagnoses before and during the initial months of the COVID-19 pandemic. METHOD: Crosssectional study at an Outpatient Gynecology Clinic in Brazil involving medical consultations performed during the pre-pandemic and pandemic periods. The number of visits, prevalence of non-oncological gynecological diagnoses, and clinical-demographic data were analyzed. Parametric continuous variables were evaluated by Student's t-test and ANOVA tests, non-parametric variables were evaluated by the Mann-Whitney and Wilcoxon tests, and categorical or binary variables were evaluated by chi-square and Fisher's exact tests. Univariate logistic regression tests were performed, and variables with p ≤ 0.20 were subjected to multivariate logistic regression. Statistical significance was set at p < 0.05. RESULTS: There were 1,236 records during the pre-pandemic period and 530 during the pandemic, reflecting a significant reduction (57.88%; p = 0.001) in medical consultations. The outpatient prevalence of women older than 50 y (OR 0.85; 95%CI 0.68-1.05) reduced, and the outpatient prevalence of postmenopausal women with hot flashes (OR 1.34; 95%CI 1.09-1.65; p = 0.005) and alcohol consumption habits (OR 2.76; 95%CI 1.15-6.59; p = 0.023) increased. There was a 6% proportional increase in noninflammatory disorders of the female genital tract (p = 0.030) and a 72.4% decrease in general physical examinations, contraception, and procreation (p = 0.001). Multivariate analysis showed that there was an increased prevalence of abnormal uterine bleeding (OR, 1.7; 95% CI 1.34-2.16; p = 0.001) and endometriosis (OR 1.65; 95% CI 1.13-2.42; p = 0.01). CONCLUSION: Medical consultations for benign gynecological diseases during the pandemic prevented non-inflammatory disorders of the female genital tract, with an emphasis on abnormal uterine bleeding and endometriosis. There was an increased prevalence of women under 50 years of age, women with symptoms of hot flashes, and alcohol consumption habits and a reduction in the prevalence of general physical examinations, contraception, and procreation.

The Effect of COVID-19 on the Menstrual Cycle of Female Medical Staff: A Cross-sectional Survey in China (preprint)

Objective Coronavirus disease 2019 (COVID-19) can affect women 's health. This study aimed to investigate the association between Menopathy, COVID-19 pandemic-related anxiety, sleep dysfunction and other factors among female medical staff.Methods A cross-sectional study was conducted via administrating online questionnaires to female medical staff in China from February to May 2022. The study includes 160 women aged between 18–45 years old. The questionnaires contain sociodemographic characteristics, medical and reproductive history, lifestyle information of participants, Rating Scale for Clinical Manifestation of Menopathy (SCMM), Self-Rating Anxiety Scale (SAS), and Sleep Dysfunction Rating Scale (SDRS). Data were analyzed using chi-square, t-tests, and linear regression analysis.Results A total of 160 female medical staff were randomly selected in this research, 7 of whom scored less than 3 points, 85 of whom scored more than 2 points and less than 12 points, and 68 of whom scored more than 11 points on the total score of SCMM. The score of dizziness and tinnitus was significantly higher during than before the COVID-19 pandemic, and scores of its following clinical symptoms of Menopathy: hypaphrodisia, dim complexion, abnormal urination, languidness, dim menstruation, thin menstruation, dysmenorrhea, and empty or saggy lower abdomen (p < 0.05). However, the score of vaginal bleeding quantity was significantly higher before than during the COVID-19 pandemic (p < 0.05). The score of vaginal bleeding quantity of the female medical staff was significantly lower in the cabin hospitals than others, and the same is true for vaginal bleeding duration (all p < 0.05). Besides, the findings of the univariable and multivariable linear regression analysis revealed a link between consistent exercise, the underlying illness, the SDRS score, the SAS score, and the total score of SCMM (p < 0.05).Conclusions In this study, we found that menstruation in female health staff was affected by the COVID-19 epidemic, where regular exercise and good physical condition were protective factors, while anxiety and insomnia were risk factors for regular menstruation.

Incidence and impact of anticoagulation-associated abnormal menstrual bleeding in women after venous thromboembolism.

Preliminary data and clinical experience have suggested an increased risk of abnormal uterine bleeding (AUB) in women of reproductive age treated with anticoagulants, but solid data are lacking. The TEAM-VTE study was an international multicenter prospective cohort study in women aged 18 to 50 years diagnosed with acute venous thromboembolism (VTE). Menstrual blood loss was measured by pictorial blood loss assessment charts at baseline for the last menstrual cycle before VTE diagnosis and prospectively for each cycle during 3 to 6 months of follow-up. AUB was defined as an increased score on the pictorial blood loss assessment chart (>100 or >150) or self-reported AUB. AUB-related quality of life (QoL) was assessed at baseline and the end of follow-up using the Menstrual Bleeding Questionnaire. The study was terminated early because of slow recruitment attributable to the COVID-19 pandemic. Of the 98 women, 65 (66%) met at least one of the 3 definitions of AUB during follow-up (95% confidence interval [CI], 57%-75%). AUB occurred in 60% of women (36 of 60) without AUB before VTE diagnosis (new-onset AUB; 95% CI, 47%-71%). Overall, QoL decreased over time, with a mean Menstrual Bleeding Questionnaire score increase of 5.1 points (95% CI, 2.2-7.9), but this decrease in QoL was observed only among women with new-onset AUB. To conclude, 2 of every 3 women who start anticoagulation for acute VTE experience AUB, with a considerable negative impact on QoL. These findings should be a call to action to increase awareness and provide evidence-based strategies to prevent and treat AUB in this setting. This was an academic study registered at www.clinicaltrials.gov as #NCT04748393; no funding was received.

Menstrual irregularities and vaginal bleeding after COVID-19 vaccination reported to v-safe active surveillance, USA in December, 2020-January, 2022: an observational cohort study.

BACKGROUND: Anecdotal reports of menstrual irregularities after receiving COVID-19 vaccines have been observed in post-authorisation and post-licensure monitoring. We aimed to identify and classify reports of menstrual irregularities and vaginal bleeding after COVID-19 vaccination submitted to a voluntary active surveillance system. METHODS: This observational cohort study included recipients of a COVID-19 vaccine who were aged 18 years and older and reported their health experiences to v-safe, a voluntary smartphone-based active surveillance system for monitoring COVID-19 vaccine safety in the USA, from Dec 14, 2020, to Jan 9, 2022. Responses to survey questions on reactions after vaccination were extracted, and a pre-trained natural language inference model was used to identify and classify free-text comments related to menstruation and vaginal bleeding in response to an open-ended prompt about any symptoms at intervals after vaccination. Related responses were further categorised into themes of timing, severity, perimenopausal and postmenopausal bleeding, resumption of menses, and other responses. We examined associations between symptom theme and respondent characteristics, including vaccine type and dose number received, solicited local and systemic reactions reported, and health care sought. FINDINGS: 63 815 respondents reported on menstrual irregularities or vaginal bleeding, which included 62 679 female respondents (1·0% of 5 975 363 female respondents aged ≥18 years). Common themes identified included timing of menstruation (70 981 [83·6%] responses) and severity of menstrual symptoms (56 890 [67·0%] responses). Other themes included menopausal bleeding (3439 [4·0%] responses) and resumption of menses (2378 [2·8%] responses). Respondents submitting reports related to menopausal bleeding were more likely to seek health care than were those submitting reports related to other menstruation and vaginal bleeding themes. INTERPRETATION: Reports of heterogeneous symptoms related to menstruation or vaginal bleeding after COVID-19 vaccination are being submitted to v-safe, although this study is unable to characterise the relationship of these symptoms to COVID-19 vaccination. Methods that leverage pretrained models to interpret and classify unsolicited signs and symptoms in free-text reports offer promise in the initial evaluation of unexpected adverse events potentially associated with use of newly authorised or licensed vaccines. FUNDING: Centers for Disease Control and Prevention.

DEveloping Tests for Endometrial Cancer deTection (DETECT): protocol for a diagnostic accuracy study of urine and vaginal samples for the detection of endometrial cancer by cytology in women with postmenopausal bleeding.

INTRODUCTION: Postmenopausal bleeding (PMB), the red flag symptom for endometrial cancer, triggers urgent investigation by transvaginal ultrasound scan, hysteroscopy and/or endometrial biopsy. These investigations are costly, invasive and often painful or distressing for women. In a pilot study, we found that voided urine and non-invasive vaginal samples from women with endometrial cancer contain malignant cells that can be identified by cytology. The aim of the DEveloping Tests for Endometrial Cancer deTection (DETECT) Study is to determine the diagnostic test accuracy of urine and vaginal cytology for endometrial cancer detection in women with PMB. METHODS AND ANALYSIS: This is a multicentre diagnostic accuracy study of women referred to secondary care with PMB. Eligible women will be asked to provide a self-collected voided urine sample and a vaginal sample collected with a Delphi screener before routine clinical procedures. Pairs of specialist cytologists, blinded to participant cancer status, will assess and classify samples independently, with differences settled by consensus review or involving a third cytologist. Results will be compared with clinical outcomes from standard diagnostic tests. A sample size of 2000 women will have 80% power to establish a sensitivity of vaginal samples for endometrial cancer detection by cytology of ≥85%±7%, assuming 5% endometrial cancer prevalence. The primary objective is to determine the diagnostic accuracy of urogenital samples for endometrial cancer detection by cytology. Secondary objectives include the acceptability of urine and vaginal sampling to women. ETHICS AND DISSEMINATION: This study has been approved by the North West-Greater Manchester West Research Ethics Committee (16/NW/0660) and the Health Research Authority. Results will be disseminated through publication in peer-reviewed scientific journals, presentation at conferences and via charity websites. TRIAL REGISTRATION NUMBER: ISRCTN58863784.

Taking Call.

Telehealth proves to be more than just a stopgap in providing support to patients.

Loss of Reproductive Ability due to Late Application of Young Refugee with Choriocarcinoma During the COVID-19 Pandemic.

Choriocarcinoma is an aggressive malignant trophoblastic neoplasm. The rapid growth of neoplastic tissue and myometrial invasion can cause uterine perforation. It is important to quickly diagnose the disease and plan treatment because these tumors are nearly always curable, and fertility can be preserved in most cases with proper management. The outbreak of novel coronavirus disease has affected the whole world since January 2019 and caused delays in treatment and follow-up of patients all over the world. In this study, we report a case of choriocarcinoma who postponed her admission to the hospital after diagnosis because she was afraid of the pandemic and lost her fertility due to uterine rupture and massive intra-abdominal hemorrhage.

Experiences in Electronic Consultation (eConsult) Service in Gynecology from a Quaternary Academic Medical Center.

To evaluate an academic institution's implementation of a gynecologic electronic consultation (eConsult) service, including the most common queries, turnaround time, need for conversion to in-person visits, and to demonstrate how eConsults can improve access and convenience for patients and providers. This is a descriptive and retrospective electronic chart review. We obtained data from the UCSF eConsult and Smart Referral program manager. The medical system provided institution-wide statistics. Three authors reviewed and categorized gynecologic eConsults for the last fiscal year. The senior author resolved conflicts in coding. The eConsult program manager provided billing information and provider reimbursement. A total of 548 eConsults were submitted to the gynecology service between July 2017 and June 2020 (4.5% of institutional eConsult volume). Ninety-five percent of the eConsults were completed by a senior specialist within our department. Abnormal pap smear management, abnormal uterine bleeding, and contraception questions were the most common queries. Over half (59.3%) of all inquiries were answered on the same day as they were received, with an average of 9% declined. Gynecology was the 10th largest eConsult provider at our institution in 2020. The present investigation describes one large university-based experience with eConsults in gynecology. Results demonstrate that eConsults permit appropriate, efficient triaging of time-sensitive conditions affecting patients especially in the time of the COVID-19 pandemic. eConsult services provide the potential to improve access, interdisciplinary communication, and patient and provider satisfaction.

Increase rate of ruptured tubal ectopic pregnancy during the COVID-19 pandemic.

OBJECTIVE: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). STUDY DESIGN: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019. RESULTS: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction. CONCLUSION: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic.