Department Of Pharmacy, Sri Venkateswara College of Pharmacy, Etcherla, Srikakulam, Andhra Pradesh, India -532410.
The purpose of this systematic review is to understand correlations between psychological stress and disturbed menstrual cycles in adult women. Irregularities in the menstrual cycle- a condition that affects between 5% and 35.6% of women worldwide- result from influences including age, lifestyle, and psychological status. Stress, for example, disrupts the HPO axis leading to hormonal imbalances, anovulation, and infertility. Other contributory adverse health conditions include unhealthy diets, sleep disorders, sedentary lifestyles, severe physical exercise, and diseases like polycystic ovary syndrome (PCOS), diabetes, and thyroid diseases. Additional agents include medications as well as environmentally-induced toxins. These have been found to point at the importance of considering not just physical factors but psychological also in the management of irregularities within menstruation. Stress reduction, lifestyle changes, and early interventions would be recommended toward restoring reproductive and total wellbeing.
Most of the problems associated with menstruation are largely neglected by primary health care and treated as a minor health concern by the majority of developing countries, India being one of them [1]. Identifying the factors associated with abnormal menstrual patterns in adolescence could help in their early prevention, which, in turn, could really benefit the reproductive health of adolescents and improve their overall quality of life [2]. There have been increases in the studies that show quite a lot about the association of mental health problems such as stress, anxiety, guilt, all leading to loneliness, life dissatisfaction, suicidal thoughts, and substance use in adolescent girls in relation to their menstrual cycle dysfunction [3][4][5]. Greater psychosocial stress among medical students translates into greater instances of menstrual irregularities that showed that increased stress was strongly associated with dysmenorrhea and severe enough premenstrual symptoms to require medication [6]. In this regard, increased mental health problems in early adolescent girls could cause neuroendocrine disruption and chronic activation of the HPA axis during puberty which may lead to multiple types of menstrual irregularities [7]. Previous studies have investigated multiple risk factors associated with menstrual irregularity, such as age at menarche, moderate or vigorous exercise, and obesity. Moreover, other physical risk factors include work-related and psychosocial stress and mental illness as manifested associations between them and factors contributing to the event of these changes. Lifestyle variables like poor diet, lack of exercise, sleep disturbances, substance abuse, travel, and shift work may also cause irregularities in the menstrual cycle. It should also be noted that genetic factors, including hormone regulation genes, reproductive hormone receptor genes, and genes related to polycystic ovary syndrome, and epigenetic factors, interact with environmental and lifestyle factors contributing to the entire process of such irregularities. Some of the medications are also the fore most causative factors for menstrual irregularities.
Prevalence And Consequences On Menstrual Cycle Irregularity:
According to the current literature, the prevalence rates of irregular menstrual cycles range from 5% to 35.6%, depending on the age, nationality, and occupational status of the woman in question [8]. This prevalence has a very extensive range from country to country: 29.7% in Saudi Arabia [9], 35.7% in India [10], 33.3% in Egypt [11] ,64.2% in Nepal [12]. 14.3% in Korea [13], and 5-15% in developing countries [14]. A study in Oman found that dysmenorrhea is a very common [94%] but under-treated menstrual disorder among Omani teenage school girls, with only 3% seeking treatment for their severe pains [14]. In dubai,94.7% of adolescents reported dysmenorrhea as a significant issue [15]. In a Saudi study, the prevalence of menstrual irregularities during exams was reported to be 48.2% among students of female medical institutions with dysmenorrhea being the most common (70.9%), lengthened cycles (45.6%), and heavy bleeding (41.9%) [16].
Consequences:
Irregular menstruation has wayouth to affect health in other aspects of life and is often considered a marker for women's health itself. Different illness and diseases have also been attributed to it; some of which include metabolic syndrome, coronary heart disease, type 2 diabetes mellitus (DM), and rheumatoid arthritis (RA). Irregular menstruation has much association to pregnancy-related hypertensive disorders, asits strong association as risk for such ends have been demonstrated. Moreover, by this cause, abnormal menstruation before a conception may also predispose the female to adverse effects related to obstetric and neonatal outcomes. These health issues could also impact the availability of work opportunities. [17].
The Purpose And Scope Of The Review:
The aim of this review article is to demonstrate the association between adulthood and psychological stress on menstrual cycle irregularity.
During the period of emerging adulthood, great transitions in social roles and crisis levels are usually experienced, and thus their impact on health later in life may be considered. Stress is one of the most important psychological phenomena as regards its end results in mental and physical health. Psychologically it defines the outcome relations between an individual and an environment that the subject appraises as threatening or exceeding resource capabilities and thereby endangering his or her wellbeing. Prevalence during emerging adulthood young women and men have faced simultaneous challenges: many stressors and demands associated with changes in relationships, work, education, and residence. [18]. Stress is now emerging as an important factor in menstrual cycle irregularities in adulthood. Numerous research studies have suggested the association between psychological stress and adulthood leading to the possible menstrual cycle irregularity. Some of the hormonal changes that occur are probably due to stress-induced disruption of the hypothalamic-pituitary-gonadal (HPG) axes whose activity gets impaired through the hypothalamic-pituitary-adrenal (HPA) axis.
As discussed, adulthood is the major cause for menstrual irregularities, mainly due to: Age Related Factors:
Factors Contributing To Menstrual Cycle Irregularities In Adulthood:
Definition Of Stress: Stress is a complex and multifaced physiological and psychological response to internal or external stimuli that disrupts homeostasis and challenges an individual’s ability to cope.
Types Of Stress:
Types of stress depend on the duration, source, or response:
Acute stress: Short-term stress, usually caused by a direct stressor or problem situation. The body goes into fight-or- flight mode, changing temporarily, including increased heart rate due to adrenaline release.
Chronic stress: Present when the stress is for a protracted period. Prolonged exposure to chronic stress cumulatively could bring about physiological and psychological consequences, thus increasing susceptibility to health problems like cardiovascular disease, anxiety, and depression.
Episodic acute stress: The individual seems to go through multiple episodes of acute stress. Such a behavior could lead to defining a person as being disorganized or unorganized and under constant sense of deadline, obligation, or conflict. This cycle perpetuates health problems and deterioration of normal life functioning.
Traumatic Stress: This comes from accident-trauma events. Natural disasters, accidents, or violence are some examples of events that can create trauma so great that a person's capacity to withstand it cannot process everything that occurs. This leads to symptoms of posttraumatic stress disorder (PTSD) such as having intrusive memories, avoidance behavior, and hyperarousal.
Stress arising from the environment: These types of stressors could emanate from adverse or stressful external conditions such as noise, pollution, overcrowding, and insecure living conditions. Such stressors may damage the mental and physical health of the people and lead to discomfort or uneasiness.
Psychological Stress: This type outcome from cognitive or emotional impact such as perceived threats, worries, or negative thoughts. Typical stressors include those found in work pressures, academic expectations, social comparisons, or self-imposing demands. Symptoms may present themselves in anxiety, rumination, or perfectionism.
Physiological stress: Physiological stress may be defined as that response of the body by way of disorganization of the normally established homeostasis condition as a consequence of internal or external stressors. Diseases, injuries, lack of sleep, or lack of nutrition may trigger physiological stress pathways and jeopardize health and well-being [19].
Mechanism Of Stress Effect On Menstrual Cycle Irregularity:
Physiological stress, because it affects the hypothalamic-pituitary-ovarian axis, disrupts the menstrual cycle. The HPG axis regulates a complex array of behaviors and physiology in conjunction with the successful reproduction, both in terms of sexual functioning and fertility, as well as hormones. Within the HPG axis, activity is triggered by the hypothalamic secretion of the gonadotropin-releasing hormone (GnRH) and with downstream effects on two gonadotropins, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), both produced in the anterior pituitary gland. In females, FSH promotes the growth and maturation of ovarian follicles while LH induces ovulation and stimulates the synthesis and release of steroid sex hormones from gonads/ovaries, that is, estradiol (E2) and progesterone. The sex hormones produced by the ovaries feedback to the hypothalamus and pituitary through action on kisspeptin affecting production of GnRH, FSH, and LH. This feedback system, inhibitory-stimulatory types of combined relationships between hormones, closely regulates and keeps balanced hormone levels for optimal reproductive functioning and cyclical release of hormones [20]. Stress can unbalance the equilibrium of the reproductive axis due to inhibition of gonadotropin-releasing hormone secretion from the hypothalamus, which, in turn, reduces luteinizing hormone and follicle-stimulating hormone release from the pituitary gland. All of this results in disrupted ovarian functioning in women. stress may bring about menstrual irregularities, anovulation, and infertility among female patients, along with loss of sexual interest. Hormonal changes due to stress and disruption in reproductive functions can also lead to other conditions like polycystic ovary syndrome.
Eating Disorder: The most common eating disorders which can be seen among women in their puberty and early adult life are also the causative factors for menstruation disorders like amenorrhea or irregular menses. Anorexia nervosa is characterized by girls with very low body weight who mostly eat very little and bulimia nervosa is a compensatory behavior that is seen in women having a normal weight and binge eats but purges later on. Rapid loss of body weight, low body weight, overweight and eating behaviors of the individual and subsequent problems associated with deficiency of nutrients intake or lifestyle can be enumerated in terms of menstrual disorder [22].
Notably, about 20% of adolescents experience depressive symptoms and female adolescents are more likely to experience depressive symptoms than are male adolescents [27]. The result of strong depression is observed due to early perimenopause and menopause. The strongest association was obtained among women attaining menopause naturally before the age of 40 years. Promotional CRH levels during depression cause inhibition of the hypothalamic- pituitary-gonadal (HPG) axis and increased cortisol levels, which further inhibit the action of gonadotropin-releasing hormone (GnRH) neurons, gonadotropins, and gonads leading to changes in luteinizing hormone (LH) amplitude and follicle-stimulating hormone (FSH) level along with LH pulse frequency noted in patients with depression [28].
Figure: 1 Depression Affecting Reproductive Hormones
Anxiety typically arises in response to stressful events and can affect an individual’s quality of life [29]. An increase of 1 unit in the anxiety score increased the risk of menstrual irregularities by 1.081 times [30]. Anxiety causes systemic changes in the body, especially in the nervous system. Anxiety triggers the release of the hormone cortisol where the hormone cortisol suppresses the hypothalamus and interferes with the work and function of the hypothalamus, one of which is to secrete the menstrual hormones follicle stimulating hormone (FSH) and luteinizing hormone (LH). Changes in prolactin or endogenous opiates occur which affect the basal cortisol elevation is a disturbance in the hormones LH and FSH, it will affect the production of estrogen and progesterone so that it will cause menstrual cycle irregularities [31].
The hormonal changes and results of menstrual disturbances that were observed in various endocrine disorders.
Table: 1 Disease Conditions Alters The Menstrual Cycle Irregularity
|
Type Of Disorders/Ref |
Possible Mechanism |
Type Of Menstrual Cycle Distrubances |
|
1.PCOS [32][33] |
Increased LH and androgen secretion, prolonged exposure to estrogen |
Long and irregular menstrual cycles secondary amenorrhea and oligomenorrhea |
|
2.DIABETES [34][35] |
Increased LH and FH ratio and androgens and decreased gonadotrophin levels, hyperinsulinemia. |
Oligomenorrhea, long cycles, long and heavy menstruation |
|
3.HYPERPROLACTINEMIA [36][37] |
Inhibition of LH, GNRH, and may be FSH |
Amenorrhea, bleeding between cycles, oligomenorrhea, polymenorrhea and hypermenorrhea |
|
4.HYPER THYROIDISM [38][39] |
Deceased SHBG, estradiol (E2), testosterone levels. |
Irregular menses, heavy bleeding, oligomenorrhea, amenorrhea, breakthrough bleeding |
|
5.THYROTOXICOSIS [39] |
Increased estradiol, testosterone levels and androgen conversion to estrone. |
Oligomenorrhea, amenorrhea |
|
6.CUSHING’S SYNDROM [40][41] |
Ovarian damage, androgens, hypercortisolism. |
Amenorrhea, oligomenorrhea, polymenorrhea |
Among others, here are some of the neurological conditions that affect the proper menstrual cycle: epilepsy, multiple sclerosis, and parkinsonism.
So many medicines include hormonal contraceptives, antidepressants, antipsychotics, chemotherapeutics, antiepileptics, and immunosuppressants, which would cause most women to be thus affected with menstrual disturbance by hormonal imbalance, neurological changes, and suppression of the pituitary gland in their systems.
Puberty is not solely a process determined by external factors at the environment level but also by the internal genetic and familial variables. Genetic differences and diversity, according to a longitudinal study conducted by Tu and colleagues, present a very significant stimulating factor in the development of puberty stages [43]. The age of menarche is greatly influenced by several genes, such as those of the estrogen-metabolizing type as well as CCR3 genes and CYP17 (18-20). Maternal age is believed to be the most important factor affecting both age at menarche for adolescents and age at which the regulation of the menstrual cycle begins [44, 45]. It has been reported in two large studies that 23 to 57% of differences in the age of menarche can be attributed to genetic and familial causes [46, 47]. High levels of androgens, as mentioned earlier, modulate menstrual cycle regulation in adolescents. There has been some recent interest in genetic factors in PCOS development that affect the regulation of the menstrual cycle. Current molecular genetic studies show that genes involved in androgen regulation may be implicated in the development of hyperandrogenism [48]. Indications of genetic defects include permutations of fragile X, X chromosome abnormalities, and point mutations in the enzyme galactose-1-phosphate uridyl transferase (GALT) galactosemia, which may interfere with the menstrual cycle. The complicated surge and variations in different reproductive hormones modify the menstrual cycle [49]. Some genetic factors associated with autoimmune disorders among these 3 genetic factors associated with menstrual cycle irregularities are:
Lupus
Rheumatoid arthritis
Hashimoto's thyroiditis.
METHODS:
On 28th Nov 2024, a systematic database search of PUBMED, SCIENCE DIRECT, MDPI, NCBI, SCIENCE DIRECT.COM and BENTHAM DIRECT.COM was done with the focus on studies exploring the connection between psychological stress and adulthood on menstrual cycle irregularities. Abstract, full text screening, and data extraction was done by three independent investigators. Findings are summarized with the help of Descriptive statistics.
DISCUSSION:
The current survey seems to be the first thorough systematic assessment of the evidence available on psychological stress in adulthood and its relationship with menstrual cycle irregularity. We reviewed vast literature and extracted data from various articles.
Recommendations:
Prioritize early treatment: The prompt treatment and management of irregular menstrual cycles may prevent long-term complications and improve life quality.
By understanding the complexities, health professionals will better be able to address the needs of women who are struggling with these challenges.
CONCLUSION:
The following is the revised conclusion concerning psychology in adulthood and psychological stress regarding irregularities in the menstrual cycles. Most women tend to face such irregularities during their adult periods. Almost all women experience their changes from adolescence to adulthood, and most of this change almost everything in their lives: their bodies, moods, and even the people they associate with. Very psychological stress on the other hand causes menstrual irregularities during adulthood. Stress is prolonged; it disrupts the Hypothalamic-Pituitary-Gonadal (HPG) axis disturbance, after which there is hormone and menstrual irregularities. It defines the relationship between adulthood and psychologic distress on menstrual irregularities and typically crucial within this context. Transitions into adulthood may cause psychological stress and disrupt the regular pattern of the menstrual cycle. For example, some cycle irregularities may also contribute to psychological distress, leading to the repetition such a cycle. Understanding the dynamic interplay of adulthood, psychological stress, and the incoherence of the menstrual cycle is crucial to devising effective preventive and intervention strategies. Healthcare professionals must consider both psychological and emotional dimensions of the irregularity in the menstrual cycle when diagnosing it or providing treatment to women affected by it.
REFERENCES
Jennila Meghana*, Bhadrachalam Rohini, Sanjana Sahu, Paila Bhanujirao, A Systematic Review of The Association Between Adulthood and Psychological Stress on Menstrual Cycle Irregularity, Int. J. of Pharm. Sci., 2024, Vol 2, Issue 12, 2870-2881. https://doi.org/10.5281/zenodo.14543713
10.5281/zenodo.14543713
