Scoping Review Reveals Effects of COVID-19 on Peri- and Post-Menopausal Women

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A review published in General Hospital Psychiatry shows large, negative impacts on menopausal women.

The complete health burden of COVID-19 and its post-acute sequelae are still being investigated. Researchers from the National University of Singapore in Singapore and Monash University in Melbourne, Australia examined the virus’s effects on peri- and post-menopausal women using a scoping review to learn the direct and indirect effects of COVID-19 on this population. Researchers defined direct impacts as the consequences resulting from contracting the virus, and indirect impacts as consequences from control measures such as quarantine.1

Between September 2022 and October 2022, researchers searched CINAHL, Cochrane, EMBASE, PubMed, Scopus, Web of Science, PsycINFO, and ProQuest databases for studies in English, in addition to grey literature and reference lists. No beginning date was set for search criteria, which had an end date of October 26, 2022.

Researchers excluded literature reviews, editorials, guidelines, expert opinions, commentaries, and conference abstracts. Researchers presented results in tables and a synthesized narrative.

Thirty-one studies reported that menopausal women were negatively affected by COVID-19, while 21 studies said there was no significant impact. Fourteen studies had mixed results, with negative and neutral findings. Twenty-three studies examined direct health effects, while 11 examined indirect effects; 6 studies examined various indirect effects of the pandemic on menopausal women with different lifestyles.

The Role of Estrogen

Researchers have found that estrogen plays a protective role by reducing COVID-19 virus entry into host cells through ACE2 mRNA downregulation on bronchial epithelial cell membranes. Specifically, 17-beta estradiol decreases cytokine storm risk via the IL-6 cytokine pathway.1 Estrogen, progesterone, and androgen hormones influence immune responses differently in men and women, researchers said. Women have stronger defenses against infection, with higher levels of immunoglobulin and more circulating CD4/CD8 T-cells.1

In menopausal women, estrogen levels drop, leaving them more susceptible to COVID-19. “These sex-based differences disappeared when postmenopausal women were compared against men, due to the loss of estrogen in postmenopausal women which provides protection against the virus,” researchers wrote.1

Direct Impacts

For direct impacts on physical health, studies focused on rates of infection, severe illness, and mortality. Researchers said some studies found post-menopausal women on some type of hormone therapy seemed mildly protected from severe infection, while those with estrogen deficits, such as breast cancer patients, were more likely to die from the virus. Researchers noted a turn toward negative outcomes that began with studies published in 2022. These included that post-menopausal women had higher disease severity and higher acute infection rates, as well as more severe peri- and menopausal symptoms.1

Some studies reported that COVID-19’s direct impacts on mental health included higher levels of anxiety in peri-menopausal women and greater psychological menopausal symptoms than in uninfected women, researchers said. Direct impacts on lifestyle included higher rates of sleep issues. Researchers said studies showed that eating and physical activity levels were unaffected.

Indirect Impacts

Some studies reported indirect impacts, including increased menopause symptoms, possibly linked to stress, the authors said. Some reported decreased access to healthcare, weight gain, and an increase in poor sleep quality for menopausal women, as well as decreased Vitamin D and calcium levels. Depression, fear, anxiety, and depression increased in negative studies. Negative studies also said alcohol consumption increased. However, researchers noted that there were neutral studies that had opposite conclusions.

While study strengths included primary study-only inclusion and comprehensive evaluation, researchers noted limitations. These included only using studies in English. “Additionally, most of the included studies were retrospective cross-sectional studies, introducing recall bias and limit the inference for causation,” researchers said. They added that true menopause status was unknown for women in the studies due to the limitations of the pandemic. Different ages considered for peri-menopause and menopause also made comparisons difficult, the authors noted.

Despite contradictory findings, researchers said the overall outcomes of COVID-19 on menopausal women were largely negative, especially in studies published after 2022.

“More rigorous research of longitudinal nature is needed to validate the results,” the researchers said. “Policy-makers are encouraged to pay more attention to addressing the health needs of menopausal women during the COVID-19 pandemic.”

Reference
1. Wu X, Wong KW, Gurvich C, Dong Y. Impact of COVID-19 on health of menopausal women: A scoping review. Gen Hosp Psychiatry. 2023;84:125-141. doi:10.1016/j.genhosppsych.2023.07.001
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