How does COVID-19 affect women's health?

 As it turned out, one of the consequences of COVID-19 for women is menstrual disorders. There is even a subgroup in the group devoted to post-covid women's problems, where the Russian-speaking community shares symptoms, worries, and advice. Judging by the frequency of posts and comments, it is not easy for women who have had the coronavirus. Our correspondent has also experienced irregular menstrual cycle after the disease and terrible pains in the lower abdomen, and communication with the attending obstetrician-gynecologist eventually inspired her to gather questions from the group members about post-covids and make an extensive interview on them.

Natalia Belykh, an obstetrician-gynecologist, ultrasound doctor, gynecologist-endocrinologist, gynecologist-oncologist and pediatric gynecologist, has been working in her specialty since 2017. During the last year, almost every day she has been seen by patients with cycle disorders in the postovaginal cycle: out of 8-12 women who come for an appointment at least one encounters such a problem.

 What are the most common symptoms?

Most often it is either delayed menstruation, or prolonged menstruation, or just menstrual discharge outside the cycle, as if your period is gone, but after about 3-4 days it starts again.

Do you have any indirect information on problems in men, perhaps?

Patients have told me that they have had the disease and their husbands have had problems with potency. Women who are planning a pregnancy and the frequency of intercourse is important to them complained of this more often. Many colleagues also noted deterioration of spermogram in patients after covid, and the presence of signs of inflammation of the male genitals like prostatitis.

In men and women, does it depend on age?

No, both young and middle-aged patients complain.

What are the most common additional examinations required for women after a new coronavirus infection? What should a woman be prepared for in the first place: ultrasound, tests?

Basically, it depends on the initial presumptive diagnosis. Because covid-covid, but we do not treat the infection itself, we treat what has become the consequence.

If it is amenorrhea - absence of menstruation - then at least an ultrasound and a hormone test. If it is a long-term vaginal discharge, again, ultrasound, possibly a general blood test to see the number of platelets, because platelets can decrease, perhaps even a coagulogram study. So depending on the initial presumptive diagnosis, depending on what we're looking for. And sometimes it happens that they come in with complaints of pudding, and it turns out that she is pregnant, but the woman has not even thought about it, because she initially had an irregular cycle.

 What kind of treatment do you most often prescribe?

It depends, as I said, on the initial diagnosis and the severity of the symptoms, how much it bothers the woman. If it's one or two days of smeary discharge, we can basically say that we're going to monitor it and give the body time to recover from the covid. If it's slightly more pronounced symptoms, then there could be vitamin therapy, some lifestyle adjustments, i.e. normal sleep, normal exercise, normal diet, and so on. Normal hygienic effects on the body. In more pronounced cases, when menstruation lasts for 10 days or more, or is absent, hormonal drugs could be prescribed under indications.

Have you come across any studies, possibly foreign, on the effect of covid on fertility?

There are studies, of course, but they are still scarce. Because, of course, the effects of covid on fertility are not short-term studies. They have to go on for at least 12 months. Because we're talking about whether or not a woman can have children if she's been trying to get pregnant for 12 months. So we have to recruit women who have had the disease and tried to get pregnant for 12 months after the disease. So there are not a lot of studies, but during these studies it was found that the endometrium is the only tissue of the body that is not damaged by the virus, unlike other tissues, but sometimes in women the folliculogenesis - oocyte formation can be disturbed, and in men the spermatogenesis can be disturbed, that is the sperm are either immature, or immobile, or become incorrect in their shape and structure.

What hormonal abnormalities can most often be traced in the post-covida? What are the indicators that change?

Yes, both I as a gynecologist and fellow endocrinologists have noted that many patients who previously took L-thyroxine (ed. - synthetic hormone prescribed to normalize thyroid function in hypothyroidism) after the disease have found that their TSH values changed again, and they went back into hypothyroidism, which required a dose adjustment. As a rule, this was not a long-term period, and after 3-6 months they returned to the previous dosage of the drug. That is, these changes were temporary in nature.

 Can these hormonal changes, especially for older women, plus the changes that covid gives, bring menopause closer?

Theoretically, of course, it is possible. Any exposure of the glandular organs (thyroid, mammary gland, ovary) to a virus can lead to damage by an autoimmune mechanism, among others. Accordingly, purely theoretically, menopause can approach. But practically again I can't say, because it would take years for us to be able to say that women who had covid have gone into menopause earlier than the average woman in a given region.

Very often anticoagulants are prescribed as therapy when treating coronavirus, how can they affect women?

They can affect women directly: If a woman menstruates regularly, anticoagulants can increase the frequency and duration of her periods. They can also cause bleeding between periods. Postmenopausal women can also suddenly start bleeding. This bleeding can vary in intensity. Anticoagulants are prescribed more for vital signs so that there is no thromboembolism.

Does it make sense then to contact your gynecologist when prescribing anticoagulants to adjust the therapy?

A gynecologist should not adjust the therapy with anticoagulants, this is the job of hematologists. They have to adjust the therapy, but the gynecologist can adjust the condition of the woman so that it's better and easier to endure this period. Because prolonged bleeding may lead to a decrease in hemoglobin levels, decrease the amount of iron in the body, respectively, iron preparations may be prescribed to compensate for this deficit and improve the woman's condition.

 Can taking OCs or hormonal IUDs affect blood counts?

Estrogen-containing contraceptives can increase blood clotting during the first 10 months of taking the drug, if it coincided with the coronavirus disease, then yes, clotting is increased because of the drugs. If a woman has been taking hormonal contraceptives for years, her clotting rate is restored as in the average woman who is not taking hormones. But here, of course, you have to watch everything carefully. Because if a woman has covid in a mild form, that is, without pneumonia, or pneumonia up to 10% of lung damage, then she can continue to take hormones for contraceptive purposes. If it is a moderate to severe course of coronavirus infection, then the hormones are withdrawn so that there is no conflict with the drugs used to treat COVID-19.

Many women complain that there are flushes and flushes and increased sweating in post-covida, how can this be distinguished from menopause that began during the same period, and does it make sense to correct this in any way?

Sweating in covida is general in nature, and basically the whole body sweats, it sweats during the day, usually getting a little better at night. When you have a hot flush, first the face, head, neck, decollete, that is, as if from above, poured boiling water on the head. With menopause sweating is pronounced at night: a woman wakes up at night wet, turning over the pillow, changing the pillowcase, changing nightgowns.

What's wrong with hot flushes? It is not just discomfort in life, here suddenly it became hot, here suddenly the woman blushed, here she got wet - at work you have to change a shirt, a blouse, at night you have to get up to change the underwear. First, the rhythm of sleep is disturbed. Secondly, when the temperature rises sharply in the body, it kills neurons - brain cells. One flush is the death of about 1,000 neurons. Therefore, women who go through menopause naturally begin to have problems with memory, forgetfulness, impaired associative communication, it is more difficult to perform some work functions. Therefore, the correction of hot flashes should be. What it will be - it is decided on the basis of a woman's interests, what she wants, from indications, contraindications. It can be both hormonal and non-hormonal treatment. But one way or another it is worth correcting.

 How does COVID-19 affect the vaginal microflora specifically?

Not COVID itself, but a general decrease in immunity during the period of the body's fight against coronavirus infection leads to the fact that conditionally pathogenic flora, which always live in the vagina, such as candida, fungus, which causes thrush, or ureaplasma, mycoplasma, gardnerella, which live in the vagina in small amounts, begin to multiply actively and lead to the development of candidiasis, vulvovaginitis, bacterial vaginosis, which require treatment because they cause discomfort to a woman in the form of itching, discharge, unpleasant odor.

So the immunity drops there, too?

Immunity falls everywhere.

How do you relieve it if postcoid comes during menopause? Is there any way to relieve it?

It depends on what kind of complaint the woman has. That is, if her complaints are of general therapeutic nature: weakness, fatigue, drowsiness, shortness of breath - it will deal with a therapist, but if it is more dominated by complaints about menopause, it will deal with a gynecologist. If both, then it is a joint treatment by specialists.

How to alleviate premenstrual syndrome? Women note that after the period three days before menstruation begins weakness, dizziness, anxiety, poor appetite and so on.

Premenstrual syndrome, in principle, is very different. Some people have the cephalgic form, when the head hurts, some people have the crisis form, when the pressure rises, some people have a purely psychological form, when the mood swings occur, some people have edema, weight gain, sensitivity of the mammary glands. According to what we identify, and prescribe medications. The universal way to correct PMS is to influence its basic mechanism of occurrence.

Why, in principle, does PMS occur? It's a certain evolutionary trick in the body that people have forgotten about. That is, during a woman's menstrual cycle a follicle matures, an egg develops, ovulation occurs, if the released egg is not fertilized, pregnancy does not occur, the hormones plummet and then her period comes. Why didn't the egg get fertilized? Because there is a bad man living in a cave with this woman who is unable to fertilize, the woman needs to kick this man out of the cave. She starts screaming like an angry bear and behaving inadequately. That is roughly how PMS arises.

How do we block PMS? We either have to walk around pregnant all the time so we don't have PMS, or we have to block ovulation. Accordingly, the only way to block ovulation is to take hormonal contraceptives. This is a universal way to treat PMS. Not universal, if a woman refuses to take hormonal contraceptives, she does not need contraception or it is contraindicated, it may be cyclic vitamin therapy, antidepressants, painkillers, diuretics and blood pressure medications, depending on what exactly bothers you more during PMS.

 The change of the cycle itself in the post-covida, that is, the number of days, the duration, for what reason does it happen, and what to do about it?

After any serious infection, after a serious illness, the forward and backward communication between the cells in a woman's reproductive system can be disrupted. That is, at the head we have the brain which gathers information around, next comes the pituitary gland, a little gland in the head that secretes hormones, the pituitary gland sends a signal to the ovaries, the ovaries send a signal to the uterus to menstruate or not to menstruate. If everything around us is bad, if there is a coronavirus around us, we are all sick, all our relatives are sick, everyone is worried about each other, your job is also bad, you are on sick leave, your salary is lower, you go to work, but you have no energy to work - so you are constantly under some kind of stress. The brain collects all this information and says, "So wait, things are bad around here, and why would the reproductive system, which is not necessary in the body, function here?" In stressful situations, the body shuts down the reproductive system. The connection between the pituitary gland and the ovaries, or the ovaries and the uterus, is interrupted; accordingly, your period either does not come on time, with delays, or does not come at all.

And if you have ovarian discharge in the middle of your cycle, is it worth taking hormonal contraceptives, anticoagulants, and generally starting any self-treatment?

It is necessary to understand the reason why you have oozing in the middle of your cycle. It could be ovulatory bleeding, that is, when ovulation occurs rapidly, the follicle burst, and blood from the ovary traveled to the abdomen, a little bit got into the uterus, and a little smeared. This is no big deal, and usually does not require treatment. The second option that we have ointment in the middle of the cycle - it could be an endometrial pathology, it could be a polyp or endometrial hyperplasia, which already requires some kind of treatment: hormonal or surgical. First we understand the cause, and then we treat it.

 But first, anyway, we go to the doctor and no self-treatment?

Yes.

Why do postcovid women experience either endometriosis or growing myomas?

Honestly, I haven't noticed a connection among my patients. As a rule, women just didn't know they had a myoma there, then for some other reason they come to the gynecologist and it is discovered that there is a myoma.

What can be complications in premenopause as a result of infections, diseases?

The most common complication in the premenopause, when a woman goes from the normal regulation of the menstrual system already in the absence of menstruation is the development of bleeding, abnormal uterine bleeding in premenopause or postmenopause, which, as a rule, is corrected in the hospital by surgery, because we need to get histology at least once and make sure there is no cancer, and the second is the development of cancer according to age, that is, endometrial cancer, ovarian cancer in the postmenopause - it's a common thing.

Have you heard anything about the effect of anticoagulation on fertility, on pregnancy?

Most drugs have a prescription that you can't get pregnant.

 What could this have to do with?

The fact that there has been no research. No one in their right mind would do a study on pregnant women.

But if a woman happens to get pregnant right after COVID-19, or after taking these drugs. What to do?

Depending on what the woman wants. If the woman wants this pregnancy, then of course we will carry this pregnancy and manage it like a normal pregnancy. In other words, the woman undergoes the same three screening examinations, takes general blood and urine tests, coagulogram, biochemical blood tests and smears. Everything is the same as for women who haven't had covid. Well, maybe she will be seen by a therapist a little more often. And a note in the card after the words "pregnancy term so-and-so" will be a reconvalescent (ed. - recovery) for coronavirus infection.

How long do you think it makes sense to plan a pregnancy after you have had the disease?

Regarding all diseases, surgeries, traumas, terrible shocks in life, I always say that if you are sure and feel that you need to get pregnant, then three months we prepare for pregnancy, take pre-pregnancy preparation, take pregnancy planning tests, start taking vitamins, folic acid, iodine, vitamin D and other vitamin supplements as needed. And after that we start the pregnancy. And the medications are taken by both the woman and the man.

Why do you think women often prefer to ask for advice in social networks, from a friend, from a neighbor, but not come to the doctor?

The first reason is probably the health care system itself. To get to a free appointment is quite difficult, there is an appointment for three weeks in advance, you will come and sit for four hours, although you came to your own time, they will take you for ten minutes, look, maybe not even say anything properly, without explaining. If you go to a paid clinic, you have to pay for an appointment, for all the examinations, and you have to be prepared for that. You can also go to different doctors. You can go to a good free doctor, or you can go to a terrible paid doctor, and vice versa. The first reason is the health care system.

The second reason is that in Russia it has always been easier to ask a girlfriend, a neighbor, a grandmother, a mother, but not a specialist.

Thirdly, there is, in principle, a low level of trust in health care. Our people are disappointed in doctors, because from time to time they come across some incompetent doctors, who are little interested, maybe emotionally burned out. People just don't want to fall for it again.

Fourthly, gynecology is a rather intimate area, and you want to hear about someone else's experiences, someone else's experiences with it.

And lastly, but this is more about the older generation, people who were born and raised in the Soviet Union. They, in principle, do not like to complain, they come when they have had enough. They stood at the factory for 20 hours per shift, with a pregnancy of 36 weeks, with terrible swelling, with blood pressure, but they stood their ground, and from the same factory they went to give birth. They endured to the last, to the end. Now, even though the time has changed, they still won't go to the doctor, they will endure. It seems unpleasant and indecent for them to complain about their health. Even concerning hot flashes during menopause, they don't consider it a problem at all.

These are the main reasons why they go to forums, to social networks: first for emotional support, plus they don't trust a doctor, they don't have time to see a doctor, and so on.

 In general, if a woman has had a long break from visiting a gynecologist, where would you advise her to start?

I'll tell you an example of one woman. She never went to a gynecologist, but she had terrible problems, she had severe pain, her stomach was growing by leaps and bounds, she had not menstruated for three years, although she was only 38 years old. We started to get to know her simply by talking. She came to see me, but we did not start seeing each other until the fifth visit. We talked to her four times, and at the fourth visit I just looked at her on the couch, touched her with my hands, felt her abdomen, looked at her mammary glands, we never went to the chair. That is, we meticulously talked the whole time, sorted out all her complaints, what was bothering her. So if you are afraid to go to the gynecologist, you just come right away and say that you have such-and-such, such-and-such problems, but you are not ready for the examination, let's talk, I recognize you, you recognize me, and then everything else.

So this is normal?

Yes, of course it's normal. The relationship between a gynecologist and a girl should be like between a girl and a guy who have just met. That is, first dating, chatting, walking around, and then the intimate acquaintances. That's why when women fly into my house and run straight to the chair to have a look, I always tell them to wait, let's have a chat first. Everything has to be in order, slowly, evenly.

 And how does a mother prepare her daughter for her first examination? And at what age does it make sense to start visiting a gynecologist?

The first examination is at one year of age, but it is not a conscious age, the child does not understand anything, it is just like an ordinary examination at the pediatrician. The whole exam consists of pulling the labia apart to see if the hole is in place.

The next checkup is at the age of three. At the age of three, the child is already conscious. By the age of three, the mother should systematically introduce the girl to her reproductive system at the level that a three-year-old child should know it. The child should roughly understand that it is the vulva, the vagina, and not "pie", "cookie", "flower" and so on. A child has to understand normally what it is between her legs and what it's called, treat it adequately, and understand the limits of what is acceptable.

I don't know if you have heard this story or not, that the girl's mother called it a "cake", and the girl complained to the kindergarten teacher that the janitor who went to clean the kindergarten wanted her "cake" all the time. The kindergarten teacher replied that you are not greedy, share it. Anyway, the girl was raped. If the girl knew what it was properly called, then she would know the limits of what is permissible in relation to her body.

So you have to make sure that by the age of three the child understands that. And when you plan to come with your child, even if it's just a commission, and nothing bothers you, you need to properly prepare your child: "we're going to go to the medical exam today, there will be many doctors, this doctor will look at the mouth, teeth, this one will look at the tummy, this one will look at the arms, legs, and this special female doctor will look at what you have between your legs, he will just look, and that's all". And the child will understand.

In no case you need to scare the child, when the child starts to panic during the check up, because this is not a familiar place, some room with tiles, some strange woman is trying to touch something, in any case you should not punish the child and say that if you do not calm down, do not stop crying, if you do not lie down quietly, the doctor will give you an injection. On the contrary, you have to calmly say that you remember we talked to you at home, and repeat this whole story, and the child will calm down. Of course, it all depends on the doctor who is watching. Because there are doctors who call a nurse and say, hold your hands by your feet, and I'll take a quick look. I don't do that.

The baby and I start to look, the baby stands up on the couch, and I say, well, stand up, show me how big you are, it's worth it just to distract the baby here. The gynecologist should look not only at what the girl has between her legs, but in general the bone development, the length of her arms and legs, whether they are symmetrical or not, and whether her pelvis is symmetrical. While she is standing I tell her to stretch out her arms and stomp her legs, then she lies down and I twist her back and forth by her ass, push her, tickle her and at the same time look how well her pelvis rotates. Then I say I'm going to check her belly, tickle her belly, rub her belly to see if she's OK, check her mammary glands, you have to see how developed they are, some girls develop them before their menstruation. Then I tell her to stretch her neck like a little fatty, she stretches, I check her thyroid, then I say squeeze her legs like a grasshopper, then I tell her to stretch her legs like a frog, she spreads them, after that I checked that the child was not crying, not crying or swearing, everything was OK, I looked and she started to dress. Children need to be distracted with games, jokes, pranks.

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